Multidisciplinary rehabilitation versus medical care: a meta-analysis

How oral intake, mobility, and activity measures can inform discharge recommendations: A retrospective analysis of hospitalized inmate and non-inmate COVID-19 patients

BACKGROUND

Patients who were incarcerated were disproportionately impacted by COVID-19 compared to the general public. Further, the impact of multidisciplinary rehabilitation assessments and interventions on the outcomes of patients admitted to the hospital with COVID-19 is limited.

OBJECTIVE

To compare functional outcomes of oral intake, mobility, and activity between inmates and non-inmates who were diagnosed with COVID-19 and examine the relationships among these functional measures and discharge destination.

METHODS

A retrospective analysis was performed on patients admitted to the hospital for COVID-19 at a large academic medical center. Scores on functional measures including Functional Oral Intake Scale (FOIS) and Activity Measure for Post-Acute Care (AM-PAC) were collected and compared between inmates and non-inmates. Binary logistic regression models were used to evaluate the odds of 1) whether patients were discharged to the same place they were admitted and 2) patients being discharged with a total oral diet with no restrictions. Independent variables were considered significant if the 95% CIs of the odds ratios (ORs) did not include 1.0.

RESULTS

A total of 83 patients (inmates, n=38; non-inmates, n=45) were included in the final analysis. There were no differences between inmates and non-inmates on initial (P=.39) and final FOIS scores (P=.35) or on initial, final, or change scores (P>.05) on the AM-PAC. When examining separate regression models using AM-PAC mobility or AM-PAC activity scores as independent variables, greater age upon admission decreased the odds (OR=0.922; 95%CI=0.875 to 0.972 and OR=0.918; 95%CI=0.871 to 0.968) of patients being discharged with a total oral diet with no restrictions. The following factors increased the odds of patients being discharged to the same place they were admitted from: being an inmate (OR=5.285; 95%CI= 1.334 to 20.931) and (OR=6.083; 95%CI=1.548 to 23.912); "Other" race (OR=7.596; 95%CI=1.203 to 47.968) and (OR=8.515; 95%CI=1.311 to 55.291); and female sex (OR=4.671; 95%CI=1.086 to 20.092) and (OR=4.977; 95%CI=1.146 to 21.615).

CONCLUSIONS

Results from this study provide an opportunity to learn how functional measures may be used to better understand discharge outcomes in both inmate and non-inmate patients admitted to the hospital with COVID-19 during the initial period of the pandemic.

CLINICALTRIAL

Impact of early urinary catheter removal on successful voiding and physical function in stroke patients

OBJECTIVE

The aim of the present study was to identify factors related to the success of trial without catheter (TWOC) in patients with stroke and to examine the effect of the timing of urinary catheter removal on the course of stroke.

METHODS

Patients who were admitted to the Stroke Care Unit of our institution between March 2018 and October 2021 were included. To identify factors related to success of TWOC, a multivariate analysis was performed on the patient's condition at admission and catheter indwelling time. The patients were divided into two groups by the timing of catheter removal, and we assessed the relationship between the timing of catheter removal successful TWOC and recovery of physical function.

RESULTS

A total of 118 patients were included. The presence of comorbidities and scores of severity and function at admission were not predictors of successful voiding. The time to achieve voiding sussess was significantly shorter in the early catheter removal group than in the later group (p<0.005). Interestingly, the early group also showed better improvements in physical function.

CONCLUSION

Early removal of catheters may lead to early recovery of bladder function, improvement of physical function, and lower risk of complications in patients with stroke. J. Med. Invest. 70 : 436-442, August, 2023.

Regional variation in post-stroke multidisciplinary rehabilitation care among veteran residents in community nursing homes

INTRODUCTION

Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors' functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans' health services as well as the geographic variation of the service utilization.

AIM

The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care.

METHODS

This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans' inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays.

RESULTS

The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p<0.001) more likely to receive rehabilitation therapies than veterans from other regions. However, veterans in Southeast CNHs were significantly (p<0.001) less likely to receive restorative nursing care compared with veterans in all other regions, before and after risk adjustment.

