| Clinical guidelines recommend early mobilization for patients after stroke to prevent complications. Guidelines also recommend discharge to an inpatient rehabilitation facility (IRF), nursing home (NH) or skilled nursing facility (SNF), or home, depending on patients' rehabilitation needs and tolerances. The purpose of this study was to examine whether Medicaid provided equitable access to physical therapy services and discharge disposition following stroke compared to the access provided by private insurance. Aday and Andersen's Behavioral Model was adapted as a theoretical framework of access to care. The study was a retrospective analysis of physical therapy utilization and rehabilitation setting for adults post-stroke under the age of 65. The research involved a cross-sectional analysis of patient-level data from Academic Health Center hospitals obtained from the University HealthSystems Consortium Clinical Database for the years 1999--2002, institutional-level data from the American Hospital Association database, system-level data from the Area Resource File, and a study on relative Medicaid generosity. Research questions were addressed with a combination of logistic regression analysis and ANCOVA. Patients with Medicaid were in poorer health and stayed in the hospital longer than did patients with private insurance. Sixty-two percent of all patients received physical therapy in the hospital following stroke. Patients with Medicaid were more likely to receive Physical Therapy in the hospital (O.R. = 1.357, p < .001), and they received more PT (F = 124.94, p < .001) than did patients with private insurance. Just over 82% of patients with private insurance and 75% of patients with Medicaid were discharged home. Compared to those with private insurance, patients with Medicaid were more likely to be discharged to a NH rather than home (O.R. = 1.604, p < .000). Medicaid Index had a positive association with likelihood of receiving PT (O.R. = 3.914, p < .001), amount of PT received (F = 6.00, P = .014), and discharge disposition (O.R. = 7.20, p < .002). The influence of the Medicaid Index was not the same across all ethnic/racial groups. Patients with Medicaid have access to PT in the hospital following stroke and are more likely than those with private insurance to receive continued inpatient rehabilitation following hospital discharge. Medicaid generosity makes a difference in PT utilization and discharge disposition post-stroke. |
