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Chavez AA, Simmonds KP, Venkatachalam AM, Ifejika NL. Health Care Disparities in Stroke Rehabilitation. Phys Med Rehabil Clin N Am 2024; 35:293-303. [PMID: 38514219 DOI: 10.1016/j.pmr.2023.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.
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Affiliation(s)
- Audrie A Chavez
- Brain Injury Medicine Fellow, Spaulding Rehabilitation, Harvard University, Cambridge, MA, USA
| | - Kent P Simmonds
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA; Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Stop 9055, Dallas, TX 75390-9055, USA.
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Rothacher C, Liepert J. [Factors Modulating Motor Function Changes in Stroke Patients During Inpatient Neurological Rehabilitation]. DIE REHABILITATION 2024; 63:31-38. [PMID: 38335972 DOI: 10.1055/a-2204-3952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
PURPOSE To identify factors that have an impact on the degree of functional improvements in stroke patients during inpatient neurological rehabilitation. METHODS Retrospective analysis of 398 stroke patients who participated in an inpatient Phase C rehabilitation (Barthel index between 30 and 70 points). We correlated changes in 3 physiotherapeutic assessments (transfer from sitting to standing; transfer from bed to (wheel)chair; climbing stairs) and 3 occupational therapeutic assessments (eating/drinking; dressing of the upper part of the body; object manipulation) with the factors age, gender, Barthel-Index at admission, time since stroke, length of stay in inpatient rehab, number and extent of therapies and ischemic versus hemorrhagic stroke. In addition, a stepwise regression analysis was performed. RESULTS The patient group showed significant improvements in all assessments. Length of stay in inpatient rehab and number/extent of therapies correlated with improvements of transfer from sitting to standing, transfer from bed to (wheel)chair, climbing stairs, and dressing of the upper part of the body. Number/extent of therapies also correlated with eating/drinking. Barthel-Index at admission was negatively correlated with transfer from sitting to standing, transfer from bed to (wheel)chair, and dressing of the upper part of the body. No correlation between changes of motor functions and age or gender or type of stroke (ischemic versus hemorrhagic) was found. Patients<3 months after stroke showed stronger improvements of transfer from sitting to standing, transfer from bed to (wheel)chair, climbing stairs, dressing of the upper part of the body, and object manipulation than patients>6 months after stroke. However, patients<3 months after stroke also stayed 10 days longer in inpatient rehab. The stepwise regression analysis identified the number of physiotherapies and Barthel-Index at admission as the most important factors for changes in transfer from sitting to standing and transfer from bed to (wheel)chair, number of physiotherapies and time since stroke for climbing stairs, number of occupational therapies for eating/drinking, number of occupational therapies and time since stroke for dressing the upper part of the body and number of occupational therapies and length of inpatient rehab for object manipulation. CONCLUSION In stroke patients, a higher number of therapies is associated with greater improvements of motor functions. Age, gender and type of stroke have no relevant impact on changes of motor functions during inpatient rehabilitation.
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Gonçalves J, Filipe L, Van Houtven CH. Trajectories of Disability and Long-Term Care Utilization After Acute Health Events. J Aging Soc Policy 2023:1-24. [PMID: 37811807 DOI: 10.1080/08959420.2023.2267399] [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: 02/21/2023] [Accepted: 07/11/2023] [Indexed: 10/10/2023]
Abstract
Hip fractures, strokes, and heart attacks are common acute health events that can lead to long-term disability, care utilization, and unmet needs. However, such impacts, especially in the long term, are not fully understood. Using data from the Health and Retirement Study, 1992-2018, this study examines the long-term trajectories of individuals suffering such health shocks, comparing with individuals not experiencing health shocks. Hip fracture, stroke, and heart attack are confirmed to have severe implications for disability. In most cases of stroke and heart attack, informal caregivers provide the daily support needed by survivors, whereas following hip fracture, nursing home care is more relevant. These health shocks put individuals on worse trajectories of disability, care utilization, and unmet needs. There is no long-term recovery or convergence with individuals who do not suffer shocks. Unmet need is prevalent, even pre-shock and among individuals who do not experience health shocks, emphasizing the importance of preventative care measures. These findings support policy action to ensure hospitalized individuals, especially those aged 50 and above, receive rehabilitative services and other post-acute care. Furthermore, hospitalization is an event that requires the detection and addressing of unmet care needs beyond the short run.
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Affiliation(s)
- Judite Gonçalves
- School of Public Health, Imperial College London, London, UK
- NOVA School of Business and Economics, NOVA University Lisbon, Carcavelos, Portugal
- NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
| | - Luís Filipe
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
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Manchi MR, Venkatachalam AM, Atem FD, Stone S, Mathews AA, Abraham AM, Chavez AA, Welch BG, Ifejika NL. Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients. J Stroke Cerebrovasc Dis 2023; 32:107109. [PMID: 37031503 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107109] [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: 01/28/2023] [Revised: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 04/11/2023] Open
Abstract
OBJECTIVE To determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients. MATERIALS AND METHODS This prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days. RESULTS Among 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05). CONCLUSIONS In ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.
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Affiliation(s)
- Maunica R Manchi
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | | | - Folefac D Atem
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States
| | - Suzanne Stone
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Amy A Mathews
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | - Annie M Abraham
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | - Audrie A Chavez
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | - Babu G Welch
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States; Department of Neurology, University of Texas Southwestern Medical Center, DALLAS, TX, United States.
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Hayes HA, Mor V, Wei G, Presson A, McDonough C. Medicare Advantage Patterns of Poststroke Discharge to an Inpatient Rehabilitation or Skilled Nursing Facility: A Consideration of Demographic, Functional, and Payer Factors. Phys Ther 2023; 103:pzad009. [PMID: 37014280 PMCID: PMC10655208 DOI: 10.1093/ptj/pzad009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/19/2022] [Accepted: 12/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the factors influencing the discharge to an inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF) of people poststroke with Medicare Advantage plans. METHODS A retrospective cohort study was conducted with data from naviHealth, a company that manages postacute care discharge placement on behalf of Medicare Advantage organizations. The dependent variable was discharge destination (IRF or SNF). Variables included age, sex, prior living setting, functional status (Activity Measure for Post-Acute Care [AM-PAC]), acute hospital length of stay, comorbidities, and payers (health plans). Analysis estimated relative risk (RR) of discharge to SNF, while controlling for regional variation. RESULTS Individuals discharged to an SNF were older (RR = 1.17), women (RR = 1.05), lived at home alone or in assisted living (RR = 1.13 and 1.39, respectively), had comorbidities impacting their function "some" or "severely" (RR = 1.43 and 1.81, respectively), and had a length of stay greater than 5 days (RR = 1.16). Individuals with better AM-PAC Basic Mobility (RR = 0.95) went to an IRF, and individuals with better Daily Activity (RR = 1.01) scores went to an SNF. There was a substantial, significant variation in discharge of individuals to SNF by payer group (RR range = 1.12-1.92). CONCLUSIONS The results of this study show that individuals poststroke are more likely to be discharged to an SNF than to an IRF. This study did not find a different discharge decision-making picture for those with Medicare Advantage plans than previously described for other insurance programs. IMPACT Medicare Advantage payers have varied patterns in discharge placement to an IRF or SNF for patients poststroke.