CONCLUSION

The majority of veterans with stroke received rehabilitation therapy, and about one-third had restorative nursing care during their stay at VA-contracted CNHs. Significant regional variations in weekly days for rehabilitation therapy and restorative nursing care utilization were observed even after adjusting for potential risk factors.

Consulting Service Users: The Stroke Association Home Therapy Project

In 1999, the Stroke Association set up a project to promote home-based occupational therapy for patients who had had a stroke and been discharged home from hospital. As part of the service evaluation, focus groups for service users and carers were set up in two of the sites to consult users about the changes in their quality of life during the period of the home therapy. A total of 11 service users and 9 carers attended the groups, representing 30% of the service users and 27% of the carers involved in the project. The group discussion was taped and transcribed and then analysed using a framework approach.

The group members described their personal experiences of recovery from and limitations after the stroke and reported improvements in life issues during the period of their home therapy. The content and organisation of the service and the relationships with project staff were felt to influence the effectiveness of the occupational therapy. Other issues that affected the perceived outcome for the service users included individual choice, age, stroke consequences, other rehabilitation and community services and social limitations. This consultation process allowed the service users to describe the strengths and weaknesses of the service and provided valuable feedback that could be used to design the content and application of future home therapy services.

Seven-Year Trends in Stroke Rehabilitation: Patient Characteristics, Medical Complications, and Functional Outcomes

Studies of stroke trends have focused primarily on incidence, mortality, and hospitalization rates. There has been little evaluation of changes over time in the common patient characteristics, medical comorbidities, and functional outcomes of patients. The present study evaluated changes during a 7-year period. We found that while demographic variables, stroke severity, and most stroke characteristics remained relatively stable, disability levels at admission and discharge decreased and frequencies of both medical tube usage and many secondary medical complications increased over time. These changes have important implications for the clinical management of stroke patients in rehabilitation and for the organization and financing of stroke rehabilitation programs.

The Extent and Quality of Evidence in Neurological Physiotherapy: An Analysis of the Physiotherapy Evidence Database (PEDro)

Evidence-based practice involves the use of evidence from systematic reviews and randomised controlled trials. The extent of this evidence in neurological physiotherapy has not previously been surveyed. The aim of this study was to describe the quantity and quality of randomised controlled trials, and the quantity and scope of systematic reviews relevant to neurological physiotherapy. PEDro (the Physiotherapy Evidence Database) was searched for trials and reviews relevant to neurological physiotherapy (adult and paediatric). The quality and quantity of trials were analysed, and the topics and conclusions of reviews were synthesised. The search revealed a total of 265 records, consisting of 238 randomised controlled trials and 27 systematic reviews. Since the first trial was published in 1958, the number of trials has expanded exponentially. Fifty-four percent of trials were categorised as being of moderate to high quality, rating five or more out of ten. The first review was published in 1991. Many of the reviews have been unable to reach firm conclusions due to the paucity of available trials. The results show that there is a substantial body of evidence relevant to neurological physiotherapy. However, there remains scope for improvements in the quality of the conduct and reporting of clinical trials. There is an urgent need for more randomised controlled trials and systematic reviews.

Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review

OBJECTIVES

To summarize the efficacy of postacute rehabilitation and to outline future research strategies for increasing knowledge of its effectiveness.

DATA SOURCES

English-language systematic reviews that examined multidisciplinary therapy-based rehabilitation services for adults, published in the last 25 years and available through Cochrane, Medline, or CINAHL databases. We excluded multidisciplinary biopsychosocial rehabilitation programs and mental health services.

STUDY SELECTION

Using the search term rehabilitation, 167 records were identified in the Cochrane database, 1163 meta-analyses and reviews were identified in Medline, and 226 in CINAHL. The Medline and CINAHL search was further refined with 3 additional search terms: therapy, multidisciplinary, and interdisciplinary. In summary, we used 12 reviews to summarize the efficacy of multidisciplinary, therapy-based postacute rehabilitation; the 12 covered only 5 populations.

