Predictors of Community-based Physical and Occupational Therapy Use After Stroke

OBJECTIVE: To identify individual-, hospital-, and community-level predictors of home health and outpatient physical and/or occupational therapy (PT and/or OT) after stroke. DESIGN: The COMprehensive Postacute Stroke Services study was a pragmatic trial examining the effectiveness of a transitional care model for stroke. We conducted an observational, secondary analysis of COMprehensive Postacute Stroke Services data linked to insurance claims. SETTING: Forty acute care hospitals in North Carolina. PARTICIPANTS: A total of 6754 patients with stroke or transient ischemic attack discharged directly home from the hospital and who had linked North Carolina insurance claims data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Thirty-day use of PT and/or OT in the home or outpatient setting, time to first visit, number of visits, and receipt of both PT and OT in 90 days. Multivariable, generalized estimating equations examined individual-, hospital-, and community-level predictors of therapy use, controlling for clinical measures. RESULTS: Twenty-eight percent and 35 percent of the sample used PT and/or OT in the home or outpatient setting within 30 and 90 days, respectively. Among those who received therapy within 90 days, the mean (SD) number of visits was 9.6 (9.4), and 48% received both PT and OT. Individual-level factors associated with 30-day use and/or a shorter time to first visit included: female sex, living in a metropolitan area, living in a more educated community, having dual Medicare/Medicaid or Medicare Advantage insurance (relative to traditional Medicare), having access to an informal caregiver, and having a primary care provider. Having Medicaid insurance was associated with lower therapy use and a longer time to first visit. Few hospital-level characteristics were predictive of therapy use or time to first visit. Community-level measures of therapist supply were associated with therapy use and shorter time to first visit. CONCLUSIONS: These findings highlight opportunities for targeted interventions to improve access to community-based rehabilitation after stroke.