Ten-year trends in pediatric inpatient rehabilitation

The changing healthcare landscape has placed emphasis on improving the health of patient populations as well as the quality of care and care experience of patients -- all at a lower cost to the health care system. This quest for what is called the Triple Aim, has led to the standardizing of the process of care delivery in the United States, yet there is currently no consensus on the optimal delivery of rehabilitation care, especially in pediatrics.

Recent studies have highlighted discrepancies in the structures and processes of pediatric rehabilitation both within and between different rehabilitation facilities. Other studies have looked at what determines a child's length of stay when admitted to an inpatient rehabilitation program. When looking at these various studies as a whole, it would seem that age, diagnosis, and a child's functional status when admitted are all factors in determining length of stay; however, no studies have addressed national trends.

Researchers recently sought to fill this research gap with a retrospective study that evaluated overall trends in pediatric inpatient rehabilitation and how care is changing in regard to patient demographics, health and functional characteristics as well as the characteristics of facilities in which care is delivered.

Additionally, they sought to identify characteristics of patients and facilities that predict length of stay and effectiveness of treatment as well as characterize differences in rehabilitation care based on the different regions of the United States.

Using a standardized reporting system that reviews the operation and performance of health centers, the researchers looked at WeeFIM data -- which assigns points for independence based on how well a child performs daily tasks such as walking, communicating and getting dressed -- from 67 pediatric inpatient rehabilitation centers in the U.S between 2004 and 2014. This data represented 42,702 inpatient pediatric rehabilitation admissions.

The researchers looked at the length of stay for patients during this decade as well as their WeeFIM scores at admission, WeeFIM functional gains and WeeFIM efficiency. They also looked at 11 different variables that could impact overall trends, including length of stay, patient age, co-existing diseases and conditions, gender, race, region in which the rehabilitation facility was located, insurance type (i.e., public vs. private), admission WeeFIM score, facility type (i.e., freestanding or hospital-unit based), facility size (i.e., number of beds) and discharge year.

Length of stay varied as widely as one to 944 days over the decade studied, with the average length of stay being 28 days. More specifically, the average length of stay dropped from 31 days in 2004 to 24 days in 2014.

"Our study tells us that the number of days children spent in inpatient rehabilitation decreased during the last 10 years," says Tracy Knippel, MD; 3rd year resident, University of Pittsburgh Medical Center and Amy Houtrow, MD, PhD, MPH; associate professor of PM&R and pediatrics; University of Pittsburgh. "Our study doesn't tell us why it happened, but we do know that the number of days adults spend in inpatient rehabilitation has decreased as well in the recent past. We think that children and adults are spending less time in inpatient rehabilitation in part because the process of rehabilitation care has gotten more efficient and in part due to pressures from insurance companies to get patients home as quickly as possible."

Drs. Knippel and Houtrow also noted WeeFIM scores at admission remained relatively stable over the decade studied; WeeFIM efficiency improved significantly over time; and WeeFIM gain decreased significantly. This decrease in WeeFIM gain indicates a trend toward more children being discharged home with more functional limitations, which shifts recovery to an outpatient setting.

Drs. Knippel and Houtrow found some children improved more than others during their time doing inpatient rehabilitation. They also noted older children, children with private insurance, children who stayed only a short time in inpatient rehabilitation and children who lived in the Northeast did the best in inpatient rehabilitation, but say more research is needed to figure out why this is the case.

Next, Drs. Knippel and Houtrow evaluated trends at the facility level and found the total number of freestanding facilities remained stable over the decade studied, but decreased as a percentage of total facilities providing pediatric rehabilitation services (dropping from 26 percent in 2004 to 20 percent in 2014) showing a trend toward hospital-based rehabilitation. They also found the largest number of inpatient rehabilitation facilities during this time period were located in the Northeastern U.S.

Finally, Drs. Knippel and Houtrow evaluated specific impairment groups and the percentage change in rehabilitation admissions each experienced during the decade studied. Physical weakness, or debility, accounted for zero percent of inpatient rehabilitation admissions in 2004 and increased to five percent by 2014. In 2004, musculoskeletal conditions accounted for 15 percent of admissions; this decreased to 8.6 percent in 2014. By comparison, acquired brain injuries consistently represented about 50 percent of all inpatient rehabilitation admissions throughout the study period.