1
|
Stanik M, Hass Z, Kong N. Seizure prediction in stroke survivors who experienced an infection at skilled nursing facilities-a machine learning approach. Front Physiol 2024; 15:1399374. [PMID: 38872836 PMCID: PMC11169844 DOI: 10.3389/fphys.2024.1399374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024] Open
Abstract
Background Infections and seizures are some of the most common complications in stroke survivors. Infections are the most common risk factor for seizures and stroke survivors that experience an infection are at greater risk of experiencing seizures. A predictive model to determine which stroke survivors are at the greatest risk for a seizure after an infection can be used to help providers focus on prevention of seizures in higher risk residents that experience an infection. Methods A predictive model was generated from a retrospective study of the Long-Term Care Minimum Data Set (MDS) 3.0 (2014-2018, n = 262,301). Techniques included three data balancing methods (SMOTE for up sampling, ENN for down sampling, and SMOTEENN for up and down sampling) and three feature selection methods (LASSO, Recursive Feature Elimination, and Principal Component Analysis). One balancing and one feature selection technique was applied, and the resulting dataset was then trained on four machine learning models (Logistic Regression, Random Forest, XGBoost, and Neural Network). Model performance was evaluated with AUC and accuracy, and interpretation used SHapley Additive exPlanations. Results Using data balancing methods improved the prediction performances of the machine learning models, but feature selection did not remove any features and did not affect performance. With all models having a high accuracy (76.5%-99.9%), interpretation on all four models yielded the most holistic view. SHAP values indicated that therapy (speech, physical, occupational, and respiratory), independence (activities of daily living for walking, mobility, eating, dressing, and toilet use), and mood (severity score, anti-anxiety medications, antidepressants, and antipsychotics) features contributed the most. Meaning, stroke survivors who received fewer therapy hours, were less independent, had a worse overall mood were at a greater risk of having a seizure after an infection. Conclusion The development of a tool to predict seizure following an infection in stroke survivors can be interpreted by providers to guide treatment and prevent complications long term. This promotes individualized treatment plans that can increase the quality of resident care.
Collapse
Affiliation(s)
- Madeleine Stanik
- Purdue University, Department of Engineering, Weldon School of Biomedical Engineering, West Lafayette, IN, United States
| | - Zachary Hass
- Purdue University, Schools of Industrial Engineering and Nursing, West Lafayette, IN, United States
| | - Nan Kong
- Purdue University, Department of Engineering, Weldon School of Biomedical Engineering, West Lafayette, IN, United States
| |
Collapse
|
2
|
Brown C, Prusynski R, Baylor C, Humbert A, Mroz TM. Patient Characteristics and Treatment Patterns for Speech-Language Pathology Services in Skilled Nursing Facilities. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:912-936. [PMID: 38215225 DOI: 10.1044/2023_ajslp-23-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
PURPOSE Skilled nursing facility (SNF) care has historically been influenced by systemic issues that could impact speech-language pathology (SLP) service provision. However, there has been little study specifically on factors associated with SLP service provision in SNFs. Large administrative data sets are rarely analyzed in SLP research but can be used to understand real-world SLP services. This study investigated associations between patient and facility characteristics and SLP services. METHOD Mixed-effects logistic regression models were used to evaluate factors associated with SLP service provision in 2018 Medicare administrative data representing 833,653 beneficiaries. RESULTS Beneficiaries had higher odds of receiving SLP services when they had neurologic diagnosis (odds ratio [OR] = 3.32), had SLP-related functional impairments (ORs = 1.19-3.41), and received other rehabilitative services (ORs = 3.11-3.78). Beneficiaries had lower odds of receiving SLP services when they received care from SNFs located in hospitals versus freestanding (OR = 0.45), with need for interpreter services (OR = 0.76) and with thresholding (OR = 0.68), a financially motivated practice. Direction of association varied across racial and ethnic groups and measures of location. Odds of being provided SLP services decreased with increasing communication impairment severity. CONCLUSIONS The results suggest that clinicians are identifying patients with diagnoses most likely to warrant SLP services. However, association disparities and weakening association of service provision with increasing impairment severity have concerning clinical implications. Health services research methods can be used to further explore SLP practices in SNFs to support equitable service provision.
Collapse
Affiliation(s)
- Cait Brown
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Rachel Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Carolyn Baylor
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Andrew Humbert
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle
| |
Collapse
|
3
|
Prusynski RA, D’Alonzo A, Johnson MP, Mroz TM, Leland NE. Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage. JAMA HEALTH FORUM 2024; 5:e235454. [PMID: 38427341 PMCID: PMC10907922 DOI: 10.1001/jamahealthforum.2023.5454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024] Open
Abstract
Importance Private Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking. Objective To examine differences in home health service intensity and patient outcomes between MA and TM. Design, Setting, and Participants This cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024. Exposure TM vs MA plan. Main Outcomes and Measures Home health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health. Results Of 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08). Conclusions and Relevance The results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.
Collapse
Affiliation(s)
| | | | | | - Tracy M. Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Natalie E. Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
4
|
Prusynski RA, Frogner BK, Rundell SD, Pradhan S, Mroz TM. Is More Always Better? Financially Motivated Therapy and Patient Outcomes in Skilled Nursing Facilities. Arch Phys Med Rehabil 2024; 105:287-294. [PMID: 37541357 PMCID: PMC10837324 DOI: 10.1016/j.apmr.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/29/2023] [Accepted: 07/11/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE To determine if financially motivated therapy in Skilled Nursing Facilities (SNFs) is associated with patient outcomes. DESIGN Cohort study using 2018 Medicare administrative data. SETTING AND PARTICIPANTS 13,949 SNFs in the United States. PARTICIPANTS 934,677 Medicare Part A patients admitted to SNF for post-acute rehabilitation (N=934,677). INTERVENTIONS The primary independent variable was an indicator of financially motivated therapy, separate from intensive therapy, known as thresholding, defined as when SNFs provide 10 or fewer minutes of therapy above weekly reimbursement thresholds. MAIN OUTCOME MEASURES Dichotomous indicators of successful discharge to the community vs institution and functional improvement on measures of transfers, ambulation, or locomotion. Mixed effects models estimated relations between thresholding and community discharge and functional improvement, adjusted for therapy intensity, patient, and facility characteristics. Sensitivity analyses estimated associations between thresholding and outcomes when patients were stratified by therapy volume. RESULTS Thresholding was associated with a small positive effect on functional improvement (odds ratio 1.07; 95% CI 1.06-1.09) and community discharge (odds ratio 1.03, 95% CI 1.02-1.05). Effect sizes for functional improvement were consistent across patients receiving different volumes of therapy. However, effect sizes for community discharge were largest for patients in low-volume therapy groups (odds ratio 1.27, 95% CI 1.18-1.35). CONCLUSIONS Patients who experienced thresholding during post-acute SNF stays were slightly more likely to improve in function and successfully discharge to the community, especially for patients receiving lower volumes of therapy. While thresholding is an inefficient and financially motivated practice, results suggest that even small amounts of extra therapy time may have contributed positively to outcomes for patients receiving lower-volume therapy. As therapy volumes decline in SNFs, these results emphasize the importance of Medicare payment policy designed to promote, not disincentivize, potentially beneficial rehabilitation services for patients.
Collapse
Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle WA; Center for Health Workforce Studies, Department of Family Medicine, University of Washington, Seattle WA.
| | - Bianca K Frogner
- Center for Health Workforce Studies, Department of Family Medicine, University of Washington, Seattle WA
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle WA
| | - Sujata Pradhan
- Department of Rehabilitation Medicine, University of Washington, Seattle WA
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle WA; Center for Health Workforce Studies, Department of Family Medicine, University of Washington, Seattle WA
| |
Collapse
|
5
|
Gebran A, El Moheb M, Herrera-Escobar JP, Proaño-Zamudio JA, Maurer LR, Lamarre TE, Bou Zein Eddine S, Sanchez SE, Nehra D, Salim A, Velmahos GC, Kaafarani HMA. Insurance Not Socioeconomic Status is Associated With Access to Postacute Care After Injury: A Multicenter Cohort Study. J Surg Res 2024; 293:307-315. [PMID: 37806216 DOI: 10.1016/j.jss.2023.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 07/19/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Access to postacute care services in rehabilitation or skilled nursing facilities is essential to return trauma patients to their preinjury functional level but is often hindered by systemic barriers. We sought to study the association between the type of insurance, socioeconomic status (SES) measures, and postacute care utilization after injury. METHODS Adult trauma patients with an Injury Severity Score (ISS) ≥9 admitted to one of three Level I trauma centers were contacted 6-12 mo after injury to gather long-term functional and patient-centered outcome measures. In addition to SES inquiry specifically focused on education and income levels, patients were asked to subjectively categorize their perceived SES (p-SES) as high, mid-high, mid-low, or low. Insurance and income data were retrieved from trauma registries. Multivariable regression models were built to determine the association between type of insurance, SES, and discharge disposition after adjusting for patient and injury characteristics and hospitalization events. RESULTS A total of 1373 patients were included, of which 44% were discharged to postacute care facilities. The median age (IQR) was 65 (46, 76) years, 56% of patients were male, 11% were on Medicaid, 68% had attained education higher than high school, 27% had low income, and 29% reported a low/mid-low p-SES. Medicaid patients were less likely to be discharged to postacute care compared to privately insured (OR [95% CI]: 0.41 [0.29-0.58]) and Medicare patients (OR [95% CI]: 0.29 [0.16-0.50]). The latter relationship was true across p-SES categories. P-SES, income and educational level were not associated with discharge destination. CONCLUSIONS Insurance status, specifically having Medicaid, can pose a barrier to access to postacute care services in the trauma patient population across patients of all SES. Initiatives and policies that aim at reducing these access disparities are warranted.
Collapse
Affiliation(s)
- Anthony Gebran
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Juan P Herrera-Escobar
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Taylor E Lamarre
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Savo Bou Zein Eddine
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Sabrina E Sanchez
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston University School of Medicine, Boston, Massachusetts
| | - Deepika Nehra
- Division of Trauma, Burn & Critical Care Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
6
|
Mennella C, Maniscalco U, Pietro GD, Esposito M. A deep learning system to monitor and assess rehabilitation exercises in home-based remote and unsupervised conditions. Comput Biol Med 2023; 166:107485. [PMID: 37742419 DOI: 10.1016/j.compbiomed.2023.107485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/31/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
In the domain of physical rehabilitation, the progress in machine learning and the availability of cost-effective motion capture technologies have paved the way for innovative systems capable of capturing human movements, automatically analyzing recorded data, and evaluating movement quality. This study introduces a novel, economically viable system designed for monitoring and assessing rehabilitation exercises. The system enables real-time evaluation of exercises, providing precise insights into deviations from correct execution. The evaluation comprises two significant components: range of motion (ROM) classification and compensatory pattern recognition. To develop and validate the effectiveness of the system, a unique dataset of 6 resistance training exercises was acquired. The proposed system demonstrated impressive capabilities in motion monitoring and evaluation. Notably, we achieved promising results, with mean accuracies of 89% for evaluating ROM-class and 98% for classifying compensatory patterns. By complementing conventional rehabilitation assessments conducted by skilled clinicians, this cutting-edge system has the potential to significantly improve rehabilitation practices. Additionally, its integration in home-based rehabilitation programs can greatly enhance patient outcomes and increase access to high-quality care.
