Characteristics of Acute Stroke Patients Readmitted to Inpatient Rehabilitation Facilities: A Cohort Study

Development of a Set of Indicators for Measuring and Improving Quality of Rehabilitation Care after Ischemic Stroke

Stroke is the leading global cause of permanent disability and the second leading cause of dementia within the first year of the event. Systematic quality improvement interventions such as Audit & Feedback (A&F) can monitor and improve the performance of post-stroke care in conjunction with the use of quality indicators (QIs). The scientific literature shows limited studies on quality improvement and QIs design for poststroke rehabilitation. In Italy, the National Outcomes Evaluation Programme (PNE) annually provides several QIs concerning the acute wards. On the contrary, indicators for quality assessment of post-acute stroke rehabilitation are not available nationwide. In recent years, the Italian Ministry of Health has funded a national network project, the aim of which is to provide and evaluate the effectiveness of A&F strategies in healthcare improvement. Part of this project is the development of a set of IQs for ischemic stroke rehabilitation used to conduct an A&F. In this study, we describe the design and development process of these QIs from administrative databases and report the results of the pilot test conducted on a small sample of Sicilian rehabilitation facilities, comparing them from 2019 to 2021. Feedback from the participating centers was mainly positive, and the quality indicators were found to be comprehensible and appreciated. However, the study highlighted the need for better adherence to indicators measuring processes of rehabilitation care. The set of quality indicators presented in this study, relevant to inpatient settings, could be considered a starting point on which to base quality improvement initiatives both nationally and internationally.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation After Stroke

OBJECTIVE

The aim of the study was to identify causes for readmission to acute care of patients admitted to inpatient rehabilitation facility after stroke.

DESIGN

The institutional Uniform Data System for Medical Rehabilitation database was used to identify stroke patients who experienced readmission to acute care and an equal number of age-/sex-matched group of patients who successfully completed their inpatient rehabilitation facility stay during 2005-2018. Retrospective chart review was used to extract clinical data. The two study groups were compared using univariate and multivariate analyses.

RESULTS

The rate of readmission to acute care was 4.7% (n = 89; age = 65 ± 14 yrs; 37% female; 65% White; 73% ischemic stroke). The most common indications for transfer were neurological (31%) and cardiovascular (28%). Compared with control group, the readmission to acute care group had statistically higher rates of comorbid conditions, lower median (interquartile range) Functional Independence Measure score on inpatient rehabilitation facility admission (55 [37-65] vs. 64 [51-78], P < 0.001), and a higher rate of sedative/hypnotic prescription (82% vs. 23%, P < 0.001).

CONCLUSIONS

Readmission to acute care is not common in our cohort. Patients who experienced readmission to acute care had higher medical complexity and were prescribed more sedative/hypnotic medications than the control group. Practitioners should be vigilant in patients who meet these criteria.

Clinical impact of functional independent measure (FIM) on 180-day readmission and mortality in elderly patients hospitalized with acute decompensated heart failure

Activities of daily living (ADL) are important prognostic factors for heart failure. The functional independent measure (FIM) has emerged as a comprehensive valid measure of ADL from both physical and cognitive perspectives. This study aimed to investigate the prognostic impact of the FIM score on clinical outcomes in hospitalized patients with acute decompensated heart failure (ADHF). We retrospectively analyzed 473 ADHF patients, with available pre-discharge FIM scores, admitted to our institution between May 2018 and May 2020. Primary outcome measures, defined as a composite of 180-day all-cause deaths and readmissions, were compared among three tertiles. The median FIM score was 102 (interquartile range: 85-115). Tertile 1 corresponded to an FIM score > 111 (n = 154), Tertile 2 to that of 90-111 (n = 167), and Tertile 3 to that of < 90 (n = 152). During follow-up, 28 deaths and 114 readmissions occurred. Patients with lower FIM scores were associated with a graded increase in the risk of primary outcome measure (p = 0.001). Even after multivariable adjustment, the results remained significant [Tertile 1 vs 3; adjusted hazard ratio: 3.28 (95% confidence interval: 1.72-6.56), p < 0.001; Tertile 2 vs 3; 2.32 (1.27-4.47), p = 0.006]. FIM scores were significantly associated with readmission or death within 180 days of discharge in hospitalized ADHF patients.

Risk of Hospital Readmission among Older Patients Discharged from the Rehabilitation Unit in a Rural Community Hospital: A Retrospective Cohort Study

Rehabilitation for hospitalized older people can improve their independence for performing activities of daily living (ADL), but determining its appropriateness can be challenging because of inherent limitations in their ADL and short life expectancy. Thus, we aimed to clarify the benefit of rehabilitation among older Japanese patients. We retrospectively evaluated consecutive older patients (age > 65 years) admitted to the rehabilitation unit of a rural community hospital between 1 April 2016 and 31 March 2020. The primary outcome measure was readmission for acute conditions. Of the 732 patients evaluated, 311 patients (42.5%) were readmitted. Readmission was significantly associated with body mass index (BMI) (p < 0.001), dependent condition (p < 0.001), higher cognitive domain scores in the functional independence measure (FIM) (p = 0.019), and polypharmacy (p = 0.026). The most frequent cause of readmission was pyelonephritis (11.9%), followed by pneumonia (10.9%), compression fracture (10.6%), heat stroke (8.4%), and cerebral stroke (8.0%). In conclusion, older Japanese patients discharged from rehabilitation units have lower readmission rates than those previously reported. Thus, better nutritional control, a multidisciplinary approach to the management of cognitive dysfunction, and a decrease in polypharmacy could be associated with improved outcomes among discharged older patients.