Finis origine pendet: commentary on "Postacute care and ischemic stroke mortality: findings from an integrated health care system in northern California".

Wang et al [1] have examined 1-year mortality and its association with the highest level of postacute care (PAC) services received in a large retrospective cohort of ischemic stroke patients treated at Kaiser Permanente facilities in Northern California. In this season of looming health system reform, their data and analysis are of great interest to clinicians as we are challenged to maximize effectiveness and efficiency of stroke care pathways throughout the PAC continuum. Wang et al [1] examined more than 16,000 patients grouped by highest level of PAC services received, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), home health, or outpatient care, at 1 year after incident cerebrovascular accident (CVA). When grouped into 2 cohorts, the researchers excluded those with early death, by 14 and 61 days after acute discharge, to reduce the potential effect on the 1-year mortality of discharging patients who were sicker to an SNF. They, nonetheless, found the lowest mortality at 1 year in both cohorts to be associated with an IRF as the highest level of rehabilitation service after ischemic stroke, and the highest mortality when an SNF was the patient’s most intensive level of PCA. Wang et al [1] hypothesize that this finding is related to the intensity and breadth of services provided at the IRF, “Continued medical care and medication management, intensive rehabilitation treatment, discharge planning, patient and family education . . . may contribute to the better survival rates for patients received the IRH as the highest level of PAC rehabilitation treatment.” This is an attractive hypothesis to professionals such as the undersigned who have spent careers promoting IRF as the optimum rehabilitation environment. However, its plausibility is open to question. A common first-year trajectory after stroke is for patients to spend 2-4 weeks in the IRF, then 4-8 weeks in a SNF, then 3-4 weeks with home care, and then 3-4 months at outpatient services. Stroke survivors with significant deficits usually receive 6-10 months of PAC in total. It is unclear why survival at 12 months would be due to the 2-4 weeks of that time spent in the IRF, particularly when deaths during the IRF stay itself (up to 14 and 61 days into the PAC period) have been excluded. The medical “rehab rescue,” in which vigilant and experienced professionals in the IRF recognize and resolve a potentially fatal early complication that the acute hospital missed, such as deep venous thrombosis, pulmonary embolism, pneumonia, pulmonary edema, fractures, or medication adverse effects, is a known and celebrated phenomenon in the IRF world and could play a role in this observed association of IRF with reduced mortality. All of the benefits of IRF described above, medical management, rehabilitation treatment, discharge planning, patient and family education, however, continue throughout the 6-10 month PAC period, albeit at lesser intensity later on and cannot be ascribed just to the IRF. An additional explanation for the observed association between an IRF stay and reduced mortality deserves consideration: “finis origine pendet,” the end depends on the beginning. In rehabilitation terms, this is the well-known association of outcomes to status on admission. IRF admission is generally offered to the best rehabilitation candidates: younger patients with mid-level neurologic deficits, limited medical comorbidities, and the physical capacity for intensive rehabilitation. SNF admission tends to be offered to older patients who are too infirm or impaired to benefit from intensive rehabilitation; this group also has a higher burden of medical comorbidity. In the current study, the PAC 14-day IRF cohort