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Affiliation(s)
- Heather A Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Providence Veteran’s Administration Medical Center, Providence, Rhode Island, USA
| | - Guo Wei
- Study Design and Biostatistics Center, University of Utah, Salt Lake City, Utah, USA
| | - Angela Presson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Christine McDonough
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Pattath P, Odom EC, Tong X, Yin X, Coleman King SM. A Comparison of Acute Ischemic Stroke Patients Discharged to Inpatient Rehabilitation vs a Skilled Nursing Facility: The Paul Coverdell National Acute Stroke Program. Arch Phys Med Rehabil 2023; 104:605-611. [PMID: 36521579 PMCID: PMC11015737 DOI: 10.1016/j.apmr.2022.11.008] [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: 08/12/2022] [Revised: 10/07/2022] [Accepted: 11/13/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare the sociodemographic, clinical, and hospital related factors associated with discharge of acute ischemic stroke (AIS) survivors to inpatient rehabilitation (IRF) and skilled nursing facility (SNF) rehabilitation services. DESIGN Retrospective descriptive study from the Paul Coverdell National Acute Stroke Program (PCNASP) participating hospitals during 2016 to 2019. SETTING 9 Participating states from PCNASP in United States. PARTICIPANTS 130,988 patients with AIS from 569 hospitals (N=337,857). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Discharge to IRF and SNF. RESULTS Patients discharged to a SNF had longer length of hospital stay, more comorbidities, and higher modified Rankin scores compared with patients discharged to an IRF. Nine characteristics were associated with being less likely to be discharged to an IRF than an SNF: older age (85+ years old, adjusted odds ratio [AOR]=0.20 [confidence interval [CI]=0.18-0.21]), identifying as non-Hispanic Black (AOR=0.85 [CI=0.81-0.89]), identifying as Hispanic (AOR=0.80 [CI=0.74-0.87]), having Medicaid or Medicare (AOR=0.73 [CI=0.70-0.77]), being able to ambulate with assistance from another person (AOR=0.93 [CI=0.89-0.97]), being unable to ambulate (AOR=0.73 [CI=0.62-0.87]) and having comorbidities, prior stroke (AOR=0.69 [CI=0.66-0.73]), diabetes (AOR=0.85 [CI=0.82-0.88]), and myocardial infraction or coronary artery disease (AOR=0.94 [CI=0.90-0.97]). Four characteristics were associated with being more likely to be discharged to an IRF than an SNF: being a man (AOR=1.20 [CI=1.16-1.24]), and having a slight disability (Rankin Score 2) (AOR=1.41 [CI=1.29-1.54]), being at larger hospitals (200-399 beds: AOR=1.31 [CI=1.23-1.40]; 400+ beds: AOR=1.29 [CI=1.20-1.38]), and being at a hospital with stroke unit (AOR=1.12 [CI=1.07-1.17]). CONCLUSION This study found differences in demographic, clinical, and hospital characteristics of AIS patients discharged for rehabilitation to an IRF vs SNF. The characteristics of patients receiving rehabilitation services may be helpful for researchers and hospitals making policies related to stroke discharge and practices that optimize patient outcomes. Populations experiencing inequities in access to rehabilitation services should be identified, and those who qualify for rehabilitation in IRF should receive this care in preference to rehabilitation in SNF.
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Affiliation(s)
- Priyadarshini Pattath
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States; Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States; United States Public Health Service, Atlanta, GA, United States.
| | - Xin Tong
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Xiaoping Yin
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sallyann M Coleman King
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States; United States Public Health Service, Atlanta, GA, United States
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A Unified Model for Stroke Recovery and Rehabilitation: Why Now? Am J Phys Med Rehabil 2023; 102:S3-S9. [PMID: 36634323 DOI: 10.1097/phm.0000000000002141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
ABSTRACT The current model of stroke care delivery in the United States and in many parts of the world is fragmented, resulting in lack of continuity of care, inability to track recovery meaningfully across the continuum, and lack of access to the frequency, intensity, and duration of high-quality rehabilitation necessary to optimally harness recovery processes. The process of recovery itself has been overshadowed by a focus on length of stay and the movement of patients across levels of care. Here, we describe the rationale behind the recent efforts at the Johns Hopkins Sheikh Khalifa Stroke Institute to define and coordinate an intensive, strategic effort to develop effective stroke systems of care across the continuum through the development of a unified Sheikh Khalifa Stroke Institute model of recovery and rehabilitation.
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Hayes HA, Marcus R, Stoddard GJ, McFadden M, Magel J, Hess R. Is the Activity Measure for Postacute Care "6-Clicks" Tool Associated With Discharge Destination Postacute Stroke? Arch Rehabil Res Clin Transl 2022; 4:100228. [PMID: 36545521 PMCID: PMC9761263 DOI: 10.1016/j.arrct.2022.100228] [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] [Indexed: 12/24/2022] Open
Abstract
Objective To investigate the association of poststroke physical function, measured within 24 hours prior to discharge from the acute care hospital using Activity Measure for Postacute Care (AM-PAC) Inpatient "6-Clicks" scores and discharge destination (home vs facility and inpatient rehabilitation facility [IRF] vs skilled nursing facility [SNF]). Design Retrospective cross-sectional cohort study. Setting Acute care, University Hospital. Participants Individuals post acute ischemic stroke, N=721, 51.3% male, mean age 63.6±16.4 years. Interventions Not applicable. Main Outcome Measures AM-PAC "6-Clicks" 3 domains: basic mobility, daily activity, and applied cognition. Results AM-PAC basic mobility and daily activity were significant predictors of discharge. Those in the home discharge group had AM-PAC basic mobility mean t scale score of 48.5 compared with a score of 34.8 for individuals sent to a facility and daily activity score of 47.2 compared with 32.7 for individuals sent to a facility. The AM-PAC variables accounted for an additional 24% of the variance in the discharge destination, with basic mobility and daily activity accounting for most of the variance.The AM-PAC scores were not statistically different and were not able to discriminate between placement in an IRF vs SNF. The mean basic mobility t scale score for individuals going to an IRF was 34.9 compared with 34.6 for those going to an SNF. The daily activity score for IRF was 32.8 compared with 32.6 for SNF. The AM-PAC accounted for no additional variance in discharge destination to an IRF or SNF. Conclusions The AM-PAC Inpatient "6-Clicks" 3 domains are able to distinguish individuals with stroke being discharged to home from postacute care (PAC) but not for differentiating between PAC facilities (IRF vs SNF) in this cohort of individuals post stroke.