Collapse
Affiliation(s)
- Ciro Mennella
- Institute for High-Performance Computing and Networking (ICAR) - Research National Council of Italy (CNR), Italy.
| | - Umberto Maniscalco
- Institute for High-Performance Computing and Networking (ICAR) - Research National Council of Italy (CNR), Italy.
| | - Giuseppe De Pietro
- Institute for High-Performance Computing and Networking (ICAR) - Research National Council of Italy (CNR), Italy
| | - Massimo Esposito
- Institute for High-Performance Computing and Networking (ICAR) - Research National Council of Italy (CNR), Italy
| |
Collapse
|
7
|
Bellin EY, Markis WT, Hellebrand AM, Busby CM, Wane KA, Jordan CR, Ledvina JG, Kaplan SM, Metzroth TR, Williams GS, Nazir A, Levin NW, Kaufman AM. Improved nursing home end-stage renal disease patient participation in physical therapy with onsite, more frequent dialysis. Hemodial Int 2023; 27:465-474. [PMID: 37563763 DOI: 10.1111/hdi.13112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION For end-stage renal disease (ESRD) patients residing in skilled nursing facilities (SNFs), the logistics and physical exhaustion of life-saving hemodialysis therapy often conflict with rehabilitation goals. Integration of dialysis care with rehabilitation programs in a scalable and cost-efficient manner has been a significant challenge. SNF-resident ESRD patients receiving onsite, more frequent hemodialysis (MFD) have reported rapid post-dialysis recovery. We examined whether such patients have improved Physical Therapy (PT) participation. METHODS We conducted a retrospective electronic medical records review of SNF-resident PT participation rates within a multistate provider of SNF rehabilitation care from January 1, 2022 to June 1, 2022. We compared three groups: ESRD patients receiving onsite MFD (Onsite-MFD), ESRD patients receiving offsite, conventional 3×/week dialysis (Offsite-Conventional-HD), and the general non-ESRD SNF rehabilitation population (Non-ESRD). We evaluated physical therapy participation rates based on a predefined metric of missed or shortened (<15 min) therapy days. Baseline demographics and functional status were assessed. FINDINGS Ninety-two Onsite-MFD had 2084 PT sessions scheduled, 12,916 Non-ESRD had 225,496 PT sessions scheduled, and 562 Offsite-Conventional-HD had 9082 PT sessions scheduled. In mixed model logistic regression, Onsite-MFD achieved higher PT participation rates than Offsite-Conventional-HD (odds ratio: 1.8, CI: 1.1-3.0; p < 0.03), and Onsite-MFD achieved equivalent PT participation rates to Non-ESRD (odds ratio: 1.2, CI: 0.3-1.9; p < 0.46). Baseline mean ± SD Charlson Comorbidity score was significantly higher in Onsite-MFD (4.9 ± 2.0) and Offsite-Conventional-HD (4.9 ± 1.8) versus Non-ESRD (2.6 ± 2.0; p < 0.001). Baseline mean self-care and mobility scores were significantly lower in Onsite-MFD versus Non-ESRD or Offsite-Conventional-HD. DISCUSSION SNF-resident ESRD patients receiving MFD colocated with rehabilitation had higher PT participation rates than those conventionally dialyzed offsite and equivalent PT participation rates to the non-ESRD SNF-rehabilitation general population, despite being sicker, less independent, and less mobile. We report a scalable program integrating dialysis and rehabilitation care as a potential solution for ESRD patients recovering from acute hospitalization.
Collapse
Affiliation(s)
- Eran Y Bellin
- Departments of Epidemiology & Population Health and Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | | | - Katy A Wane
- Signature HealthCARE, Louisville, Kentucky, USA
| | | | | | | | | | | | - Arif Nazir
- SHC Med Partners, Louisville, Kentucky, USA
| | - Nathan W Levin
- Internal Medicine, Mount Sinai Icahn School of Medicine, New York, New York, USA
| | | |
Collapse
|
8
|
David Gomez JC, Cochran A, Smith M, Zayas-Cabán G. Prediction of rehospitalization and mortality risks for skilled nursing facilities using a dimension reduction approach. BMC Geriatr 2023; 23:394. [PMID: 37380969 PMCID: PMC10304328 DOI: 10.1186/s12877-023-03995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/24/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Hospitals are incentivized to reduce rehospitalization rates, creating an emphasis on skilled nursing facilities (SNFs) for post-hospital discharge. How rehospitalization rates vary depending on patient and SNF characteristics is not well understood, in part because these characteristics are high-dimensional. We sought to estimate rehospitalization and mortality risks by patient and skilled nursing facility (SNF) leveraging high-dimensional characteristics. METHODS Using 1,060,337 discharges from 13,708 SNFs of Medicare patients residing or visiting a provider in Wisconsin, Iowa, and Illinois, factor analysis was performed to reduce the number of patient and SNF characteristics. K-means clustering was applied to SNF factors to categorize SNFs into groups. Rehospitalization and mortality risks within 60 days of discharge was estimated by SNF group for various values of patient factors. RESULTS Patient and SNF characteristics (616 in total) were reduced to 12 patient factors and 4 SNF groups. Patient factors reflected broad conditions. SNF groups differed in beds and staff capacity, off-site services, and physical and occupational therapy capacity; and in mortality and rehospitalization rates for some patients. Patients with cardiac, orthopedic, and neuropsychiatric conditions are associated with better outcomes when assigned to SNFs with greater on-site capacity (i.e. beds, staff, physical and occupational therapy), whereas patients with conditions related to cancer or chronic renal failure are associated with better outcomes when assigned to SNFs with less on-site capacity. CONCLUSIONS Risks of rehospitalization and mortality appear to vary significantly by patient and SNF, with certain SNFs being better suited for some patient conditions over others.
Collapse
Affiliation(s)
- Juan Camilo David Gomez
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, USA
| | - Amy Cochran
- Department of Population Health Sciences, Department of Mathematics, University of Wisconsin-Madison, Madison, USA
| | - Maureen Smith
- Department of Population Health Sciences, Department of Mathematics, University of Wisconsin-Madison, Madison, USA
| | - Gabriel Zayas-Cabán
- Department of Industrial and Systems Engineering and BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 3107 Mechanical Engineering Building, 1513 University Avenue, Madison, WI 53726 USA
| |
Collapse
|
9
|
Su JM, Chen KY, Wu SM, Lee KY, Ho SC. A mobile-based airway clearance care system using deep learning-based vision technology to support personalized home-based pulmonary rehabilitation for COAD patients: Development and usability testing. Digit Health 2023; 9:20552076231207206. [PMID: 37841513 PMCID: PMC10571692 DOI: 10.1177/20552076231207206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023] Open
Abstract
Background Excessive mucus secretion is a serious issue for patients with chronic obstructive airway disease (COAD), which can be effectively managed through postural drainage and percussion (PD + P) during pulmonary rehabilitation (PR). Home-based (H)-PR can be as effective as center-based PR but lacks professional supervision and timely feedback, leading to low motivation and adherence. Telehealth home-based pulmonary (TH-PR) has emerged to assist H-PR, but video conferencing and telephone calls remain the main approaches for COAD patients. Therefore, research on effectively assisting patients in performing PD + P during TH-PR is limited. Objective This study developed a mobile-based airway clearance care for chronic obstructive airway disease (COAD-MoAcCare) system to support personalized TH-PR for COAD patients and evaluated its usability through expert validation. Methods The COAD-MoAcCare system uses a mobile device through deep learning-based vision technology to monitor, guide, and evaluate COAD patients' PD + P operations in real time during TH-PR programs. Medical personnel can manage and monitor their personalized PD + P and operational statuses through the system to improve TH-PR performance. Respiratory therapists from different hospitals evaluated the system usability using system questionnaires based on the technology acceptance model, system usability scale (SUS), and task load index (NASA-TLX). Results Eleven participant therapists were highly satisfied with the COAD-MoAcCare system, rating it between 4.1 and 4.6 out of 5.0 on all scales. The system demonstrated good usability (SUS score of 74.1 out of 100) and a lower task load (NASA-TLX score of 30.0 out of 100). The overall accuracy of PD + P operations reached a high level of 97.5% by comparing evaluation results of the system by experts. Conclusions The COAD-MoAcCare system is the first mobile-based method to assist COAD patients in conducting PD + P in TH-PR. It was proven to be usable by respiratory therapists, so it is expected to benefit medical personnel and COAD patients. It will be further evaluated through clinical trials.
Collapse
Affiliation(s)
- Jun-Ming Su
- Department of Information and Learning Technology, National University of Tainan, Tainan, Taiwan
| | - Kuan-Yuan Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Ming Wu
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kang-Yun Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shu-Chuan Ho
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
10
|
Morgenstern LB, Almendarez EM, Mehdipanah R, Kwicklis M, Case E, Smith MA, Lisabeth LD. Methods and early recruitment of the Brain Attack Surveillance in Corpus Christi-Post-acute Care (BASIC-PAC) Project. J Stroke Cerebrovasc Dis 2022; 31:106851. [PMID: 36335753 PMCID: PMC10024336 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Compared with non-Hispanic whites (NHWs), Mexican Americans (MAs) have worse stroke outcomes. We report here the methods, background literature, and initial recruitment of the Brain Attack Surveillance in Corpus Christi-Post Acute Care (BASIC-PAC) Project which aims to explore PAC in MAs and NHWs from multiple perspectives: patients, caregivers, and community. MATERIALS AND METHODS Rigorous active and passive stroke surveillance captures all strokes in Nueces County, Texas. Stroke patients are followed for 90 days to determine their care transitions and factors influencing their rehabilitation setting. Informal caregivers of the stroke patients are identified and interviewed at 90 days to determine aspects of their caregiving and caregiver outcomes. Available community resources are compared with stated needs among stroke patient and caregivers to determine unmet needs. RESULTS Between October, 2019 and October, 2021, among the 629 stroke patients eligible, 413 were MA, 227 were NHW. Of the 629, all of the six follow-up calls were completed by 355 of the MAs (87%) and 191 of the NHWs (87%). During this same time period, we attempted to approach 621 potential caregivers. Of these, 458 (73.8%) potential caregivers participated in interviews to determine caregiver eligibility, and 373 (81.4%) of these participating potential caregivers met the eligibility criteria. CONCLUSIONS BASIC-PAC has strong initial recruitment and is poised to provide valuable data on multiple aspects of PAC and how PAC differs by ethnicity and contributes to worse stroke outcomes in MAs. Based on the study findings, interventions can be developed that will improve stroke health equity.
