Inpatient rehabilitation utilization for acute stroke under a universal health insurance system

To explore the population-level utilization and factors associated with the use of inpatient stroke rehabilitation services under a single-payer government-based National Health Insurance (NHI) program in Taiwan.

Retrospective cohort study based on claims data.

Inpatients with stroke were sampled from a nationally representative cohort of 200,000 NHI program enrollees. Multiple inpatient claims for individuals were merged to create a patient-level file; the first-ever admission was considered the index stroke. Proxy indicators to represent stroke severity, comorbidity, and complications were constructed. Predisposing, need, and enabling characteristics associated with rehabilitation use were explored.

Among 2639 identified patients with stroke from January 1, 1997, to December 31, 2002, the overall inpatient rehabilitation utilization was 34.0% (33.0% for physical therapy, 19.6% for occupational therapy, and 5.3% for speech therapy). Stroke type and stroke severity were immediate causes of rehabilitation use. Except in neurology wards, rehabilitation use was unaffected by physician or facility characteristics. Among 898 patients receiving rehabilitation services, the median number of treatment sessions was 8 (interquartile range, 4-19), and the total rehabilitation costs were US $114.00 (interquartile range, $47.80-$258.30), with a mean (SD) length of stay of 22.2 (21.8) days.

In a setting in which ability to pay is neutralized, inpatient stroke rehabilitation service in this universal NHI program was equitable but inadequate relative to use elsewhere or estimated need. Less severe case mix and financial or human resources constraints might partially account for the low utilization. Further studies measuring stroke severity and functional status are needed to clarify the actual utilization, requirements, and cost-effectiveness of inpatient stroke rehabilitation services.