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Affiliation(s)
- Heather Anne Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Robin Marcus
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | | | - Molly McFadden
- Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Jake Magel
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Rachel Hess
- Division of Health System Innovation and Research, University of Utah, Salt Lake City, UT
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Koumo M, Goda A, Maki Y, Yokoyama K, Yamamoto T, Hosokawa T, Ishibashi R, Katsura J, Yanagibashi K. Clinical Items for Geriatric Patients with Post-Stroke at Discharge or Transfer after Rehabilitation Therapy in a Chronic-Phase Hospital: A Retrospective Pilot Study. Healthcare (Basel) 2022; 10:healthcare10081577. [PMID: 36011234 PMCID: PMC9408440 DOI: 10.3390/healthcare10081577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 12/02/2022] Open
Abstract
Clinical factors related to destination after rehabilitation therapy for geriatric patients with post-stroke in chronic-phase hospitals have not been elucidated. This study analyzed the clinical characteristics of geriatric patients with post-stroke at discharge/transfer after rehabilitation therapy in a chronic-phase hospital. Fifty-three patients (20 men, 33 women; mean age 81.36 ± 8.14 years) were recruited (the period analyzed: October 2013−March 2020). Clinical data were statistically analyzed among patients discharged to homes or facilities for older adults or transferred to another hospital. In addition, we analyzed the clinical items at discharge and transfer after rehabilitation therapy using a decision tree analysis. Twelve patients were discharged, eighteen were discharged to facilities for older adults, and twenty-three were transferred to another hospital. There were significant differences in the modified Rankin Scale, admission dates, functional independence measure (FIM) score, and Barthel Index score in the three groups (p < 0.05). Patients with motor subtotal functional independence scores of ≥14 (chronologically improved ≥5) after rehabilitation therapy for <291 days were more likely to be discharged home. Patients in a chronic-phase hospital who improved within a limited period were discharged to their homes, whereas those who were bedridden tended to be transferred to another hospital.
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Affiliation(s)
- Masatoshi Koumo
- Department of Rehabilitation, Hikari Hospital, Otsu 520-0002, Japan
| | - Akio Goda
- Department of Physical Therapy, Faculty of Health Sciences, Kyoto Tachibana University, Kyoto 607-8175, Japan
- Correspondence: ; Tel.: +81-(0)75-574-4313
| | - Yoshinori Maki
- Department of Rehabilitation, Hikari Hospital, Otsu 520-0002, Japan
- Department of Neurosurgery, Hikone Chuo Hospital, Hikone 522-0054, Japan
| | - Kouta Yokoyama
- Department of Rehabilitation, Hikari Hospital, Otsu 520-0002, Japan
| | - Tetsuya Yamamoto
- Department of Rehabilitation, Hikari Hospital, Otsu 520-0002, Japan
| | - Tsumugi Hosokawa
- Department of Rehabilitation, Hikari Hospital, Otsu 520-0002, Japan
| | - Ryota Ishibashi
- Department of Neurosurgery, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka 530-0025, Japan
| | - Junichi Katsura
- Department of Rehabilitation, Hikari Hospital, Otsu 520-0002, Japan
| | - Ken Yanagibashi
- Department of Rehabilitation, Hikari Hospital, Otsu 520-0002, Japan
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Casertano LO, Bassile CC, Pfeffer JS, Morrone TM, Stein J, Willey JZ, Rao AK. Utility of the AM-PAC "6 Clicks" Basic Mobility and Daily Activity Short Forms to Determine Discharge Destination in an Acute Stroke Population. Am J Occup Ther 2022; 76:23318. [PMID: 35771733 DOI: 10.5014/ajot.2022.047381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE The American Heart Association and American Stroke Association recommend early identification of level of rehabilitative care as a priority after stroke. OBJECTIVE To evaluate the utility of the Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" Daily Activity and Basic Mobility forms to determine the next level of rehabilitation after hospitalization for adults with stroke. DESIGN Retrospective cohort design using medical records from 2015 to 2016. SETTING Major urban hospital. PARTICIPANTS Patients admitted to the stroke service, with a confirmed stroke, who were seen by a physical or occupational therapist; who had a 6 Clicks Basic Mobility or Daily Activity score at initial evaluation; and who were discharged to home, an acute inpatient rehabilitation facility (IRF), or a subacute skilled nursing facility (SNF). OUTCOMES AND MEASURES Length of stay and discharge destination. RESULTS Seven hundred four participants (M age = 68.28 yr; 51.21% female) were included. Analysis of variance and receiver operating characteristic curves were performed. Daily Activity scores were highest for home discharge, lower for IRF discharge, and lowest for SNF discharge; Basic Mobility showed a similar pattern. Cutoff values distinguishing home from further inpatient rehabilitation were 44.50 for Basic Mobility and 39.40 for Daily Activity scores (area under the curve [AUC] = .82 for both forms), with scores of 34.59 (AUC = 0.64) and 31.32 (AUC = 0.67) separating IRF from SNF, respectively. CONCLUSIONS AND RELEVANCE Therapists should incorporate 6 Clicks scores into their discharge planning. What This Article Adds: This research demonstrates the utility of an outcome measure in the acute care setting that assists in planning discharge destination for patients with stroke.