Collapse
Affiliation(s)
- Lewis B Morgenstern
- Stroke Program, University of Michigan Medical School, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, United States.
| | - Elizabeth M Almendarez
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Roshanak Mehdipanah
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, United States
| | - Madeline Kwicklis
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Melinda A Smith
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Lynda D Lisabeth
- Stroke Program, University of Michigan Medical School, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, United States
| |
Collapse
|
11
|
Seim CE, Ritter B, Starner TE, Flavin K, Lansberg MG, Okamura AM. Design of a wearable vibrotactile stimulation device for individuals with upper-limb hemiparesis and spasticity. IEEE Trans Neural Syst Rehabil Eng 2022; 30:1277-1287. [PMID: 35552152 PMCID: PMC10139869 DOI: 10.1109/tnsre.2022.3174808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vibratory stimulation may improve post-stroke symptoms such as spasticity; however, current studies are limited by the large, clinic-based apparatus used to apply this stimulation. A wearable device could provide vibratory stimulation in a mobile form, enabling further study of this technique. An initial device, the vibrotactile stimulation (VTS) Glove, was deployed in an eight-week clinical study in which sixteen individuals with stroke used the device for several hours daily. Participants reported wearing the glove during activities such as church, social events, and dining out. However, 69% of participants struggled to extend or insert their fingers to don the device. In a follow-up study, eight individuals with stroke evaluated new VTS device prototypes in a three-round iterative design study with the aims of creating the next generation of VTS devices and understanding features that influence interaction with a wearable device by individuals with impaired upper-limb function. Interviews and interaction tasks were used to define actionable design revisions between each round of evaluation. Our analysis identified six new themes from participants regarding device designs: hand supination is challenging, separate finger attachments inhibit fit and use, fingers may be flexed or open, fabric coverage impacts comfort, a reduced concern for social comfort, and the affected hand is infrequently used. Straps that wrap around the arm and fixtures on the anterior arm were other challenging features. We discuss potential accommodations for these challenges, as well as social comfort. New VTS device designs are presented and were donned in an average time of 48 seconds.
Collapse
|
12
|
Marston C, Koye DN, Goonan R, Lim K, Juj G, Klaic M. Is there a relationship between intensity of occupational therapy and functional outcomes in hospitalised older patients? A prospective cohort study. Aust Occup Ther J 2022; 69:536-545. [PMID: 35502588 DOI: 10.1111/1440-1630.12808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Delivering high-intensity occupational therapy can improve functional outcomes for patients and reduce length of stay. However, there is little published evidence of this in the aged rehabilitation setting. This study aims to explore the association between intensity of occupational therapy interventions and functional outcomes in geriatric rehabilitation inpatients. METHODS A prospective cohort study was conducted with adult inpatients admitted to a geriatric rehabilitation program. The intervention was the intensity of occupational therapy measured as high (≥30 minutes per day) versus low (<30 minutes per day). The primary outcome measured was change in functional performance, defined as a minimum of half a point improvement in the Katz Index of Activities of Daily Living (ADL) and/or the Lawton and Brody Scale of Instrumental ADL (IADL) at admission to rehabilitation, discharge and 3months post-discharge. RESULTS A total of 693 patients were included in the analysis. The mean age was 82.2 years (standard deviation [SD] = 7.9), 57% were females, and 64% had cognitive impairment. Patients (n = 210) who received greater than or equal to 30 minutes of occupational therapy daily were more likely to have clinically relevant functional improvements.; for both ADL (odds ratio [OR] = 1.87, 95% confidence interval [CI]: 1.24-2.83) and IADL (OR = 3.00, 95% CI: 1.96-4.61), after adjusting for age, sex, severity of function (ADL ≤ 2) at admission, frailty and cognitive impairment. Improvements in ADL and IADL were maintained for at least 3 months following discharge. CONCLUSION This study found that geriatric rehabilitation inpatients who received higher intensity of occupational therapy interventions were more likely to functionally improve than those who received lower intensity. Further research is required to determine if other factors, such as therapy type, influence functional outcomes.
Collapse
Affiliation(s)
- Celia Marston
- Allied Health, Occupational Therapy Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
| | - Digsu N Koye
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,MISCH (Methods and Implementation Support for Clinical Health research platform), Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rose Goonan
- Allied Health, Occupational Therapy Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kwang Lim
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Genevieve Juj
- Allied Health, Occupational Therapy Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Marlena Klaic
- Allied Health, Occupational Therapy Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| |
Collapse
|
13
|
Prusynski RA, Pradhan S, Mroz TM. Skilled Nursing Facility Organizational Characteristics Are More Strongly Associated With Multiparticipant Therapy Provision Than Patient Characteristics. Phys Ther 2022; 102:pzab292. [PMID: 34972865 PMCID: PMC9097255 DOI: 10.1093/ptj/pzab292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/25/2021] [Accepted: 11/19/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Multiparticipant physical and occupational therapy provision has fluctuated significantly in skilled nursing facilities (SNFs) under shifts in Medicare reimbursement policy. Multiparticipant therapy includes group (2-6 individuals per therapist) and concurrent therapy (2 individuals per therapist). This study uses recent patient-level data to characterize multiparticipant therapy provision in SNFs to help anticipate shifts under new Medicare policy and the COVID-19 pandemic. METHODS This secondary analysis used data on 1,016,984 post-acute rehabilitation stays in SNFs in 2018. This analysis identified patient predictors (eg, demographic, clinical) and organizational predictors (eg, ownership, quality, staffing) of receiving multiparticipant therapy using mixed-effects logistic regression. Among individuals who received any multiparticipant therapy, those patient or facility factors associated with high rates of multiparticipant therapy provision were also determined. RESULTS Less than 3% of individuals received multiparticipant therapy in 2018. Patient functional and cognitive impairment and indicators of market regulation were associated with lower odds of multiparticipant therapy. Effect sizes for organizational factors associated with multiparticipant therapy provision were generally larger compared with patient factors. High multiparticipant therapy provision was concentrated in <2% of SNFs and was positively associated with for-profit ownership, contract staffing, and low 5-star quality ratings. CONCLUSION SNF organizational characteristics tended to have stronger associations with multiparticipant therapy provision than patient factors, suggesting that changes in patient case-mix, as expected during the COVID-19 pandemic, may have less of an impact on multiparticipant therapy provision than organizational factors. Results suggest that for-profit SNFs in states with higher market regulation, SNFs providing high volumes of therapy, and SNFs utilizing high proportions of assistants and contract staff may be more responsive to Medicare policy by increasing multiparticipant therapy provision. IMPACT This study may help identify SNFs that are more likely to increase multiparticipant therapy provision under new Medicare payment policy.
Collapse
Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Sujata Pradhan
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
14
|
Simmonds KP, Burke J, Kozlowski AJ, Andary M, Luo Z, Reeves MJ. Emulating Three Clinical Trials that Compare Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities. Arch Phys Med Rehabil 2022; 103:1311-1319. [PMID: 35245481 DOI: 10.1016/j.apmr.2021.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To inform the design of a potential future randomized controlled trial, we emulated three trials where patient-level outcomes were compared following stroke rehabilitation at Inpatient Rehabilitation Facilities (IRFs) to Skilled Nursing Facilities (SNFs). DESIGN Trials were emulated using a 1:1 matched propensity score analysis. The three trials differed as facilities from rehabilitation networks with different case-volumes were compared. Rehabilitation network case-volumes were based on the number of stroke patients that each hospital discharged to each specific IRF or SNF. Trial 1 included 60,529 patients from all networks, trial 2 included 34,444 patients from networks with medium- and large case-volumes (i.e., ≥5 patients), trial 3 included 19,161 patients from networks with large case-volumes (i.e., ≥10 patients). E-values were calculated to estimate the minimum strength that an unmeasured confounder would need to be to nullify the results. SETTING A national sample of IRFs and SNFs from across the United States. PARTICIPANTS Acute Fee-for-service Medicare stroke patients who received IRF or SNF based rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE(S) 1-year successful community discharge (home for >30 consecutive days) and all-cause mortality. RESULTS Overall, 29,500, 15,156, and 7,450 patients were matched for trials 1, 2 and 3. For 1-year successful community discharge, absolute risk differences for IRF patients were 0.21 (95% CI: 0.20, 0.22), 0.17 (95% CI: 0.16, 0.19), and 0.12 (95% CI: 0.10, 0.14) in trials 1, 2 and 3, respectively. For 1-year all-cause mortality, corresponding risk differences were -0.11 (95% CI: -0.12, -0.11), -0.11 (95% CI: -0.12, -0.09), and -0.08 (95% CI: -0.10, -0.06). E-values indicated that a moderately sized unmeasured confounder, with a relative risk of 1.6 to 2.0 would nullify differences in successful community discharge. CONCLUSION(S) IRF patients had superior outcomes, but differences were attenuated when IRFs and SNFs from larger rehabilitation networks were compared. The vulnerability of the findings to unmeasured confounding supports the need for an RCT.
Collapse
Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, Michigan State University - College of Human Medicine
| | - James Burke
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, Mi
| | - Allan J Kozlowski
- Department of Epidemiology and Biostatistics, Michigan State University - College of Human Medicine; John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital
| | - Michael Andary
- Department of Physical Medicine & Rehabilitation, Michigan State University - College of Osteopathic Medicine
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, Michigan State University - College of Human Medicine
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University - College of Human Medicine.
| |
Collapse
|
15
|
Garcia-Rodriguez N, Rodriguez S, Tejada PI, Miranda-Artieda ZM, Ridao N, Buxó X, Pérez-Mesquida ME, Beseler MR, Salom JB, Pérez LM, Inzitari M, Otero-Villaverde S, Martin-Mourelle R, Molleda M, Quintana M, Olivé-Gadea M, Penalba A, Rosell A. Functional Recovery and Serum Angiogenin Changes According to Intensity of Rehabilitation Therapy After Stroke. Front Neurol 2021; 12:767484. [PMID: 34899582 PMCID: PMC8655101 DOI: 10.3389/fneur.2021.767484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/22/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Rehabilitation is still the only treatment available to improve functional status after the acute phase of stroke. Most clinical guidelines highlight the need to design rehabilitation treatments considering starting time, intensity, and frequency, according to the tolerance of the patient. However, there are no homogeneous protocols and the biological effects are under investigation. Objective: To investigate the impact of rehabilitation intensity (hours) after stroke on functional improvement and serum angiogenin (ANG) in a 6-month follow-up study. Methods: A prospective, observational, longitudinal, and multicenter study with three cohorts: strokes in intensive rehabilitation therapy (IRT, minimum 15 h/week) vs. conventional therapy (NO-IRT, <15 h/week), and controls subjects (without known neurological, malignant, or inflammatory diseases). A total of seven centers participated, with functional evaluations and blood sampling during follow-up. The final cohort includes 62 strokes and 43 controls with demographic, clinical, blood samples, and exhaustive functional monitoring. Results: The median (IQR) number of weekly hours of therapy was different: IRT 15 (15–16) vs. NO-IRT 7.5 (5–9), p < 0.01, with progressive and significant improvements in both groups. However, IRT patients showed earlier improvements (within 1 month) on several scales (CAHAI, FMA, and FAC; p < 0.001) and the earliest community ambulation achievements (0.89 m/s at 3 months). There was a significant difference in ANG temporal profile between the IRT and NO-IRT groups (p < 0.01). Additionally, ANG was elevated at 1 month only in the IRT group (p < 0.05) whereas it decreased in the NO-IRT group (p < 0.05). Conclusions: Our results suggest an association of rehabilitation intensity with early functional improvements, and connect the rehabilitation process with blood biomarkers.