DATA EXTRACTION

Two reviewers extracted information about study populations, sample sizes, study designs, the settings and timing of rehabilitation, interventions, and findings.

DATA SYNTHESIS

Based on systematic reviews, the evidence for efficacy of postacute rehabilitation services across the continuum was strongest for stroke. There was also strong evidence supporting multidisciplinary inpatient rehabilitation for patients with rheumatoid arthritis, moderate to severe acquired brain injury, including traumatic etiologies, and for older adults. Heterogeneity limited our ability to conclude a benefit or a lack of a benefit for rehabilitation in other postacute settings for the other conditions in which systematic reviews had been completed. The efficacy of multidisciplinary rehabilitation services has not been systematically reviewed for many of the diagnostic conditions treated in rehabilitation. We did not complete a summary of findings from individual studies.

CONCLUSIONS

Given the limitations and paucity of systematic reviews, information from carefully designed nonrandomized studies could be used to complement randomized controlled trials in the study of the effectiveness of postacute rehabilitation. Consequently, a stronger evidence base would become available with which to inform policy decisions, guide the use of services, and improve patient access and outcomes.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary

BACKGROUND

A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.

METHODS

Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.

RESULTS

Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient's deficits and needs. Medical therapy for depression or emotional lability is strongly recommended. A speech and language pathologist should evaluate communication and related cognitive disorders and provide treatment when indicated. The patient, caregiver, and family are essential members of the rehabilitation team and should be involved in all phases of the rehabilitation process. These recommendations are available in their entirety at http://stroke.ahajournals.org/cgi/content/full/36/9/e100. Evidence tables for each of the recommendations are also in the full document.

CONCLUSIONS

These recommendations should be equally applicable to stroke patients receiving rehabilitation in all medical system settings and are not based on clinical problems or resources unique to the Federal Medical System.

Patterns of rehabilitation utilization after hip fracture in acute hospitals and skilled nursing facilities

BACKGROUND

Hospitalized hip fracture patients may receive physical therapy (PT) in acute and/or postacute settings. Patterns of PT use may vary by patient, clinical, and hospital characteristics. These patterns can be analyzed if the acute and postacute stays are linked.

OBJECTIVES

We classified the following patterns of PT use: acute PT only, skilled nursing facility (SNF) PT only, acute and SNF PT, and no PT. For each pattern, we compared (1) characteristics of hip fracture patients, (2) length of stay (LOS), and (3) discharge outcomes.

SUBJECTS

The study included 187,990 hospitalized hip fracture patients derived from Medicare administrative data.

MEASURES

Dependent variables were PT use patterns, acute hospital and SNF LOS, total episode days of care, and discharge destination. Independent variables were demographic, clinical, and facility characteristics. PT use patterns were also used as independent variables in the LOS and discharge destination models.

RESULTS

Patterns of PT use were influenced by demographic and clinical characteristics such as age, race, and surgery type. Similarly, different LOS measures and discharge destinations varied by the PT use patterns. Patients receiving acute PT had longer acute LOSs; however, those patients who were subsequently transferred to SNFs had shorter SNF LOSs and total episode days of care. Patients utilizing PT were more likely to be discharged to home after the acute or SNF stay.

CONCLUSIONS

Disparities in PT use exist for subgroups of patients such as the elderly and blacks. Providers should determine the most appropriate setting for initiation of PT to achieve better discharge outcomes with efficient use of resources.

Best place of care for older people after acute and during subacute illness: a systematic review

OBJECTIVES

To assess the evaluative research literature on the costs, quality and effectiveness of different locations of care for older patients.

METHODS

A systematic review of evaluative research from 1988 using CRD4 guidelines. Twenty-five databases were searched, using processes developed specially for this review. Library OPACS, the Internet and research registers were also searched for relevant material. The final stage of the review was confined to randomised and pseudorandomised trials. Studies were selected for review by pairs of researchers working independently who then met to reach a decision. Analysis was predominantly descriptive; simple pooled odds ratios were used to explore some outcomes.