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Affiliation(s)
- Lorenzo O Casertano
- Lorenzo O. Casertano, PT, DPT, NCS, is Advanced Clinician-Acute Care Neurology, Department of Physical Therapy, New York-Presbyterian Hospital, New York, NY;
| | - Clare C Bassile
- Clare C. Bassile, PT, EdD, is Associate Professor, Program in Physical Therapy, Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center, New York, NY
| | - Jacqueline S Pfeffer
- Jacqueline S. Pfeffer, PT, MPH, is Compliance Coordinator, Department of Physical Therapy, New York-Presbyterian Hospital, New York, NY
| | - Theresa M Morrone
- Theresa M. Morrone, PT, MS, CCS, passed away during the process of resubmission. At the time of the study, Morrone was Director, Department of Physical Therapy, New York-Presbyterian Hospital, New York, NY
| | - Joel Stein
- Joel Stein, MD, is Professor and Chair, Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, and Chief, Department of Rehabilitation Medicine, New York-Presbyterian Hospital, New York, NY
| | - Joshua Z Willey
- Joshua Z. Willey, MD, MS, is Assistant Attending and Associate Professor of Neurology, Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Ashwini K Rao
- Ashwini K. Rao, OTR, EdD, FAOTA, is Professor, Program in Physical Therapy, Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center, New York, NY
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11
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Kinney AR, Graham JE, Middleton A, Edelstein J, Wyrwa J, Malcolm MP. Mobility status and acute care physical therapy utilization: The Moderating roles of age, significant others, and insurance type. Arch Phys Med Rehabil 2022; 103:1600-1606.e1. [PMID: 35007549 DOI: 10.1016/j.apmr.2021.12.013] [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: 04/12/2021] [Revised: 11/03/2021] [Accepted: 12/16/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To investigate whether a direct measure of need for PT, mobility status, was associated with acute care PT utilization and whether this relationship differs across sociodemographic factors and insurance type. DESIGN In a secondary analysis of electronic health records data, we estimated logistic regression models to determine whether mobility status was associated with acute care PT utilization. Interactions between mobility and both sociodemographic factors (sex; age; significant other; minority status) and insurance type were included to investigate whether the relationship between mobility and PT utilization varied across patient characteristics. SETTING Five regional hospitals from one health system. PARTICIPANTS 60,459 adults admitted between 2014 and 2018 who received a PT evaluation. INTERVENTIONS None. MAIN OUTCOME MEASURE(S) Received acute care PT; Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measure of mobility. RESULTS Half of patients who received a PT evaluation received subsequent treatment. Patients with mobility limitations were more likely to receive PT. Interaction terms indicated that among patients with mobility limitations, those who 1) were younger; 2) had significant others; and 3) had private insurance (vs. public) were more likely to receive PT. Among patients with greater mobility status, older patients and those without a significant other were more likely to receive PT. CONCLUSIONS The relationship between acute care PT need and utilization differed across sociodemographic factors and insurance type. We offer potential explanations for these findings to guide studies targeting equitable distribution of beneficial PT services.
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Affiliation(s)
- Adam R Kinney
- Rocky Mountain Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Aurora, Colorado; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - James E Graham
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO
| | - Addie Middleton
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA
| | - Jessica Edelstein
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO
| | - Jordan Wyrwa
- UCHealth, University of Colorado Hospital, Anschutz Medical Campus, Aurora, Colorado
| | - Matt P Malcolm
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO; Colorado School of Public Health, Colorado State University, Fort Collins, CO
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Malcolm MP, Kinney AR, Graham JE. Predicting Community Discharge for Occupational Therapy Recipients in the Neurological Critical Care Unit. Am J Occup Ther 2022; 76:23111. [PMID: 34935915 DOI: 10.5014/ajot.2022.045450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Occupational therapy in the neurological critical care unit (NCCU) may enable safe community discharge by restoring functional ability. However, the influence of patient characteristics and NCCU occupational therapy on discharge disposition is largely unknown. OBJECTIVE To examine how patient factors and receipt of occupational therapy predict discharge disposition for NCCU patients. DESIGN Retrospective cross-sectional cohort study of electronic health records data from adults admitted to the NCCU between May 2013 and September 30, 2015. SETTING NCCU in a large urban academic hospital. PARTICIPANTS Adults age 18 yr or older (N = 1,134) admitted to the NCCU. Outcomes and Measures: Using logistic regression with discharge disposition as the dependent variable, we entered sex, age, length of stay (LOS), baseline Glasgow Coma Scale score, Elixhauser Comorbidity Index, and receipt of occupational therapy services as predictor variables. RESULTS Of NCCU patients, 39% received occupational therapy. Younger age, shorter LOS, lower comorbidity burden, and not receiving occupational therapy services increased the likelihood of discharge to the community. Men who received occupational therapy were less likely to be discharged to the community than men who did not receive occupational therapy. As age increased, differences in the probability of community discharge decreased between recipients and nonrecipients of occupational therapy services. CONCLUSIONS AND RELEVANCE Our results suggest that patients receiving occupational therapy services in the NCCU may have a lower likelihood of community discharge. However, these findings may result from therapist's consideration of the safest discharge location to ensure the greatest balance between independence and support. What This Article Adds: This study's findings suggest that receipt of occupational therapy in the NCCU is associated with higher likelihood for noncommunity discharge (i.e., to inpatient rehabilitation, skilled nursing, or long-term care). However, activity limitations and comorbidity burden may be greater for recipients of occupational therapy, and these NCCU patients are presumably less prepared for community discharge.
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Affiliation(s)
- Matt P Malcolm
- Matt P. Malcolm, PhD, OTR/L, is Associate Professor, Department of Occupational Therapy, Colorado State University, Fort Collins, and Associate Professor, Colorado School of Public Health, Aurora;
| | - Adam R Kinney
- Adam R. Kinney, PhD, OTR/L, is Research Health Science Specialist, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, U.S. Department of Veterans Affairs, Aurora, CO, and Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora
| | - James E Graham
- James E. Graham, PhD, DC, FACRM, is Professor, Department of Occupational Therapy, Colorado State University, Fort Collins
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Stein J, Rodstein BM, Levine SR, Cheung K, Sicklick A, Silver B, Hedeman R, Egan A, Borg-Jensen P, Magdon-Ismail Z. Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study. Stroke 2021; 53:947-955. [PMID: 34706561 DOI: 10.1161/strokeaha.121.034815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients. METHODS We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies. RESULTS In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%). CONCLUSIONS This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.
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Affiliation(s)
- Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, NY (J.S.).,Department of Rehabilitation Medicine, Weill Cornell Medical College, NY (J.S.).,NewYork-Presbyterian Hospital, NY (J.S.)
| | - Barry M Rodstein
- University of Massachusetts Medical School-Baystate Health, Springfield (B.M.R.)
| | - Steven R Levine
- Departments of Neurology and Emergency Medicine, and Stroke Center, SUNY Downstate Health Sciences University, Brooklyn, NY (S.R.L.).,Department of Neurology, Kings County Hospital Center, Brooklyn, NY (S.R.L.).,Jaffe Stroke Center and Department of Neurology, Maimonides Medical Center, Brooklyn, NY (S.R.L.)
| | - Ken Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, NY (K.C.)
| | | | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester (B.S.)
| | | | - Abigail Egan
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.)
| | - Pamela Borg-Jensen
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.)
| | - Zainab Magdon-Ismail
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.).,Capital District Physician's Health Plan, Albany NY (Z.M.-I.)