Collapse
Affiliation(s)
- Nicolás Garcia-Rodriguez
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Unidad de Rehabilitación Neurológica y Daño Cerebral, Hospital Vall d'Hebron, Barcelona, Spain
| | - Susana Rodriguez
- Unidad de Rehabilitación Neurológica y Daño Cerebral, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | - Natalia Ridao
- Servei de Medicina Física i Rehabilitació, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Sabadell, Spain
| | - Xavi Buxó
- Unidad de Rehabilitación Neurológica y Daño Cerebral, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Maria Rosario Beseler
- Servicio de Medicina Física y Rehabilitación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Juan B Salom
- Unidad Mixta de Investigación Cerebrovascular, Instituto de Investigación Sanitaria La Fe-Universitat de Valencia, Valencia, Spain.,Departamento de Fisiología, Universidad de Valencia, Valencia, Spain
| | - Laura M Pérez
- RE-FiT Barcelona Research Group, Vall d'Hebron Institute of Research, Parc Sanitari Pere Virgili, Barcelona, Spain.,Parc Sanitari Pere Virgili, Area of Intermediate Care, Barcelona, Spain
| | - Marco Inzitari
- RE-FiT Barcelona Research Group, Vall d'Hebron Institute of Research, Parc Sanitari Pere Virgili, Barcelona, Spain.,Universitat Oberta de Catalunya, Barcelona, Spain
| | | | | | | | - Manuel Quintana
- Epilepsy Research Group and Epilepsy Unit, Vall d'Hebron Research Institute and Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Anna Penalba
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Rosell
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
16
|
Mitsutake S, Ishizaki T, Yano S, Tsuchiya-Ito R, Jin X, Watanabe T, Uda K, Livingstone I, Tamiya N. Characteristics associated with hospitalization within 30 days of geriatric intermediate care facility admission. Geriatr Gerontol Int 2021; 21:1010-1017. [PMID: 34549493 PMCID: PMC9290842 DOI: 10.1111/ggi.14278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/14/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
AIM To identify facility-level characteristics associated with hospitalization within 30 days after admission to a geriatric intermediate care facility (GICF) (30-day hospitalization) in Japan. METHODS This retrospective cohort study used nationwide long-term care insurance claims data and a national survey of long-term geriatric care facilities. The study population was residents admitted to GICFs between October 2016 and February 2018. The outcome variable was 30-day hospitalization. The independent variables were facility-level characteristics such as level of healthcare professionals. RESULTS The final sample for analysis comprised 282 991 residents of mean age ± SD, 85.8 ± 7.2 years, of whom 12 814 (4.5%) experienced 30-day hospitalization. In a multivariable logistic generalized estimating equation model adjusted for facility- and resident-level characteristics, and clustering GICFs, the odds of 30-day hospitalization were 0.906 times lower (95% confidence interval [CI] 0.857-0.958) among residents in a GICF with dental hygienist than in those in a facility without. Furthermore, the risk of 30-day hospitalization was lower among residents who had been admitted to a GICF with higher staffing levels of pharmacists (adjusted odds ratio [aOR] 0.941, 95% CI 0.899-0.985), registered nurses (aOR 0.931, 95% CI 0.880-0.986), care workers (aOR 0.920, 95% CI 0.879-0.964) and speech-language pathologists (aOR 0.926, 95% CI 0.874-0.982) than in those who had been admitted to a GICF with fewer of these healthcare professionals. CONCLUSIONS Transitional care including dental hygienist or higher staffing levels of pharmacists, registered nurses, care workers and speech-language pathologists may be a more effective way to prevent 30-day hospitalization. Geriatr Gerontol Int 2021; 21: 1010-1017.
Collapse
Affiliation(s)
- Seigo Mitsutake
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Shohei Yano
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,The Salvation Army Booth Memorial Hospital, Tokyo, Japan
| | - Rumiko Tsuchiya-Ito
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
| | - Xueying Jin
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Taeko Watanabe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Kazuaki Uda
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | | | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| |
Collapse
|
17
|
Downer B, Reistetter TA, Kuo YF, Li S, Karmarkar A, Hong I, Goodwin JS, Ottenbacher KJ. Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement. Arch Phys Med Rehabil 2021; 102:1717-1728.e7. [PMID: 33812884 PMCID: PMC8429053 DOI: 10.1016/j.apmr.2021.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016. DESIGN Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design. SETTING Skilled nursing facilities (n=12,829). PARTICIPANTS Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments. RESULTS The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016. CONCLUSIONS Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.
Collapse
Affiliation(s)
- Brian Downer
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston, TX; University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX.
| | - Timothy A Reistetter
- University of Texas Health Science Center at San Antonio, School of Health Professions, Department of Occupational Therapy, San Antonio, TX
| | - Yong-Fang Kuo
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX; University of Texas Medical Branch, Preventive Medicine and Population Health, Office of Biostatistics, Galveston, TX
| | - Shuang Li
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX
| | - Amol Karmarkar
- Virginia Commonwealth University, School of Medicine, Department of Physical Medicine and Rehabilitation, Richmond, VA
| | - Ickpyo Hong
- Yonsei University, College of Health Sciences, Department of Occupational Therapy, Seoul, Korea
| | - James S Goodwin
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX; University of Texas Medical Branch, Department of Internal Medicine, Division of Geriatrics, Galveston, TX
| | - Kenneth J Ottenbacher
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston, TX; University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX
| |
Collapse
|
18
|
Prusynski RA, Frogner BK, Skillman SM, Dahal A, Mroz TM. Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities. J Appl Gerontol 2021; 41:352-362. [PMID: 34291695 DOI: 10.1177/07334648211033417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Therapy staffing declined in response to Medicare payment policy that removes incentives for intensive physical and occupational therapy in skilled nursing facilities, with therapy assistant staffing more impacted than therapist staffing. However, it is unknown whether therapy assistant staffing is associated with patient outcomes. Using 2017 national data, we examined associations between therapy assistant staffing and three outcomes: patient functional improvement, community discharge, and hospital readmissions, controlling for therapy intensity and facility characteristics. Assistant staffing was not associated with functional improvement. Compared with employing no assistants, staffing 25% to 75% occupational therapy assistants and 25% to 50% physical therapist assistants were associated with more community discharges. Higher occupational therapy assistant staffing was associated with higher readmissions. Higher intensity physical therapy was associated with better quality across outcomes. Skilled nursing facilities seeking to maximize profit while maintaining quality may be successful by choosing to employ more physical therapy assistants rather than sacrificing physical therapy intensity.
Collapse
|
19
|
Effects of Self RehAbilitation Video Exercises (SAVE) on Functional Restorations in Patients with Subacute Stroke. Healthcare (Basel) 2021; 9:healthcare9050565. [PMID: 34064979 PMCID: PMC8150768 DOI: 10.3390/healthcare9050565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Additional exercise therapy has been shown to positively affect acute stroke rehabilitation, which requires an effective method to deliver increased exercise. In this study, we designed a 4-week caregiver-supervised self-exercise program with videos, named “Self rehAbilitation Video Exercises (SAVE)”, to improve the functional outcomes and facilitate early recovery by increasing the continuity of rehabilitation therapy after acute stroke. Methods: This study is a non-randomized trial. Eighty-eight patients were included in an intervention group (SAVE group), who received conventional rehabilitation therapies and an additional self-rehabilitation session by watching bedside exercise videos and continued their own exercises in their rooms for 60 min every day for 4 weeks. Ninety-six patients were included in a control group, who received only conventional rehabilitation therapies. After 4 weeks of hospitalization, both groups assessed several outcome measurements, including the Berg Balance Scale (BBS), Modified Barthel Index (MBI), physical component summary (PCS) and the mental component summary of the Short-Form Survey 36 (SF-36), Mini-Mental State Examination, and Beck Depression Inventory. Results: Differences in BBS, MBI, and PCS components in SF-36 were more statistically significant in the SAVE group than that in the control group (p < 0.05). Patients in the SAVE group showed more significant improvement in BBS, MBI, and PCS components in SF-36 as compared to that in the control group. Conclusions: This evidence-based SAVE intervention can optimize patient recovery after a subacute stroke while keeping the available resources in mind.
Collapse
|
20
|
Prusynski RA, Leland NE, Frogner BK, Leibbrand C, Mroz TM. Therapy Staffing in Skilled Nursing Facilities Declined after Implementation of the Patient-Driven Payment Model. J Am Med Dir Assoc 2021; 22:2201-2206. [PMID: 33965404 DOI: 10.1016/j.jamda.2021.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/25/2021] [Accepted: 04/03/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The Patient-Driven Payment Model (PDPM), a new reimbursement policy for Skilled Nursing Facilities (SNFs), was implemented in October 2019. PDPM disincentivizes provision of intensive physical and occupational therapy, however, there is concern that declines in therapy staffing may negatively impact patient outcomes. This study aimed to characterize the SNF industry response to PDPM in terms of therapy staffing. DESIGN Segmented regression interrupted time series. SETTING AND PARTICIPANTS 15,432 SNFs in the United States. METHODS Using SNF Payroll Based Journal data from January 1, 2019, through March 31, 2020, we calculated national weekly averages of therapy staffing minutes per patient-day for all therapy staff and for subgroups of physical and occupational therapists, therapy assistants, contract staff, and in-house employees. We used interrupted time series regression to estimate immediate and gradual effects of PDPM implementation. RESULTS Total therapy staffing minutes per patient-day declined by 5.5% in the week immediately following PDPM implementation (P < .001), and the trend experienced an additional decline of 0.2% per week for the first 6 months after PDPM compared with the negative pre-PDPM baseline trend (P < .001), for a 14.7% total decline by the end of March 2020. Physical and occupational therapy disciplines experienced similar immediate and gradual declines in staffing. Assistant and contract staffing reductions were larger than for therapist and in-house employees, respectively. All subgroups except for assistants and contract staff experienced significantly steeper declines in staffing trends compared with pre-PDPM trends. CONCLUSIONS AND IMPLICATIONS SNFs appeared to have responded to PDPM with both immediate and gradual reductions in therapy staffing, with an average decline of 80 therapy staffing minutes over the average patient stay. Assistant and contract staff experienced the largest immediate declines. Therapy staffing and quality outcomes require ongoing monitoring to ensure staffing reductions do not have negative implications for patients.
