Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs)
and After Discharge: Study Highlights for Amputees




39.9 percent (11.8 percentage point difference) lower all-cause
mortality rate over a two-year period
77.7 day difference in days alive over a two-year period
85.4 more days residing at home (i.e., not receiving facility-based
care) over a two year period
155.4 fewer emergency room visits per 1,000 patients per year (p <
0.047)


428.3 fewer hospital readmissions per 1,000 patients per year
There was no statistical difference in average cost per day between
IRF and SNF settings over two years.
Discussion: Our findings are consistent with the published literature on
comparative effectiveness of IRF and SNF rehabilitation for lower-limb
amputees. The average cost of IRF amputees’ initial rehabilitation stay was
nearly two times more expensive than the average SNF stay ($17, 387 vs.
$9,051; p < 0.0001), but the overall Medicare payments aggregated over two
years were similar, as the higher average healthcare cost after SNF
rehabilitation offset IRF amputees’ higher initial rehabilitation stay costs.
Therefore, amputees treated in IRFs experienced better clinical outcomes for
the same two-year healthcare cost as SNF patients.
Dysvascular disease, the leading cause of most amputations in the U.S.,8 is
expected to increase among Americans over 65 years as the relative incidence
of diabetes in the pre-Medicare aged population grows.2,9 Some researchers
attribute favorable outcomes in this population to IRFs’ ability to provide
Two Year Mortality Rate
Difference in Mortality Rate between IRF and
SNF Amputees Two Years after Initial
Rehabilitation Stay
11.8 Percentage
50%
Point Lower
Mortality Rate
40%
30%
50.7%
20%
35.1%
10%
0%
IRF
SNF
Difference in Number of Home Days* between
IRF and SNF Amputees Over Two Years
*Number of days not receiving facility-based care
700
Number of Days at Home
Key Findings: Results from our analysis of 1,756 clinically and
demographically matched SNF to IRF Medicare amputation patients finds that
IRF rehabilitated patients experience better long-term clinical outcomes than
patients who received rehabilitation in a SNF. The average length of
rehabilitation stay for the IRF cohort was less than half that of the average
SNF patients (14.0 vs 29.6 days; p < 0.0001). Following the initial
rehabilitation stay, compared to matched SNF discharged amputees, IRF
patients experienced on average (all statistically significant at p < 0.0001
unless otherwise noted):
comprehensive care for unstable
conditions with appropriately intense and
varied rehabilitation services.5,6,10 Our
findings underscore the importance of
policies that preserve, if not expand,
access to IRF services for the amputee
population.
85.4 More
Days at Home
600
500
400
300
517
Days
200
422
Days
100
0
IRF
SNF
Difference in Readmissions per 1,000 Patients
per Year between IRF and SNF Amputees
2,500
Readmissions per 1,000
Patients per Year
Background: An estimated 185,000 upper and lower limb amputations are
performed each year,1 contributing to an estimated prevalence of limb loss in
the U.S. of 1.6 million persons.2 Rehabilitation after amputation is designed to
limit the adverse effects of prolonged bed-rest following major surgery and
stabilize underlying chronic diseases–like complicated diabetes–exacerbated
by general anesthesia.3 Studies suggest that the post-acute care setting in
which amputees receive rehabilitative care contributes to different patient
outcomes. Among trauma-related and dysvascular-caused amputations of the
lower limb, researchers find that amputees treated in inpatient rehabilitation
facilities (IRFs) have significantly better six and 12 month post-amputation
survival, functional status, and patient-reported physical and mental and
emotional health outcomes, as well as fewer reamputations and a higher
likelihood of obtaining prostheses compared to skilled nursing facility (SNF)
placed amputees and amputees discharged home. 4,5,6,7
2,000
428.3 Fewer
Readmissions
per 1,000
1,500
1,966.6
1,000
1,538.3
500
IRF
SNF
Source: Dobson | DaVanzo analysis of research identifiable
20% sample of Medicare beneficiaries, 2005-2009.
1
Owings M, Kozak L. Ambulatory and inpatient procedures in the United States, 1996. National Center for Health Statistics. Vital Health Stat; 13(139).
November 1998.
2
Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Me Rehabil. 2008;
89:422-29.
3
Dillingham TR, Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Arch Phys Med Rehabil.
2008; 89:1038-45.
4
Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil.
2000; 81:292-300.
5
Dillingham TR, Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Arch Phys Med Rehabil.
2008; 89:1038-45.
6
Sauter CN, Pezzin LE, Dillingham TR. Functional outcomes of persons undergoing dysvascular lower extremity amputionats: effect of a post-acute
rehabilitation setting. Am J Phys Med Rehabil. 2013; 92(4):287-96.
7
Pezzin LE, Padalik SE, Dillingham TR. Effect of postacute rehabilitation setting on
mental and emotional health among persons with dysvascular amputations. PM R.
2013; 5:583-90.
8
Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency:
epidemiology and recent trends in the United States. South Med J. 2002;
95(8):875-83.
9
Centers for Disease Control and Prevention, National Center for Health Statistics.
Percentage of civilian, noninstitutionalized population with diagnosed diabetes, by age,
United States, 1980-2011. March 2013. Accessed July 2014.
10
Czerniecki JM, Turner AP, Williams RM, et al. The effects of rehabilitation in a
comprehensive inpatient rehabilitation unit on mobility outcome after dysvascular
lower extremity amputation. Arch Phys Med Rehabil. 2012; 93(8):1384-91.
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