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14
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Simmonds KP, Burke J, Kozlowski AJ, Andary M, Luo Z, Reeves MJ. Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities. Arch Phys Med Rehabil 2021; 103:1213-1221. [PMID: 34480886 DOI: 10.1016/j.apmr.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Abstract
In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.
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Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - James Burke
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Allan J Kozlowski
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI
| | - Michael Andary
- Department of Physical Medicine & Rehabilitation, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI.
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Vázquez-Guimaraens M, Caamaño-Ponte JL, Seoane-Pillado T, Cudeiro J. Factors Related to Greater Functional Recovery after Suffering a Stroke. Brain Sci 2021; 11:brainsci11060802. [PMID: 34204420 PMCID: PMC8234682 DOI: 10.3390/brainsci11060802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022] Open
Abstract
Background: In a stroke, the importance of initial functional status is fundamental for prognosis. The aim of the current study was to investigate functional status, assessed by the Functional Independence Measure (FIM) scale, and possible predictors of functional outcome at discharge from inpatient rehabilitation. Methods: This is a retrospective study that was carried out at the Physical Medicine and Rehabilitation Service in A Coruña (Spain). A total of 365 consecutive patients with primary diagnosis of stroke were enrolled. The functional assessments of all patients were performed through the FIM. A descriptive and a bivariate analysis of the variables included in the study was made and a succession of linear regression models was used to determine which variables were associated with the total FIM at discharge. Results: Prior to having the stroke, 76.7% were totally independent in activities of daily living. The FIM scale score was 52.5 ± 25.5 points at admission and 83.4 ± 26.3 at hospital discharge. The multivariate analysis showed that FIM scores on admission were the most important predictors of FIM outcomes. Conclusions: Our study indicates that the degree of independence prior to admission after suffering a stroke is the factor that will determine the functionality of patients at hospital discharge.
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Affiliation(s)
- María Vázquez-Guimaraens
- Hospital Universitario de A Coruña, Servizo Galego de Saúde, 15009 A Coruña, Spain
- Correspondence:
| | - José L. Caamaño-Ponte
- CTX a Veiga (Láncara), 27360 Lugo, Spain;
- Universitat Oberta de Catalunya, 08018 Barcelona, Spain
| | - Teresa Seoane-Pillado
- Área de Medicina Preventiva y Salud Pública, Departamento de Ciencias de la Salud, Universidad de A Coruña–INIBIC, 15403 A Coruña, Spain;
| | - Javier Cudeiro
- Neuroscience and Motor Control Group (NEUROcom)-Instituto Biomédico de A Coruña (INIBIC), Universidad de A Coruña, 15006 Oza, Spain;
- Centro de Estimulación Cerebral de Galicia, 15009 A Coruña, Spain
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16
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Impacts of stroke and cognitive impairment on activities of daily living in the Taiwan longitudinal study on aging. Sci Rep 2021; 11:12199. [PMID: 34108582 PMCID: PMC8190118 DOI: 10.1038/s41598-021-91838-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/26/2021] [Indexed: 11/14/2022] Open
Abstract
Stroke and cognitive impairment are common in older population. They often occur together and their combined effects significantly increase disability in both basic (BADLs) and instrumental (IADLs) activities of daily living. We investigated the individual and combined impacts of stroke and cognitive impairment on BADLs and IADLs. A total of 3331 community-dwelling older adults were enrolled from the Taiwan longitudinal study on aging in 2011. Both BADLs and IADLs were analyzed. Combination of stroke and cognitive impairment increased severity of ADL disabilities, but similar prevalence, similar numbers of summed BADL and IADL tasks with disability, and similar levels of difficulty for each BADL and IADL task were found between the stroke group and cognitive impairment group. The former had more difficult in dressing while the latter had more difficult in using the telephone, transport, and managing finances. A hierarchy of ADLs was also observed in all groups. ADL skill training supplemented with cognitive and physical interventions should focus on secondary prevention of dementia and improve motor functional capacity to reduce loss of ADLs.
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Most Important Factors for Deciding Rehabilitation Provision for Severe Stroke Survivors Post Hospital Discharge: A Study Protocol for a Best-Worst Scaling Experiment. Methods Protoc 2021; 4:mps4020027. [PMID: 34066439 PMCID: PMC8163167 DOI: 10.3390/mps4020027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 11/24/2022] Open
Abstract
Efficient decision-making is crucial to ensure adequate rehabilitation with optimal use of healthcare resources. Establishing the factors associated with making decisions concerning rehabilitation provision is important to guide clinical staff towards person-centred decisions for rehabilitation after severe stroke. In this study we conduct a best–worst scaling (BWS) experiment to identify the most important factors and their relative weight of importance for deciding the type of ongoing rehabilitation services a person with severe stroke might receive post hospital discharge. Fractional, efficient designs are applied regarding the survey design. Key multidisciplinary staff regularly involved in making decisions for rehabilitation in a stroke unit will be recruited to participate in an online BWS survey. Hierarchical Bayes estimation will be used as the main analysis method, with the best–worst count analysis as a secondary analysis. The survey is currently being piloted prior to commencing the process of data collection. Results are expected by the end of September 2021. The research will add to the current literature on clinical decision-making in stroke rehabilitation. Findings will quantify the preferences of factors among key multi-disciplinary clinicians working in stroke units in the UK, involved in decision-making concerning rehabilitation after stroke.