Collapse
Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | - Natalie E Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bianca K Frogner
- Center for Health Workforce Studies, University of Washington, Seattle, WA, USA
| | - Christine Leibbrand
- Center for Studies in Demography & Ecology, University of Washington, Seattle, WA, USA
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; Center for Health Workforce Studies, University of Washington, Seattle, WA, USA
| |
Collapse
|
21
|
Roberts PS, Ouellette D, Solis N, Walters R, Chambers K, Brown D, DiVita MA. Retrospective study demonstrating therapy time impact on inpatient rehabilitation functional gains. Disabil Rehabil 2021; 44:4639-4647. [PMID: 33899629 DOI: 10.1080/09638288.2021.1912836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this retrospective study is to evaluate the association of total therapy time during inpatient rehabilitation and gain in functional independence for patients admitted to an inpatient rehabilitation facility (IRF). MATERIALS AND METHODS The study utilized a retrospective design that included all IRF patients from three IRFs in California from January 1, 2012 to December 31, 2013. Patient data collected as part of usual, routine medical, and rehabilitation care were used and includes demographics, medical variables, and functional outcomes data. RESULTS There were 3212 patients discharged from the three IRFs, with 2,777 patients having received speech language pathology (SLP) therapy along with occupational therapy and physical therapy. Speech language pathology services were not provided for 435 patients in the database. Our results support that among all types of patients, increased therapy hours were associated with increased functional gains. For total functional independence measure (FIM) gain, an additional hour of PT therapy per day was associated with an increase of 7.55 FIM gain points (p < 0.001) and an additional hour of OT therapy per day was associated with an increase of 1.16 FIM gain points (p = 0.045), when adjusted for other variables in the model. SLP hours per day did not remain in the FIM gain model. CONCLUSIONS The findings of this study add to the understanding of therapy time and functional gain in an inpatient rehabilitation program. There is a positive relationship between total therapy time and functional gain. In the future determining the intensity and the related therapy activities provided will be needed to impact functional change. This has implications for shaping rehabilitation practice in the future.Implications for rehabilitationIncreased number of therapy hours were associated with functional gains in an inpatient rehabilitation program for all types of patients.An additional hour of physical therapy per day was associated with an increase of 7.55 functional independence measure (FIM) point gain.An additional hour of occupational therapy per day was associated with an increase of 1.16 FIM point gain.Determining the intensity and related activities are needed to impact functional change which has implications for shaping rehabilitation practice.
Collapse
Affiliation(s)
- Pamela S Roberts
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, CA, USA
| | - Debra Ouellette
- Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - Nuvia Solis
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, CA, USA
| | | | | | - David Brown
- Sharp Memorial Medical Center, San Diego, CA, USA
| | - Margaret A DiVita
- Health Department, State University of New York at Cortland, Cortland, NY, USA
| |
Collapse
|
22
|
Prusynski RA, Gustavson AM, Shrivastav SR, Mroz TM. Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review. Phys Ther 2021; 101:6059293. [PMID: 33388761 DOI: 10.1093/ptj/pzaa230] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/02/2020] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs. METHODS PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome. RESULTS Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function. CONCLUSIONS This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions. IMPACT This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.
Collapse
Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195-6490, USA
| | - Allison M Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Siddhi R Shrivastav
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195-6490, USA
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195-6490, USA
| |
Collapse
|
23
|
Seim CE, Wolf SL, Starner TE. Wearable vibrotactile stimulation for upper extremity rehabilitation in chronic stroke: clinical feasibility trial using the VTS Glove. J Neuroeng Rehabil 2021; 18:14. [PMID: 33485371 PMCID: PMC7824932 DOI: 10.1186/s12984-021-00813-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Evaluate the feasibility and potential impacts on hand function using a wearable stimulation device (the VTS Glove) which provides mechanical, vibratory input to the affected limb of chronic stroke survivors. METHODS A double-blind, randomized, controlled feasibility study including sixteen chronic stroke survivors (mean age: 54; 1-13 years post-stroke) with diminished movement and tactile perception in their affected hand. Participants were given a wearable device to take home and asked to wear it for three hours daily over eight weeks. The device intervention was either (1) the VTS Glove, which provided vibrotactile stimulation to the hand, or (2) an identical glove with vibration disabled. Participants were randomly assigned to each condition. Hand and arm function were measured weekly at home and in local physical therapy clinics. RESULTS Participants using the VTS Glove showed significantly improved Semmes-Weinstein monofilament exam results, reduction in Modified Ashworth measures in the fingers, and some increased voluntary finger flexion, elbow and shoulder range of motion. CONCLUSIONS Vibrotactile stimulation applied to the disabled limb may impact tactile perception, tone and spasticity, and voluntary range of motion. Wearable devices allow extended application and study of stimulation methods outside of a clinical setting.
Collapse
Affiliation(s)
- Caitlyn E Seim
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA.
| | - Steven L Wolf
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Thad E Starner
- College of Computing, Georgia Institute of Technology, Atlanta, CA, USA
| |
Collapse
|
24
|
Nagayama H, Tomori K, Ikeda K, Yamauchi K. Medical Costs and Readmissions After Intensive Poststroke Rehabilitation: Japanese Claims Data. J Am Med Dir Assoc 2021; 22:1762-1766.e1. [PMID: 33476570 DOI: 10.1016/j.jamda.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study examined the association between intensive rehabilitation for subacute stroke patients and medical costs and readmission ratio during the year after discharge. DESIGN This was a natural experiment study. SETTING AND PARTICIPANTS We identified individuals with a diagnosis of cerebrovascular disorder (ICD-10: I60-I69 cerebrovascular disease) in an insurance claims database in Japan from January 2005 to December 2017. From the database, 980 patients who were admitted to a convalescent rehabilitation unit with stroke were identified. After excluding 575 patients, 405 were eligible for the study. METHODS In Japan, from April 2011, a new policy was established that allows special costs to be added as rehabilitation time increases. This policy provides an additional medical fee for inpatients in a convalescent rehabilitation unit who receive more than 120 minutes of rehabilitation therapy. We defined high-intensity rehabilitation as transfer from hospitalization to a convalescent rehabilitation unit after April 2011. Outcomes were total direct medical costs and readmission ratio during the year after discharge from the convalescent rehabilitation unit. RESULTS Daily rehabilitation time, total rehabilitation time, and total medical costs of the high-intensity rehabilitation group were significantly higher than those of the low-intensity rehabilitation group (P < .001, P < .001, P = .011, respectively). However, there was no significant difference in the medical costs during the year after discharge (P = .653) or in the readmission ratio (hazard ratio: 1.09, 95% confidence interval: 0.55-2.18, P = .804). CONCLUSIONS AND IMPLICATIONS Intensive rehabilitation did not reduce medical costs or the readmission ratio during the first year after discharge. Future studies should consider the necessary rehabilitation intensity given the severity of the patient's condition, using large sample sizes.
Collapse
Affiliation(s)
- Hirofumi Nagayama
- Department of Occupational Therapy, Kanagawa University of Human Services, Kanagawa, Japan.
| | - Kounosuke Tomori
- Department of Occupational Therapy, School of Health Science, Tokyo University of Technology, Tokyo, Japan
| | - Kohei Ikeda
- Department of Occupational Therapy, Kanagawa University of Human Services, Kanagawa, Japan
| | - Keita Yamauchi
- Graduate School of Health Management, Keio University, Kanagawa, Japan
| |
Collapse
|
25
|
Nguyen DQ, Ifejika NL, Reistetter TA, Makam AN. Factors Associated with Duration of Rehabilitation Among Older Adults with Prolonged Hospitalization. J Am Geriatr Soc 2020; 69:10.1111/jgs.16988. [PMID: 33393088 PMCID: PMC8217402 DOI: 10.1111/jgs.16988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/17/2020] [Accepted: 11/21/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES Older adults are prone to functional decline during prolonged hospitalization. Although rehabilitation therapy is critical to preserving function, little is known about rehabilitation duration (RD) in this population. We sought to determine the extent of rehabilitation therapy provided to older adults during prolonged hospitalization, and whether this differs by sociodemographic and clinical characteristics. DESIGN Retrospective cohort. SETTING Single-site safety-net hospital. PARTICIPANTS Older adults (≥65 years) hospitalized for ≥14 days between 2016 and 2017. MEASUREMENTS The primary outcome was RD, defined as the average number of minutes of physical and occupational therapy per week. We used a multivariable generalized linear model to assess for differences in RD by sociodemographic and clinical characteristics. For a sub-cohort of hospitalizations with a baseline mobility assessment, we repeated analyses including mobility limitation as a covariate. RESULTS Among 1,031 hospitalizations by 925 unique patients (median age 72, 49% female, 79% non-white, 40% non-English speaking), the median RD was 61.3 minutes/week (interquartile range = 16.5-127.3). Covariates associated with lesser RD included black (57.2 fewer minutes/week; 95% confidence interval (CI) = 22.9-91.4) and Hispanic (75.6 fewer minutes/week; 95% CI = 33.8-117.4) race/ethnicity, speaking a language other than English or Spanish (51.7 fewer minutes/week; 95% CI = 21.3-82.0), prolonged mechanical ventilation (30.0 fewer minutes/week; 95% CI = 6.6-53.3), and do-not-resuscitate code status (36.0 fewer minutes/week; 95% CI = 17.1-54.8). The inclusion of mobility limitation among the sub-cohort (n = 350) did not meaningfully change the associations. CONCLUSION We found large disparities in RD for racial/ethnic and language minorities and clinically vulnerable older adults (mechanical ventilation and do-not-resuscitate code status), independent of clinical severity and functional and cognitive impairment. Greater RD for these groups may improve functional outcomes and narrow the disparity gap.
Collapse
Affiliation(s)
- Danh Q. Nguyen
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Nneka L. Ifejika
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Timothy A. Reistetter
- Department of Occupational Therapy, University of Texas Medical Branch, Galveston, Texas
- Department of Occupational Therapy, University of Texas Health Science Center, San Antonio, Texas
| | - Anil N. Makam
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California
- Center for Vulnerable Populations, University of California, San Francisco, California
| |
Collapse
|
26
|
Prusynski RA, Frogner BK, Dahal AD, Skillman SM, Mroz TM. Skilled Nursing Facility Characteristics Associated With Financially Motivated Therapy and Relation to Quality. J Am Med Dir Assoc 2020; 21:1944-1950.e3. [DOI: 10.1016/j.jamda.2020.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
|
27
|
Livingstone I, Hefele J, Leland N. Physical and Occupational Therapy Staffing Patterns in Nursing Homes and Their Association with Long-stay Resident Outcomes and Quality of Care. J Aging Soc Policy 2020; 34:723-741. [DOI: 10.1080/08959420.2020.1824544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Ian Livingstone
- Department of Gerontology, University of Massachusetts Boston, Boston, MA, USA
- Quality Measurement and Health Policy, RTI International, Waltham, MA, USA
| | - Jennifer Hefele
- Department of Gerontology, University of Massachusetts Boston, Boston, MA, USA
- Health Group, Booze Allen Hamilton, McLean, VA, USA
| | - Natalie Leland
- Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
28
|
Spalding K, Gustafsson L, Di Tommaso A. Occupation-based group programs in the inpatient hospital rehabilitation setting: a scoping review. Disabil Rehabil 2020; 44:2138-2148. [PMID: 32931331 DOI: 10.1080/09638288.2020.1813818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Occupation-based practice involves the inclusion of meaningful occupations in the therapeutic process and is promoted within hospital-based general rehabilitation contexts for individual clients or within a group setting. The purpose of this paper is to summarise the current literature regarding the types of occupation-based group programs used within general inpatient rehabilitation and the reported outcomes. METHODS A scoping review was conducted and included papers if they described an occupation-based intervention, delivered in a group setting, conducted in an inpatient rehabilitation hospital context, with an adult population. Studies were collated, summarized and key findings are presented. RESULTS Ten articles met inclusion criteria. The results indicate that occupation-based groups are used in inpatient rehabilitation across a variety of settings, the approach is valued by the occupational therapy profession and it appears to have an influence on patient satisfaction and experience. However, the impact on a patient's confidence and occupational performance outcomes post-inpatient rehabilitation remains unclear. CONCLUSIONS There is a dearth of evidence on the impact of occupation-based group service focus in the inpatient rehabilitation setting. Considering the importance of occupation to the profession, further investigation into the use of this approach in a group setting is required.Implications for rehabilitationOccupation-based groups are used in inpatient rehabilitation to achieve more therapy time but there is variability in group processes and outcomes measured.Patient centred occupation-based groups appear to have an influence on patient satisfaction and experience.For the occupation-based groups reviewed, providing explicit links between patient goals, therapeutic activity and real life was important for improving outcomes.There is a growing focus for the use of occupation-based groups in occupational therapy and more research is needed to establish effectiveness.
