Race and Medicare-Medicaid Dual Enrollment Disparities in Access to Quality and Intensity of Post-Acute Rehabilitation Care and Health Outcomes in Patients with Stroke

Variation in stroke-related care remains among the most compelling health service concerns in the United States. Stroke patients account for about 20% of all inpatient rehabilitation facility (IRF) admissions. However, there is limited research to date exploring patient-centered outcomes associated with the quality and intensity of IRF-based rehabilitation services among stroke patients who are racial/ethnic minority groups (African Americans and Hispanics) and are dual eligible for Medicare and Medicaid. Our proposal uses an integrative mixed methods design to study how individual- and provider-level factors contribute to disparities in IRF quality rating and amount of therapy, and subsequently, the combined effect of the two on patient health outcomes. The qualitative aim will identify facilitators and barriers to IRF selection among racial/ethnic minority groups (African Americans and Hispanics) and those with dual eligibility after stroke and the impact of the selection of quality IRFs on patient perceptions of IRF quality of care. This study will use 100% Medicare claims and assessment data (2017-2022), and perspectives from patients/caregivers, hospital discharge planners, and rehabilitation clinicians from different regions to understand selection processes of IRF and outcomes. We will utilize the Medicare Inpatient Standard Analytical File, Beneficiary Summary, Inpatient Rehabilitation Facilities Patient Assessment Instrument, Provider of Service, and publicly available IRF Medicare compare data. Patients with ‘index stroke’ admitted directly to IRFs from acute hospitals will serve as our primary cohort. For the first three aims, a) change in functional status, b) 30-day hospital readmission, and c) community discharge will serve as primary outcomes, adjusting for patient-, hospital-, and market-level characteristics. For the fourth, qualitative aim, patient perception of IRF quality and perceived functional recovery will be primary dependent variables for assessing the impact of variation in rehabilitation care.