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Simmonds KP, Luo Z, Reeves M. Race/Ethnic and Stroke Subtype Differences in Poststroke Functional Recovery After Acute Rehabilitation. Arch Phys Med Rehabil 2021; 102:1473-1481. [PMID: 33684363 DOI: 10.1016/j.apmr.2021.01.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Significant racial/ethnic disparities in poststroke function exist, but whether these disparities vary by stroke subtype is unknown. Study goals were to (1) determine if racial/ethnic disparities in the recovery of poststroke function varied by stroke subtype and (2) identify confounding factors associated with these racial/ethnic disparities. DESIGN Secondary analysis of the 1-year Stroke Recovery in Underserved Populations Cohort Study. SETTING Eleven inpatient rehabilitation facilities (IRFs) across the United States. PARTICIPANTS A total of 1066 patients (n=868 with ischemic stroke and n=198 with hemorrhagic stroke, N=1066) who self-identified as White (n=813), Black (n=183), or Hispanic (n=70). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM scores at IRF admission, discharge, 3 months, and 12 months were modeled using multivariable mixed effects longitudinal regression. RESULTS Compared with White patients, Black (-6.1 and -4.6) and Hispanic (-10.1 and -9.9) patients had significantly lower FIM scores at 3 and 12 months, respectively. A significant (P<.01) 3-way interaction (race/ethnic*subtype*time) indicated that disparities varied by stroke subtype. The stroke subtype differences were most prominent for Black-White disparities because disparities in hemorrhagic stroke were present at IRF admission (vs 3 months for ischemic stroke). Additionally, at 12 months, the magnitude of Black-White disparities was over 3 times larger for hemorrhagic stroke (-10.4) than ischemic stroke (-3.1). Age primarily influenced Black-White disparities (especially for hemorrhagic stroke), but factors that influenced Hispanic-White disparities were not identified. Sensitivity analyses showed that there were stroke subtype differences in racial/ethnic disparities for cognitive (but not motor) function, and results were robust to adjustments for missing data because of attrition. CONCLUSIONS There are significant differences between stroke subtypes in the timing and magnitude of Black-White disparities in poststroke function. Age was a major confounding factor for Black-White disparities (particularly for hemorrhagic stroke). Overall, Hispanic patients had the lowest levels of poststroke function, and more work is needed to identify significant factors that influence Hispanic-White disparities.
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Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; DO/PhD Program, College of Osteopathic Medicine, Michigan State University, East Lansing, MI.
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
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The Relationship Between Fall Risk and Hospital-Based Therapy Utilization Is Moderated by Demographic Characteristics and Insurance Type. Arch Phys Med Rehabil 2020; 102:1124-1133. [PMID: 33373599 DOI: 10.1016/j.apmr.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate whether indicators of patient need (comorbidity burden, fall risk) predict acute care rehabilitation utilization, and whether this relation varies across patient characteristics (ie, demographic characteristics, insurance type). DESIGN Secondary analysis of electronic health records data. SETTING Five acute care hospitals. PARTICIPANTS Adults (N=110,209) admitted to 5 regional hospitals between 2014 and 2018. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Occupational therapy (OT) and physical therapy (PT) utilization. Logistic regression models determined whether indicators of patient need predicted OT and PT utilization. Interactions between indicators of need and both demographic factors (eg, minority status, presence of significant other) and insurance type were included to investigate whether the relation between patient need and therapy access varied across patient characteristics. RESULTS Greater comorbidity burden was associated with a higher likelihood of receiving OT and PT. Relative to those with low fall risk, those with moderate and high fall risk were more likely to receive OT and PT. The relation between fall risk and therapy utilization differed across patient characteristics. Among patients with higher levels of fall risk, those with a significant other were less likely to receive OT and PT; significant other status did not explain therapy utilization among patients with low fall risk. Among those with high fall risk, patients with VA insurance and minority patients were more likely to receive PT than those with private insurance and nonminority patients, respectively. Insurance type and minority status did not appear to explain PT utilization among those with lower fall risk. CONCLUSIONS Patients with greater comorbidity burden and fall risk were more likely to receive acute care rehabilitation. However, the relation between fall risk and utilization was moderated by insurance type, having a significant other, and race/ethnicity. Understanding the implications of these utilization patterns requires further research.
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20
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Pelisch N, Rosas Almanza J, Stehlik KE, Aperi BV, Kroner A. CCL3 contributes to secondary damage after spinal cord injury. J Neuroinflammation 2020; 17:362. [PMID: 33246483 PMCID: PMC7694914 DOI: 10.1186/s12974-020-02037-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/17/2020] [Indexed: 12/19/2022] Open
Abstract
Background Secondary damage after spinal cord injury (SCI) is characterized by a cascade of events including hemorrhage, apoptosis, oxidative stress, and inflammation which increase the lesion size which can influence the functional impairment. Thus, identifying specific mechanisms attributed to secondary injury is critical in minimizing tissue damage and improving neurological outcome. In this work, we are investigating the role of CCL3 (macrophage inflammatory protein 1-α, MIP-1α), a chemokine involved in the recruitment of inflammatory cells, which plays an important role in inflammatory conditions of the central and peripheral nervous system. Methods A mouse model of lower thoracic (T11) spinal cord contusion injury was used. We assessed expression levels of CCL3 and its receptors on the mRNA and protein level and analyzed changes in locomotor recovery and the inflammatory response in the injured spinal cord of wild-type and CCL3−/− mice. Results The expression of CCL3 and its receptors was increased after thoracic contusion SCI in mice. We then examined the role of CCL3 after SCI and its direct influence on the inflammatory response, locomotor recovery and lesion size using CCL3−/− mice. CCL3−/− mice showed mild but significant improvement of locomotor recovery, a smaller lesion size and reduced neuronal damage compared to wild-type controls. In addition, neutrophil numbers as well as the pro-inflammatory cytokines and chemokines, known to play a deleterious role after SCI, were markedly reduced in the absence of CCL3. Conclusion We have identified CCL3 as a potential target to modulate the inflammatory response and secondary damage after SCI. Collectively, this study shows that CCL3 contributes to progressive tissue damage and functional impairment during secondary injury after SCI. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-020-02037-3.
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Affiliation(s)
- Nicolas Pelisch
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, 53295, USA
| | - Jose Rosas Almanza
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, 53295, USA
| | - Kyle E Stehlik
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, 53295, USA
| | - Brandy V Aperi
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, 53295, USA
| | - Antje Kroner
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, 53226, USA. .,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, 53295, USA. .,Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.
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Young DL, Colantuoni E, Friedman LA, Seltzer J, Daley K, Ye B, Brotman DJ, Hoyer EH. Prediction of Disposition Within 48 Hours of Hospital Admission Using Patient Mobility Scores. J Hosp Med 2020; 15:540-543. [PMID: 31869298 DOI: 10.12788/jhm.3332] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022]
Abstract
Delayed hospital discharges for patients needing rehabilitation in a postacute setting can exacerbate hospital-acquired mobility loss, prolong functional recovery, and increase costs. Systematic measurement of patient mobility by nurses early during hospitalization has the potential to help identify which patients are likely to be discharged to a postacute care facility versus home. To test the predictive ability of this approach, a machine learning classification tree method was applied retrospectively to a diverse sample of hospitalized patients (N = 761) using training and validation sets. Compared with patients discharged to home, patients discharged to a postacute facility were older (median, 64 vs 56 years old) and had lower mobility scores at hospital admission (median, 32 vs 41). The final decision tree accurately classified the discharge location for 73% (95% CI, 67%-78%) of patients. This study emphasizes the value of systematically measuring mobility in the hospital and provides a simple decision tree to facilitate early discharge planning.