Collapse
Affiliation(s)
- Kaitlyn Spalding
- Discipline of Occupational Therapy, School of Allied Health Sciences, Griffith University, Queensland, Australia.,Occupational Therapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Louise Gustafsson
- Discipline of Occupational Therapy, School of Allied Health Sciences, Griffith University, Queensland, Australia
| | - Amelia Di Tommaso
- Discipline of Occupational Therapy, School of Allied Health Sciences, Griffith University, Queensland, Australia
| |
Collapse
|
29
|
Hsieh CJ, DeJong G, Vita M, Zeymo A, Desale S. Effect of Outpatient Rehabilitation on Functional Mobility After Single Total Knee Arthroplasty: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2016571. [PMID: 32940679 PMCID: PMC7499127 DOI: 10.1001/jamanetworkopen.2020.16571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/26/2020] [Indexed: 11/16/2022] Open
Abstract
Importance Even without evidence, rehabilitation practitioners continue to introduce new interventions to enhance the mobility outcomes for the increasing population with a recent total knee arthroplasty (TKA). Objective To compare post-TKA functional mobility outcomes among 3 newly developed physical therapy protocols with a standard-of-care post-TKA rehabilitation protocol. Design, Setting, and Participants This randomized clinical trial included 4 study arms implemented in 15 outpatient clinics within a single health system in the Baltimore, Maryland, and Washington, District of Columbia, region from October 2013 to April 2017. Participants included patients who underwent elective unilateral TKA, were aged 40 years and older, and began outpatient physical therapy within 24 days after TKA. A total of 505 patients were screened and 386 participants were enrolled. Patients provided informed consent and were randomly assigned to 1 of 4 groups. Blinding patients and treating therapists was not feasible owing to the nature of the intervention. Analysis was conducted under the modified intent-to-treat principle from October 2017 to May 2019. Interventions The control group used a standard recumbent bike for 15 to 20 minutes each session. Interventions used 1 of 3 modalities for 15 to 20 minutes each session: (1) a body weight-adjustable treadmill, (2) a patterned electrical neuromuscular stimulation device, or (3) a combination of the treadmill and electrical neuromuscular stimulation. Main Outcomes and Measures Outcomes included the Activity Measure for Post-acute Care basic mobility score, a patient-reported outcome measure, and the 6-minute walk test. Outcomes were measured at baseline, monthly, and on discharge from outpatient therapy. Results Data from 363 patients (mean [SD] age, 63.4 [7.9] years; 222 [61.2%] women) were included in the final analysis, including 92 participants randomized to the control group, 91 participants randomized to the treadmill group, 90 participants randomized to the neuromuscular stimulation device group, and 90 participants randomized to the combination intervention group. Activity Measure for Post-acute Care scores at discharge were similar across groups, ranging from 61.1 to 61.3 (P = .99) with at least 9.0 points improvement (P = .80) since baseline. The distances as measured by the 6-minute walking test were not statistically different across groups (range, 382.9-404.5 m; P = .60). Conclusions and Relevance This randomized clinical trial found no statistically or clinically significant differences in outcomes across the 4 arms. Because outcomes were similar among arms, clinicians should instead consider relative cost in tailoring TKA rehabilitation. Trial Registration ClinicalTrials.gov Identifier: NCT02426190.
Collapse
Affiliation(s)
- Chinghui Jean Hsieh
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, Maryland
| | - Gerben DeJong
- MedStar National Rehabilitation Hospital, Washington, District of Columbia
- Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, District of Columbia
| | - Michele Vita
- MedStar National Rehabilitation Network, Washington, District of Columbia
| | | | - Sameer Desale
- MedStar Health Research Institute, Hyattsville, Maryland
| |
Collapse
|
30
|
Liao Y, Vakanski A, Xian M, Paul D, Baker R. A review of computational approaches for evaluation of rehabilitation exercises. Comput Biol Med 2020; 119:103687. [PMID: 32339122 PMCID: PMC7189627 DOI: 10.1016/j.compbiomed.2020.103687] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 02/26/2020] [Accepted: 02/29/2020] [Indexed: 12/27/2022]
Abstract
Recent advances in data analytics and computer-aided diagnostics stimulate the vision of patient-centric precision healthcare, where treatment plans are customized based on the health records and needs of every patient. In physical rehabilitation, the progress in machine learning and the advent of affordable and reliable motion capture sensors have been conducive to the development of approaches for automated assessment of patient performance and progress toward functional recovery. The presented study reviews computational approaches for evaluating patient performance in rehabilitation programs using motion capture systems. Such approaches will play an important role in supplementing traditional rehabilitation assessment performed by trained clinicians, and in assisting patients participating in home-based rehabilitation. The reviewed computational methods for exercise evaluation are grouped into three main categories: discrete movement score, rule-based, and template-based approaches. The review places an emphasis on the application of machine learning methods for movement evaluation in rehabilitation. Related work in the literature on data representation, feature engineering, movement segmentation, and scoring functions is presented. The study also reviews existing sensors for capturing rehabilitation movements and provides an informative listing of pertinent benchmark datasets. The significance of this paper is in being the first to provide a comprehensive review of computational methods for evaluation of patient performance in rehabilitation programs.
Collapse
Affiliation(s)
- Yalin Liao
- Department of Computer Science, University of Idaho, Idaho Falls, USA
| | | | - Min Xian
- Department of Computer Science, University of Idaho, Idaho Falls, USA
| | - David Paul
- Department of Movement Sciences, University of Idaho, Moscow, USA
| | - Russell Baker
- Department of Movement Sciences, University of Idaho, Moscow, USA
| |
Collapse
|
31
|
Livingstone I, Hefele J, Leland N. Characteristics of Nursing Home Providers With Distinct Patterns of Physical and Occupational Therapy Staffing. J Appl Gerontol 2020; 40:443-451. [PMID: 32028819 DOI: 10.1177/0733464820903902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Previous work found a substantial growth in therapy staffing among nursing home providers following the introduction of Medicare's Prospective Payment System (PPS). Since the PPS, however, several new Medicare policies have been implemented that may impact the provision of rehabilitative care in nursing homes. In view of the rising focus on patient outcomes and provider performance, it is worthwhile to explore more recent therapy staffing patterns following the introduction of these Medicare programs. While our results show stable staffing levels through prior policy changes, upcoming Medicare payment changes will likely have a stronger impact that may result in reduced therapy staffing. In addition, given that our findings show that staffing patterns vary across provider type, we may see greater variation as a result of the upcoming changes. Thus, therapy staffing should continue to be monitored and deeper explorations into the impact of staffing changes on patient outcomes should be undertaken.
Collapse
Affiliation(s)
- Ian Livingstone
- University of Massachusetts Boston, USA.,RTI International, Waltham, MA, USA
| | | | | |
Collapse
|
32
|
Bland MD, Barco P, Lang CE, Lenard E, Kallmi S, Pennock S, Lenze EJ. Activity Level and Intensity of Older Adults in Skilled Nursing Rehabilitation Measured via Actigraphy. J Geriatr Phys Ther 2020; 44:45-50. [DOI: 10.1519/jpt.0000000000000259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
33
|
Shimoda K, Imai H, Tsuji T, Tsuchiya K, Tajima H, Kanemaki H, Tozato F. Factors affecting the performance of activities of daily living in patients with advanced cancer undergoing inpatient rehabilitation: results from a retrospective observational study. J Phys Ther Sci 2019; 31:795-801. [PMID: 31645809 PMCID: PMC6801346 DOI: 10.1589/jpts.31.795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/04/2019] [Indexed: 01/19/2023] Open
Abstract
[Purpose] Many clinicians believe that rehabilitation for patients with advanced cancer
is futile. We determined factors affecting the performance of activities of daily living
in patients with advanced cancer based on age, gender, marital status, living arrangement,
rehabilitation intensity, type of cancer, impairment, metastasis, and active cancer
treatment. [Participants and Methods] We assessed the Barthel Index to evaluate the
performance of activities of daily living. Of the 120 adult patients with cancer who
underwent inpatient rehabilitation, we analyzed the Barthel Index scores, consisting of 10
items, and reviewed the clinical characteristics from the medical records of 48 patients
who completed supportive or palliative rehabilitation according to Dietz and showed an
increased or maintained total Barthel Index score at final evaluation. [Results] The
median total Barthel Index score increased from 45 (5–95) to 72.5 (5–100); the
rehabilitation intensity was 320 (40–1,240) minutes. The analytical results showed that
the increase of total Barthel Index score was positively associated with rehabilitation
intensity (β=0.350) and negatively associated with the initial grooming score (β=−0.277).
[Conclusion] Adequate rehabilitation positively affects performance of activities of daily
living, especially in patients with advanced cancer who lost their grooming ability at the
onset of rehabilitation. Importantly, rehabilitation may be beneficial for patients with
advanced cancer.