RESULTS

Eighty-four papers from 45 trials were included. Firm conclusions were difficult to draw, except in relation to some outcomes for stroke units, early discharge schemes and geriatric assessment units. Few trials in this area have adequately addressed issues of patients' quality of life and costs to health services, social care providers, patients and their families.

CONCLUSIONS

Despite considerable recent development of different forms of care for older patients, evidence about effectiveness and costs is weak. However, evidence is also weak for longer-standing care models. A substantial service evaluation agenda emerges from this review. This study also raises questions about the usefulness of systematic review techniques in the area of service delivery and organisation.

Rehabilitation, chronic illness and disability: the missing elements in nurse education

Chronic illnesses represent one of the most significant health challenges in all developed countries and currently there is considerable debate about how to meet the rehabilitative needs of chronically ill and disabled people. The literature suggests that nursing has a potentially significant, but largely unrealized, role to play in addressing areas of current deficit. However, to fulfil this potential it is vital that the educational preparation of nurses at both qualifying and post-qualifying levels equips them with the necessary knowledge and skills. This paper describes a study which analysed curriculum documents from an extensive range of courses in the United Kingdom (UK) in order to determine the emphasis placed on rehabilitation, chronic illness and disability. The results reveal the overall lack of attention given to these important areas and the superficial manner in which key concepts are addressed. The need to identify more clearly the nursing contribution to rehabilitation is highlighted and indicative areas of knowledge and skill required to develop an expanded role are presented.

Hospital-based rehabilitative care versus outpatient services: effect on functioning and health status

PURPOSE

The goal of this clinical trial was to examine the long-term impact of rehabilitative care on the health status of patients diagnosed with a disabling disorder.

METHOD

Study patients consisted of first-time hospitalizations from diagnostic groups commonly admitted for inpatient rehabilitation, including nervous, circulatory, and musculoskeletal disorders or injury. Patients were randomly assigned to inpatient rehabilitation (n = 43) or to outpatient follow-up (n = 42) in which the usual medical services were provided but no scheduled rehabilitative therapies were offered. Specific objectives of the study were to determine the effects of impatient rehabilitation on: (1) functional ability, (2) health and mental health status, (3) personal adjustment, and (4) family function. Cost and use of health-care resources were descriptively assessed.

RESULTS

Analysis of covariance found no significant treatment effects, either at 6 months or at 1 year, for any of the variables under study. In addition, there were no differences between groups in their use of nursing homes, length of hospital stay, mortality, or in the number of hospital readmissions or clinic visits during the first year after hospital discharge. Use of rehabilitation services and cost of care was significantly higher than outpatient services. The findings were consistent with previous studies for most outcomes, with the major exception being functional improvements. Contrary to earlier studies, rehabilitation was not found to effectively produce lasting functional outcomes. However, study conditions may not have fully corresponded to those of previous studies, and further research is needed. The patient sample was representative of a full inpatient service and therefore more heterogeneous than samples reported in prior studies, but the small sample size (due to reductions in the number of admitted patients to the rehabilitation unit during the course of the study) precluded subgroup analysis of diagnostic groupings.

CONCLUSION

The findings suggest that hospital-based rehabilitative care does not have lasting benefits, and that alternative care or supportive follow-up by a subacute-care facility may be needed to assist patients in maintaining functional gains and health benefits.

Stroke rehabilitation outcome variation in Veterans Affairs rehabilitation units: accounting for case-mix

OBJECTIVE

To assess variation in stroke outcomes and create a case-mix adjustment model for stroke rehabilitation in Veterans Affairs Medical Centers.

DESIGN

Observational

SETTING AND PATIENTS

Within Veteran's Health Administration hospitals, there are 63 acute rehabilitation bedservice units that care for approximately 2,000 stroke patients annually.

MAIN OUTCOME MEASURES

Functional gain in FIM points, length of stay (LOS), LOS efficiency (FIM gain/LOS).