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Affiliation(s)
- Daniel L Young
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Department of Physical Therapy, University of Nevada Las Vegas, Las Vegas, Nevada
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa Aronson Friedman
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jason Seltzer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Kelly Daley
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Bingqing Ye
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Daniel J Brotman
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
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22
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Stein J, Borg-Jensen P, Sicklick A, Rodstein BM, Hedeman R, Bettger JP, Hemmitt R, Silver BM, Thode HC, Magdon-Ismail Z. Are Stroke Survivors Discharged to the Recommended Postacute Setting? Arch Phys Med Rehabil 2020; 101:1190-1198. [PMID: 32272107 DOI: 10.1016/j.apmr.2020.03.006] [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] [Received: 01/07/2020] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine the processes and barriers involved in providing postdischarge stroke care. DESIGN Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination. SETTING Twenty-three hospitals in the northeastern United States. PARTICIPANTS After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. INTERVENTIONS None. MAIN OUTCOME MEASURES Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. RESULTS In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). CONCLUSIONS Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.
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Affiliation(s)
- Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, New York, New York.
| | - Pamela Borg-Jensen
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
| | | | | | | | - Janet Prvu Bettger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Roseanne Hemmitt
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
| | - Brian M Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Henry C Thode
- Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Zainab Magdon-Ismail
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
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Kubo K, Kamo T, Momosaki R, Mitsutomi K. Development of a Point System to Predict Discharge to Home for Acute Stroke Patients. PM R 2020; 13:38-44. [PMID: 32248651 DOI: 10.1002/pmrj.12371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/25/2020] [Accepted: 03/20/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND While in an acute hospital setting, it is challenging for clinicians to make discharge decisions due to the multifactorial process and individual patient characteristics. OBJECTIVE To evaluate and develop a scoring system utilizing the Japan Rehabilitation Database (JRD) to identify acute stroke patients with a high possibility of discharge to home. DESIGN Retrospective observational cohort study. SETTING Thirty-seven acute hospitals in Japan. PARTICIPANTS A total of 10 270 patients admitted to the acute hospitals with stroke were identified. The inclusion criteria were (1) admission within 3 days of onset and (2) admission from home. Exclusion criteria were (1) incomplete data and (2) death in hospital. A total of 4216 patients were included in the study. INTERVENTION Not applicable. MAIN OUTCOME MEASUREMENTS Discharge destination from acute care hospital, that is, home versus other locations. RESULTS In the multivariate logistic regression, age, stroke type, Barthel Index on admission, modified Rankin scale on admission, the National Institutes of Health Stroke Scale on admission, and extent of paralysis were retained. When the cutoff point was 33, the scoring system showed a sensitivity of 80.4% and specificity of 80.3%. The area under curve (AUC) was 0.88. On evaluating the predictive performance, the model showed a sensitivity of 78.2% and a specificity of 78.5% with an AUC = 0.86. CONCLUSIONS We developed a point system to identify acute stroke patients with a high possibility of discharge to home using the JRD. This point system may provide useful information for clinicians to plan the discharge of acute stroke patients.
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Affiliation(s)
- Kosei Kubo
- Department of Rehabilitation Medicine, Iwata City Hospital, Iwata City, Japan
| | - Tomohiko Kamo
- Department of Physical Therapy, School of Health Sciences, Japan University of Health Sciences, Satte City, Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Teikyo University School of Medicine Hospital Mizonokuchi, Kawasaki City, Japan
| | - Kazuhiko Mitsutomi
- Department of Rehabilitation Medicine, Iwata City Hospital, Iwata City, Japan
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Exploring discharge destination following severe stroke. BRAIN IMPAIR 2020. [DOI: 10.1017/brimp.2020.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Patients with severe stroke frequently present with substantial impairments but are often not prioritised for post-discharge rehabilitation. There is a need to determine where these patients are discharged to in order to facilitate appropriate allocation of post-discharge pathway resources.Aim:The present study aimed to describe the discharge pathways of patients with severe stroke and to identify predictors of discharge destination for these patients.Method:A descriptive, retrospective design was utilised to determine the discharge destination for 770 patients with severe stroke in Queensland, Australia. Binomial logistic regression was used to determine the variables that predicted discharge destination.Results:The results indicated that 58.44% of patients were discharged home (n = 450). Age, length of stay, discharge ward and geographical region emerged as significant predictors of discharge destination. The full model containing all predictors was statistically significant and, as a whole, explained 36.50% of the variance in discharge destination.Conclusion:These results highlight the importance of these variables in influencing the outcomes of patients with severe stroke, which may assist post-hospital discharge services in allocating resources for patients with severe stroke.
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Abstract
Activities of daily living (ADLs) is an important measure of the quality of care provided in home healthcare (HHC), but few studies describe the ADLs of HHC patients. The objectives of this study were to (1) describe the types and levels of ADL dependency among patients receiving home care, (2) identify the risk factors for severe ADL dependency at admission, and (3) identify the predictors of ADL improvement during an HHC stay. This was a secondary data analysis of a 5% random sample (n = 105,654) of the national Outcome and Assessment Information Set (OASIS-C) for the year 2013. The dependent variables were severe ADL dependency level at admission and ADL improvement from admission to discharge. About two thirds (65%) of the patients (n = 99,991) had severe ADL dependency (dependence in seven or more ADLs) at admission. Older age, female gender, and impaired decision-making were associated with severe ADL dependency on admission. Of the 105,654 patients, 58.1% (n = 89,997) experienced ADL improvement. ADL improvement was associated with increasing HHC length of stay, being female, and prior inpatient stay. Clinicians, policy makers, and agencies could focus on modifiable characteristics to achieve the goal of ADL improvement.
