Cost-Effectiveness of Post-Acute Stroke Rehabilitation From a U.S. Healthcare Payer Perspective: Inpatient Rehabilitation Facilities Versus Skilled Nursing Facilities.

Abstract

To evaluate the cost-effectiveness of IRF versus SNF discharge following stroke from a US healthcare payer perspective. We developed a decision analytic model to simulate 90-day outcomes among stroke survivors discharged to IRFs or SNFs. Inpatient rehabilitation facilities (IRFs) provide higher-intensity therapy than skilled nursing facilities (SNFs) and are associated with better outcomes but are perceived as more costly. Adults (≥ 18 years) with either ischemic or hemorrhagic stroke who required institutional post-acute care services to an IRF or SNF. Not applicable MAIN OUTCOME MEASURES: Modeled outcomes included mortality, disability (modified Rankin Scale 0-2 vs. 3-6), community discharge, and readmission. Costs (2024 US Dollar) included rehabilitation stay, long-term care, home health, and readmissions. Utilities for four health states (home vs. long-term care; minor vs. moderate disability) were applied to estimate 90-day quality-adjusted life years (QALYs). Secondary analyses incorporated functional recovery using AM-PAC and Functional Independence Measure (FIM) domains. One-way and probabilistic sensitivity analyses tested robustness. In the base case, IRF was the dominant strategy, with lower 90-day mean costs ($43,062 vs. $49,319) and greater effectiveness (0.57 vs. 0.37 QALYs), yielding incremental savings of $6,257 per patient. Functional analyses confirmed IRF dominance, with higher probabilities of clinically meaningful improvement in AM-PAC mobility (86% vs. 30%), AM-PAC self-care (91% vs. 37%), and FIM mobility (60% vs. 26%). IRF remained cost-effective across wide parameter ranges and in 81% of 10,000 probabilistic simulations. Among stroke survivors requiring institutional rehabilitation, discharge to IRF was associated with greater effectiveness and lower 90-day costs compared with SNF discharge, supporting equitable access to intensive rehabilitation.