Collapse
Affiliation(s)
- Kaori Shimoda
- Department of Rehabilitation Sciences, Gunma University Graduate School of Health Sciences: 3-39-22 Showa-machi, Maebashi-shi, Gunma 371-8514, Japan
| | - Hisao Imai
- Division of Respiratory Medicine, Gunma Prefectural Cancer Center, Japan
| | - Tetsuya Tsuji
- Department of Rehabilitation Medicine, Keio University School of Medicine, Japan
| | - Kenji Tsuchiya
- Department of Rehabilitation Sciences, Gunma University Graduate School of Health Sciences: 3-39-22 Showa-machi, Maebashi-shi, Gunma 371-8514, Japan
| | - Hiroshi Tajima
- Division of Rehabilitation, Gunma Prefectural Cancer Center, Japan
| | - Hatsumi Kanemaki
- Division of Rehabilitation, Gunma Prefectural Cancer Center, Japan
| | | |
Collapse
|
34
|
|
35
|
Kamo T, Momosaki R, Suzuki K, Asahi R, Azami M, Ogihara H, Nishida Y. Effectiveness of Intensive Rehabilitation Therapy on Functional Outcomes After Stroke: A Propensity Score Analysis Based on Japan Rehabilitation Database. J Stroke Cerebrovasc Dis 2019; 28:2537-2542. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/15/2019] [Accepted: 06/02/2019] [Indexed: 11/27/2022] Open
|
36
|
Tijsen LM, Derksen EW, Achterberg WP, Buijck BI. Challenging rehabilitation environment for older patients. Clin Interv Aging 2019; 14:1451-1460. [PMID: 31496672 PMCID: PMC6697645 DOI: 10.2147/cia.s207863] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/07/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction After hospitalization, 11% of the older patients are referred to rehabilitation facilities. Nowadays, there is a trend to formalize the rehabilitation process for these patients in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support and the environment on a rehabilitation ward. However, since literature on the principles of CRE is scarce, this review aimed to explore and describe the principles of CRE. Methods A search was made in PubMed for relevant literature concerning CRE. Then, articles were hand searched for relevant keywords (ie, task-oriented training, therapy intensity, patient-led therapy, group training), references were identified, and topics categorized. Results After evaluating 51 articles, 7 main topics of CRE were identified: 1) Therapy time; ie, the level of (physical) activity; the intensity of therapy and activity is related to rehabilitation outcomes, 2) group training; used to increase practice time and can be used to achieve multiple goals (eg, activities of daily living, mobility), 3) patient-regulated exercise; increases the level of self-management and practice time, 4) family participation; may lead to increased practice time and have a positive effect on rehabilitation outcomes, 5) task-oriented training; in addition to therapy, nurses can stimulate rehabilitants to perform meaningful tasks that improve functional outcomes, 6) enriched environment; this challenges rehabilitants to be active in social and physical activities, and 7) team dynamics; shared goals during rehabilitation and good communication in a transdisciplinary team improve the quality of rehabilitation. Discussion This is the first description of CRE based on literature; however, the included studies discussed rehabilitation mainly after stroke and for few other diagnostic groups. Conclusion Seven main topics related to CRE were identified that may help patients to improve their rehabilitation outcomes. Further research on the concept and effectivity of CRE is necessary.
Collapse
Affiliation(s)
- Lian Mj Tijsen
- Department Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Oktober , Bladel, The Netherlands.,De Zorgboog , Bakel, The Netherlands
| | - Els Wc Derksen
- Department Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wilco P Achterberg
- Department Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bianca I Buijck
- Oktober , Bladel, The Netherlands.,De Zorgboog , Bakel, The Netherlands
| |
Collapse
|
37
|
Kroll C, Fisher T. The congressional mandate: standardised post-acute care quality measures. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2019. [DOI: 10.12968/ijtr.2019.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims This study describes the relationships between rehabilitation services intensity, post-acute care measures of Functional Performance Change, and length of stay for episodes of care provided in 93 skilled nursing facilities in the US. Methods The study used a secondary analysis of existing data on Medicare beneficiaries admitted to skilled nursing facilities from acute hospitals (n=518) who subsequently returned to the community. Data were selected from Minimum Data Set Section GG items reported by therapists. Results Statistically significant correlations were identified between rehabilitation services intensity and functional outcomes (P<0.001); and between rehabilitation intensity, medical condition, and length of stay (P<0.001) for rehabilitation patients in skilled nursing facilities. Conclusions The intensity of occupational and physical rehabilitation therapy services correlate with patients achieving higher functional outcomes, specifically improvement in self-care and mobility.
Collapse
Affiliation(s)
- Christine Kroll
- Assistant Professor, Occupational Therapy, Indiana University - Purdue, University of Indianapolis, Greenwood, Indiana, United States
| | - Thomas Fisher
- Dean and Professor of Health Sciences Kuali Coeus Institutional Review Board, Indiana University, South Bend, Indiana, United States
| |
Collapse
|
38
|
Simning A, Caprio TV, Szanton SL, Temkin-Greener H, Conwell Y. The association of patient-reported improvement and rehabilitation characteristics with mortality. Geriatr Nurs 2019; 40:620-628. [PMID: 31296405 DOI: 10.1016/j.gerinurse.2019.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 11/26/2022]
Abstract
This study aims to investigate the association of patient-reported improvement and rehabilitation characteristics with mortality among older adults who received rehabilitation. To do so, a national sample of Medicare beneficiaries from the National Health and Aging Trends Study was examined. Among those who reported receiving rehabilitation services in the 2015 interview (N = 1,188), 4.2% were deceased at the 2016 follow-up interview. Mortality was more common among those who had received rehabilitation in nursing home or inpatient and in-home settings compared to outpatient rehabilitation settings. In multivariable analyses accounting for demographics and health status, patient-reported worsening of functioning during rehabilitation (OR=15.69; 95% CI: 1.84-133.45) and cardiovascular disease (OR=4.15; 95% CI: 1.41-12.17) were associated with mortality. Among older adults who received rehabilitation, 1 in 25 were deceased at follow-up. That patient-reported functioning is associated with mortality suggests that more systematically including patient-reported outcomes in rehabilitation care may be clinically pertinent.
Collapse
Affiliation(s)
- Adam Simning
- Department of Psychiatry, University of Rochester Medical Center (URMC), 300 Crittenden Blvd, Rochester, NY 14642, USA.
| | - Thomas V Caprio
- Division of Geriatrics, Department of Medicine, URMC, 435 East Henrietta Road, Rochester, NY 14620, USA
| | - Sarah L Szanton
- School of Nursing, Johns Hopkins University, 525 North Wolfe Street #424, Baltimore, MD 21205, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, URMC, 265 Crittenden Blvd, Rochester, NY 14642, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center (URMC), 300 Crittenden Blvd, Rochester, NY 14642, USA; Office for Aging Research and Health Services, URMC, 300 Crittenden Blvd, Rochester, NY 14642, USA
| |
Collapse
|
39
|
Lenze EJ, Lenard E, Bland M, Barco P, Miller JP, Yingling M, Lang CE, Morrow-Howell N, Baum CM, Binder EF, Rodebaugh TL. Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e198199. [PMID: 31365113 PMCID: PMC6669784 DOI: 10.1001/jamanetworkopen.2019.8199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Enhanced medical rehabilitation (EMR) is a systematic and standardized approach for physical and occupational therapists to engage patients. Higher patient engagement in therapy might lead to improved functional recovery in rehabilitation settings, such as skilled nursing facilities (SNFs). OBJECTIVE To determine whether EMR improves older adults' functional recovery. DESIGN, SETTING, AND PARTICIPANTS A double-blind, parallel-group, randomized clinical trial was conducted from July 29, 2014, to July 13, 2018, in 229 adults aged 65 years or older admitted to 2 US SNFs. Participants were randomized to receive EMR (n = 114) vs standard-of-care rehabilitation (n = 115). Intention-to-treat analysis was used. INTERVENTIONS The intervention group received their physical and occupational therapy from therapists trained in EMR. Based on models of motivation and behavior change, EMR is a toolkit of techniques to increase patient engagement and therapy intensity. The control group received standard-of-care rehabilitation from physical and occupational therapists not trained in EMR. MAIN OUTCOMES AND MEASURES The primary outcome was change in function in activities of daily living and mobility, as assessed with the Barthel Index, which measures 10 basic activities of daily living or mobility items (scale range, 0-100), from SNF admission to discharge; secondary outcomes were gait speed for 10 m, 6-minute walk test, discharge disposition, rehospitalizations, and self-reported functional status at days 30, 60, and 90. To examine the rehabilitation process, therapists' engagement with patients and patient active time during therapy were measured for a sample of the sessions. RESULTS Of the 229 participants, 149 (65.1%) were women; 177 (77.3%) were white, and 51 (22.3%) were black; mean (SD) age was 79.3 (8.0) years. Participants assigned to EMR showed greater recovery of function than those assigned to standard of care (mean increase in Barthel Index score, 35 points; 95% CI, 31.6-38.3 vs 28 points; 95% CI, 25.2-31.7 points; P = .007). There was no evidence of a difference in the length of stay (mean [SD], 23.5 [13.1] days). However, there were no group by time differences in secondary outcome measures, including self-reported function after SNF discharge out to 90 days as measured on the Barthel Index (mean [SE] score: EMR, 83.65 [2.20]; standard of care, 84.67 [2.16]; P = .96). The EMR therapists used a median (interquartile range) of 24.4 (21.0-37.3) motivational messages per therapy session vs 2.3 (1.1-2.9) for nontrained therapists (P < .001), and EMR patients were active during a mean (SD) of 52.5 (6.6%) of the therapy session time vs 41.2 (6.8%) for nontrained therapists (P = .001). CONCLUSIONS AND RELEVANCE Enhanced medical rehabilitation modestly improved short-term functional recovery for selected older adults rehabilitating in SNFs. However, there was no evidence that the benefits persisted over the longer term. This study demonstrates the value of engaging and motivating older adults in rehabilitation therapy, but more work is needed to extend these benefits to longer-term outcomes after discharge home. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02114879.
Collapse
Affiliation(s)
- Eric J. Lenze
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Emily Lenard
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Marghuretta Bland
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Peggy Barco
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - J. Philip Miller
- Division of Biostatistics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael Yingling
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Catherine E. Lang
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nancy Morrow-Howell
- Brown School of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Carolyn M. Baum
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ellen F. Binder
- Division of Geriatrics and Nutritional Science, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas L. Rodebaugh
- Department of Psychological and Brain Sciences, Washington University in St Louis, St Louis, Missouri
| |
Collapse
|
40
|
Kortebein P. Post-Acute Care Determination for Hospitalized Older Adults. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00219-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
41
|
Zhang T, Jambhekar B, Kumar A, Rizvi SA, Resnik L, Shireman TI. Assessing the effects of post-acute rehabilitation services on health care outcomes for people with multiple sclerosis. Mult Scler Relat Disord 2019; 30:277-283. [DOI: 10.1016/j.msard.2019.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 12/12/2022]
|
42
|
The Relationship Between Quality of Care, Physical Therapy, and Occupational Therapy Staffing Levels in Nursing Homes in 4 Years' Follow-up. J Am Med Dir Assoc 2019; 20:462-469. [DOI: 10.1016/j.jamda.2019.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/15/2022]
|
43
|
Racial disparities in post-discharge healthcare utilization after trauma. Am J Surg 2019; 218:842-846. [PMID: 30954233 DOI: 10.1016/j.amjsurg.2019.03.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/18/2019] [Accepted: 03/23/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Racial disparities in trauma outcomes have been documented, but little is known about racial differences in post-discharge healthcare utilization. This study compares the utilization of post-discharge healthcare services by African-American and Caucasian trauma patients. METHODS Trauma patients with an Injury Severity Score (ISS)≥9 from three Level-I trauma centers were contacted between 6 and 12 months post-injury. Utilization of trauma-related healthcare services was asked. Coarsened exact matching (CEM) was used to match African-American and Caucasian patients. Conditional logistic regression then compared matched patients in terms of post-discharge healthcare utilization. RESULTS 182 African-American and 1,117 Caucasian patients were followed. Of these, 141 African-Americans were matched to 628 Caucasians. After CEM, we found that African-American patients were less likely to use rehabilitation services [OR:0.64 (95% CI:0.43-0.95)] and had fewer injury-related outpatient visits [OR:0.59 (95% CI:0.40-0.86)] after discharge. CONCLUSIONS This study shows the existence of racial disparities in post-discharge healthcare utilization after trauma for otherwise similarly injured, matched patients.
