Hospitals vary in whether they send patients to inpatient rehabilitation or skilled nursing facilities to receive treatment after a stroke, and the reasons why aren’t exactly clear, according to a new study.

A team of investigators with Duke University’s Clinical Research Institute set out to study what factors may sway a hospital to refer patients to either an IRF or a SNF. They used patient data from more than 30,000 Medicare beneficiaries who experienced acute ischemic stroke and were discharged into post-acute care between 2006 and 2008. The team also analyzed hospital characteristics from more than 900 acute-care providers, as well as geographic availability of the IRFs and SNFs.

Using pre-Affordable Care Act data allowed the investigators to analyze referral patterns in a “stable policy and payment framework” before quality metrics changed for both settings, researcher Janet Prvu Bettger, ScD, FAHA, told McKnight’s.

Their findings, published Tuesday in the journal Stroke, showed a “marked unexplained variation” among hospitals in their discharge practices. Of the patients studied, just over 55% were discharged to an IRF, compared to 44% who went to a SNF. Their findings showed that those patients who received post-acute care at an IRF tended to be younger, male, had less healthcare use in the six months leading up to their stroke and had fewer comorbidities/complications.

The hospital-level gaps between the two discharge locations remained despite adjustments for patient, clinical and geographic factors, the study showed.

The study’s findings follow a recommendation published last year by the American Heart Association/American Stroke Association, which also publishes Stroke, advising hospitals and patients to choose an IRF over a SNF “unless there is a good reason not to.”

The recommendation quickly garnered backlash from the skilled nursing sector. One provider group slammed the guidelines as perpetuating a perception that stroke patients who are discharged with SNFs were receiving “lower-level care,” and that it may cause some patients to “ignore” facilities’ therapy capabilities.

Further research on the use of the two settings for stroke rehabilitation may delve into ways that SNFs tout their strengths to hospital partners and affect referral patterns, Bettger said.

“We really have very little information nationally on how hospitals are choosing to build these relationships,” Bettger said. “We needed to have this data to show that there was variation.”