RESULTS

Significant variation in average patient functional gain, LOS, and LOS efficiency was observed among the 37 highest-volume rehabilitation units. Using analysis of covariance, a model was developed that adjusted functional gain and LOS (logged LOS) unit means using 10 potential covariates identified in a literature review and in pilot studies. Four and six covariates, respectively, were retained in the final models for FIM gain and LOS. The R2 for FIM gain and LOS accounted for by rehabilitation unit alone increased from .07 to .31 (FIM gain) and from .13 to .34 (logLOS) with the addition of the significant covariates to each model.

CONCLUSIONS

As much as 24% of the variation in two important stroke rehabilitation outcomes is attributable to largely immutable patient and system characteristics (eg, patient function on admission, age, days since stroke onset, year of discharge, marital status, and referral source). Hence, controlling for case-mix is critical for accurate comparison of unit outcomes. Further, the variation in LOS efficiency between VA rehabilitation units suggests a large potential for cost and resource utilization savings system-wide.

Nursing home rehabilitation after acute rehabilitation: predictors and outcomes

OBJECTIVE

To determine the predictive factors and functional outcomes of patients who were discharged from an acute rehabilitation unit to a nursing home care unit (NHCU) at a Veterans Affairs (VA) hospital.

DESIGN

Cohort descriptive study.

SETTING

An academically affiliated urban VA Medical Center.

PATIENTS

All patients (n = 81, median age 68 years) admitted to a VA rehabilitation unit over a 1-year period.

OUTCOME MEASURES

Discharge locations, predictors for NHCU transfer, and functional status as determined by Functional Independence Measure (FIM) scores.

RESULTS

Patients discharged to the NHCU (17%) were compared with those discharged to the community (80%). Multiple logistic regression analysis showed that acute rehabilitation length of stay (LOS), admission, and discharge FIM scores were the only independent variables that predicted discharge to the VA NHCU. Although overall FIM gains in both groups during acute rehabilitation were similar, the NHCU group had significantly lower admission FIM scores and lower LOS efficiency because of longer acute rehabilitation LOS. Postacute NHCU rehabilitation resulted in significant gains in FIM scores at a slower rate. Sixty-four percent of these nursing home patients eventually returned to the community.

CONCLUSION

Nursing home rehabilitation can result in favorable functional and community outcomes for selected patients.

Evaluating rehabilitation medicine: effects on survival, function, and home care

The goal of this study was to measure the clinical impact of rehabilitation on adults diagnosed with a disabling disorder in four major diagnostic groups (nervous, circulatory, musculoskeletal, and injury). To summarize the current knowledge in this area, a meta-analysis of rehabilitation studies was also completed. Specific objectives of the clinical trial were to determine the effects of inpatient rehabilitation on: (1) survival, (2) function, (3) home care, and related variables such as family function and use of health care resources. Patients hospitalized for the first time with a disabling condition (n = 85) were randomly assigned to inpatient rehabilitation (n = 43) or to outpatient follow-up (n = 42) in which the usual medical services were provided but no scheduled rehabilitative therapies were offered. To compare the two groups, analyses of covariance were conducted for functional ability, health care use, survival, health status, personal adjustment and family function. The between subjects factor was inpatient rehabilitation versus the control group. The within subjects factor was time of assessment (index, six months, and 1 year). No significant treatment effect was found at six months or one year for any of the variables under study using analyses of covariance. There were also no differences between groups in their use of nursing homes, length of hospital stay, survival, or in the number of hospital readmissions or clinic visits during the first year after hospital discharge. Rehabilitation did cost significantly more than medical care, primarily due to the cost of inpatient services. Some clinical trials have noted a treatment effect on functional ability but not on mortality, need for skilled care, or mental health status. The current study is consistent with these previous findings except for the lack of impact on physical function. This exception may be due to the fact that prior studies looked only at homogeneous groups, whereas the current study utilized heterogeneous grouping across four major diagnostic categories. Any apparent benefit may not be detectable across disability groups and may require more specialized scrutiny, or even tailored rehabilitative care, to detect a difference. It is recommended that health care systems evaluate the benefits of subacute rehabilitative care and consider outpatient programs that can be provided at home for implementation.