Collapse
|
44
|
Lewis CB. Academy of Geriatric Physical Therapy Inaugural Carole B. Lewis Lecture Award Address to the Membership at the Combined Sections Meeting Washington, DC January 24, 2019. J Geriatr Phys Ther 2019; 42:59-62. [PMID: 30882546 DOI: 10.1519/jpt.0000000000000232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
45
|
Snowdon DA, Leggat SG, Harding KE, Boyd J, Scroggie G, Taylor NF. The association between effectiveness of clinical supervision of allied health professionals and improvement in patient function in an inpatient rehabilitation setting. Disabil Rehabil 2019; 42:1173-1182. [PMID: 30668167 DOI: 10.1080/09638288.2018.1518493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose: Clinical supervision is widely accepted as an important element of practice for allied health professionals to ensure a high quality of patient care. However, it is unknown whether effective clinical supervision of allied health professionals improves patients' outcomes. This study investigated whether effective clinical supervision of allied health professionals is associated with improved patient functional independence. Methods: A prospective longitudinal study design and multi-level regression analysis were used to explore the association between effective clinical supervision and patient functional independence. The effectiveness of clinical supervision was assessed using the Manchester Clinical Supervision Scale. Functional improvement in patients treated by allied health professionals was measured utilising the mobility and self-care subscales of the functional independence measure.Results: Physiotherapists (n = 27) and occupational therapists (n = 26) in inpatient rehabilitation were recruited and the medical records of their patients (n = 1846) audited. The effectiveness of clinical supervision of physiotherapists was positively associated with improvement in personal care. Therapist variables accounted for less than 2.5% of the variation in patient improvement in functional independence.Conclusions: Effectiveness of a reflective model of clinical supervision of physiotherapists and occupational therapists was not associated with an improvement in their patients' mobility or personal care, respectively.Implications for rehabilitationEffective clinical supervision of physiotherapists and occupational therapists using a reflective model of practice is a poor predictor of improved functional independence in rehabilitation inpatients.Patient variables, such as the intensity of therapy, were more important predictors of patient functional improvement than effective clinical supervision.Initiatives aimed at increasing intensity of therapy will likely have a greater effect on improving patient functional independence compared with initiatives aimed at improving the effectiveness of clinical supervision using a reflective model of practice.Initiatives to improve the effectiveness of clinical supervision in improving quality of care could explore the use of a direct model of practice where supervisors directly observe and support supervisees during patient treatment sessions.
Collapse
Affiliation(s)
- David A Snowdon
- School of Allied Health, La Trobe University, Melbourne, Australia
| | - Sandra G Leggat
- School of Public Health, La Trobe University, Melbourne, Australia
| | - Katherine E Harding
- School of Allied Health, La Trobe University, Melbourne, Australia.,Allied Health Clinical Research Office, Eastern Health, Box Hill, Australia
| | - Jude Boyd
- Allied Health Department, Eastern Health, Box Hill, Australia
| | - Grant Scroggie
- Allied Health Department, Eastern Health, Box Hill, Australia
| | - Nicholas F Taylor
- School of Allied Health, La Trobe University, Melbourne, Australia.,Allied Health Clinical Research Office, Eastern Health, Box Hill, Australia
| |
Collapse
|
46
|
Dorsch S, Weeks K, King L, Polman E. In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study. J Physiother 2019; 65:23-27. [PMID: 30573440 DOI: 10.1016/j.jphys.2018.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/08/2018] [Accepted: 11/20/2018] [Indexed: 12/18/2022] Open
Abstract
QUESTIONS When a hospital gymnasium used for inpatient rehabilitation is set up to allow semi-supervised practice: what percentage of practice is performed as semi-supervised practice, what percentage of patients in the gym are actively engaged in practice at one time, and is the semi-supervised practice that occurs safe? DESIGN An observational study using periodic behaviour mapping. PARTICIPANTS Patients in general and stroke rehabilitation units of a metropolitan hospital. OUTCOME MEASURES Observations in the rehabilitation gym quantified the number of patients in the gym and the numbers of patients practising and resting. In observations of patients practising, the condition of practice was recorded as being with a therapist, with a family member, or with no direct supervision. The number of adverse events during the data collection period was collected from the hospital Incident Information Management System. RESULTS The rehabilitation gym was observed on 113 occasions, resulting in 1319 individual patient observations. An average of 12 patients were in the gym during the observations. Practice was being performed with family supervision in 15% of observations and with no direct supervision in 26% of observations, resulting in semi-supervised practice accounting for 41% of all observations of practice. The percentage of observations that were of patients taking part in active practice was 78%. There were no adverse events in the gym. CONCLUSION In an inpatient setting, a large percentage of practice can be performed as semi-supervised practice. This does not appear to compromise the time spent in active practice or patient safety.
Collapse
Affiliation(s)
- Simone Dorsch
- School of Allied Health, Australian Catholic University, Sydney, Australia; StrokeEd Collaboration, Sydney, Australia.
| | - Kevin Weeks
- Brindabella Rehabilitation Service, University of Canberra Hospital, ACT Health, Canberra, Australia
| | - Laura King
- Physiotherapy Department, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - Etesa Polman
- Physiotherapy Department, Bankstown-Lidcombe Hospital, Sydney, Australia
| |
Collapse
|
47
|
Lee AJ, Liu X, Borza T, Qin Y, Li BY, Urish KL, Kirk PS, Gilbert S, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Role of Post-Acute Care on Hospital Readmission After High-Risk Surgery. J Surg Res 2018; 234:116-122. [PMID: 30527462 DOI: 10.1016/j.jss.2018.08.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/31/2018] [Accepted: 08/24/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Payment models, including the Hospital Readmissions Reduction Program and bundled payments, place pressures on hospitals to limit readmissions. Against this backdrop, we sought to investigate the association of post-acute care after major surgery and readmission rates. METHODS We identified patients undergoing high-risk surgery (abdominal aortic aneurysm repair, coronary bypass grafting, aortic valve replacement, carotid endarterectomy, esophagectomy, pancreatectomy, lung resection, and cystectomy) from 2005 to 2010 using the Healthcare Cost and Utilization Project's State Inpatient Database. The primary outcome was readmission rates after major surgery. Secondary outcome was readmission length of stay. RESULTS We identified 135,523 patients of whom 56,720 (42%) received post-acute care. Patients receiving post-acute care had higher readmission rates than those who were discharged home (16% versus 10%, respectively; P < 0.001). The risk-adjusted readmission length of stay was greatest for patients who received care from a skilled nursing facility, followed by those who received home care, and lowest for those who did not receive post-acute care (7.1 versus 5.4 versus 4.8 d, respectively; P < 0.001). CONCLUSIONS The use of post-acute care was associated with higher readmission rates and higher readmission lengths of stay. Improving the support of patients in post-acute care settings may help reduce readmissions and readmission intensity.
Collapse
Affiliation(s)
- Austin J Lee
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Xiang Liu
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Tudor Borza
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Yongmei Qin
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Y Li
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter S Kirk
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Scott Gilbert
- Department of Urology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Brent K Hollenbeck
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Jonathan E Helm
- W.P. Carey School of Business, Arizona State University, Tempe, Arizona
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Tempe, Arizona
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
48
|
Jiang J, Lee KM, Ji J. Review of anatomy-based ankle–foot robotics for mind, motor and motion recovery following stroke: design considerations and needs. INTERNATIONAL JOURNAL OF INTELLIGENT ROBOTICS AND APPLICATIONS 2018. [DOI: 10.1007/s41315-018-0065-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
49
|
Liu H, Lou VWQ. Functional recovery of older stroke patients discharged from hospital to home: The effects of cognitive status and different levels of therapy intensity. J Clin Nurs 2018; 28:47-55. [DOI: 10.1111/jocn.14617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Huiying Liu
- Department of Social Work & Social Administration; University of Hong Kong; Hong Kong China
| | - Vivian W. Q. Lou
- Department of Social Work & Social Administration; University of Hong Kong; Hong Kong China
- Sau Po Center on Ageing; The University of Hong Kong; Hong Kong China
| |
Collapse
|
50
|
Hershkovitz A, Brill S, Sulam LN, Luria T, Heller S. Stability of extracapsular hip fracture: Does it affect rehabilitation outcome of post-acute patients? Injury 2018; 49:1313-1318. [PMID: 29880226 DOI: 10.1016/j.injury.2018.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/13/2018] [Accepted: 05/24/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Various factors have been shown to affect rehabilitation outcome of hip fractured patients. The degree of extracapsular fracture stability may also affect functional recovery. The aim of our study was to assess the relationship between extracapsular hip fracture stability and rehabilitation outcome in a post-acute setting. METHODS A retrospective cohort study of 144 hip fractured patients was carried out in a post-acute geriatric rehabilitation center from 1/2014 to 6/2015. The main outcome measures were the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). The associations between patients with stable vs. unstable and clinical, demographic and comorbidity variables, were assessed by the Mann-Whitney U and chi-square tests. A multiple linear regression model was used to estimate the association between fracture stability and LOS score after controlling for sociodemographic characteristics and chronic diseases. RESULTS Rehabilitation outcomes (FIM and mFIM score changes, mFIM MRFS) were found independent of extracapsular hip fracture stability. Patients with an unstable fracture presented with a significantly longer LOS compared with a stable fracture (p = .008). Multiple linear regression analysis showed that fracture stability was significantly associated with LOS after adjustment for confounding demographic, clinical and functional variables (p = .009). CONCLUSION Patients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures.
Collapse
Affiliation(s)
- Avital Hershkovitz
- Department of Geriatrics, 'Beit Rivka' Geriatric Rehabilitation Center, Petach Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Shai Brill
- Department of Geriatrics, 'Beit Rivka' Geriatric Rehabilitation Center, Petach Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Lior Neuhaus Sulam
- Department of Geriatrics, 'Beit Rivka' Geriatric Rehabilitation Center, Petach Tikva, Israel
| | - Tal Luria
- Department of Orthopedic Surgery, Rabin Medical Center, Petach Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Snir Heller
- Department of Orthopedic Surgery, Rabin Medical Center, Petach Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| |
Collapse
|