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26
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Labberton AS, Barra M, Rønning OM, Thommessen B, Churilov L, Cadilhac DA, Lynch EA. Patient and service factors associated with referral and admission to inpatient rehabilitation after the acute phase of stroke in Australia and Norway. BMC Health Serv Res 2019; 19:871. [PMID: 31752874 PMCID: PMC6873491 DOI: 10.1186/s12913-019-4713-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background Unequal access to inpatient rehabilitation after stroke has been reported. We sought to identify and compare patient and service factors associated with referral and admission to an inpatient rehabilitation facility (IRF) after acute hospital care for stroke in two countries with publicly-funded healthcare. Methods We compared two cohorts of stroke patients admitted consecutively to eight acute public hospitals in Australia in 2013–2014 (n = 553), and to one large university hospital in Norway in 2012–2013 (n = 723). Outcomes were: referral to an IRF; admission to an IRF if referred. Logistic regression models were used to identify and compare factors associated with each outcome. Results Participants were similar in both cohorts: mean age 73 years, 40–44% female, 12–13% intracerebral haemorrhage, ~ 77% mild stroke (National Institutes of Health Stroke Scale < 8). Services received during the acute admission differed (Australia vs. Norway): stroke unit treatment 82% vs. 97%, physiotherapy 93% vs. 79%, occupational therapy 83% vs. 77%, speech therapy 78% vs. 13%. Proportions referred to an IRF were: 48% (Australia) and 37% (Norway); proportions admitted: 35% (Australia) and 28% (Norway). Factors associated with referral in both countries were: moderately severe stroke, receiving stroke unit treatment or allied health assessments during the acute admission, living in the community, and independent pre-stroke mobility. Directions of associations were mostly congruent; however younger patients were more likely to be referred and admitted in Norway only. Models for admission among patients referred identified few associated factors suggesting that additional factors were important for this stage of the process. Conclusions Similar factors were associated with referral to inpatient rehabilitation after acute stroke in both countries, despite differing service provision and access rates. Assuming it is not feasible to provide inpatient rehabilitation to all patients following stroke, the criteria for the selection of candidates need to be understood to address unwanted biases.
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Affiliation(s)
- Angela S Labberton
- Health Services Research Unit, Akershus University Hospital, PO Box 1000, 1478, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Mathias Barra
- Health Services Research Unit, Akershus University Hospital, PO Box 1000, 1478, Lørenskog, Norway.,Centre for Connected Care, Oslo University Hospital, Oslo, Norway
| | - Ole Morten Rønning
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Bente Thommessen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Leonid Churilov
- Department of Medicine (Austin Health), Melbourne Medical School, The University of Melbourne, Heidelberg, Australia.,NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne and Newcastle, Melbourne, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Dominique A Cadilhac
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne and Newcastle, Melbourne, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - Elizabeth A Lynch
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne and Newcastle, Melbourne, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.,Adelaide Nursing School, University of Adelaide, Adelaide, Australia
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Kasner SE, Siegler JE, Zamzam A, Kleindorfer D. Expanding Eligibility in Stroke Prevention Trials to Patients with Early Disability. J Stroke Cerebrovasc Dis 2019; 28:2268-2272. [PMID: 31160220 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.016] [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] [Received: 03/21/2019] [Revised: 05/06/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Early disability after stroke is common, though many patients improve. Stroke secondary prevention trials often prohibit the recruitment of nonambulatory patients, limiting their access to potential treatment options and impeding trial enrollment. We aimed to determine outcomes after early dependence around the time of transition from acute care to recovery. METHODS Data were obtained from a composite of patients enrolled in acute stroke clinical trials within the Virtual International Stroke Trials Archive (VISTA-Acute). Early disability was defined by the modified Rankin Scale (mRS) of 4 or 5 between days 3-10 after onset, representing the time of discharge or transition to a rehabilitation-focused care setting. We developed multivariable models to identify factors associated with recovery to independent ambulatory function and recurrent stroke during the 90 days after stroke. RESULTS 4965 patients were included, with 2905 (59%) having early disability. Patients with early dependence were older, more likely to be women, had higher baseline NIHSS scores, and had more atrial fibrillation and diabetes mellitus, compared with those who were initially ambulatory. Recovery to ambulatory function occurred in 58% with early mRS = 4, compared to only 16% with early mRS = 5. Of those with early mRS = 4, return to independent ambulatory status by 90 days was associated in multivariable analysis with age, diabetes, prior stroke, NIH motor and gaze subscores, and thrombolysis. Recurrent ischemic stroke through day 90 was reported in 126 of 2905 (4.3%) subjects with early dependence compared to 63 of 2060 (3.1%), which was not different after adjustment for age, sex, and risk factors (odds ratio 1.27; 95% confidence interval 0.92-1.73). CONCLUSIONS Favorable outcomes are common among ischemic stroke patients previously enrolled in acute clinical trials despite early dependence (mRS = 4) after initial acute hospital care. Further, their risk of recurrent stroke is high in the short term. These patients likely benefit from aggressive poststroke care and should be actively recruited into secondary prevention trials.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - James E Siegler
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmad Zamzam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dawn Kleindorfer
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
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Rakesh N, Boiarsky D, Athar A, Hinds S, Stein J. Post-stroke rehabilitation: Factors predicting discharge to acute versus subacute rehabilitation facilities. Medicine (Baltimore) 2019; 98:e15934. [PMID: 31145364 PMCID: PMC6709303 DOI: 10.1097/md.0000000000015934] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to examine predictors of discharge of hospitalized stroke patients to either an acute inpatient rehabilitation facility (IRF) or subacute skilled nursing facility (SNF).A retrospective cohort study was done in a large multicampus urban academic medical center of individuals hospitalized for stroke between January 1, 2015 and December 31, 2015 and who were discharged to either an IRF (n = 84) or SNF (n = 59). A set of characteristics and scales were collected on each patient and assessed using univariate and multivariate regression analyses.Although univariate analyses revealed multiple measures were associated with discharge destination, the most predictive multivariate logistic regression model for discharge to SNF incorporated age (odds ratio [OR] = 1.09, 95% confidence interval [CI], 1.05-1.13), premorbid physical disability (OR 7.52, 95% CI 1.66-34.14), and inability to ambulate before discharge (OR 5.84, 95% CI 2.01-16.92) with an overall c-statistic of 0.85.Increasing age, premorbid physical disability, and inability to ambulate increase the overall likelihood of discharge to a SNF. These findings need to be replicated in larger samples to determine whether they are generalizable.
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Affiliation(s)
- Neal Rakesh
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
- Department of Rehabilitation Medicine, Weill Cornell Medical College
- NewYork-Presbyterian Hospital, New York, NY
| | - Daniel Boiarsky
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
| | - Ammar Athar
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
| | - Shaliesha Hinds
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
| | - Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
- Department of Rehabilitation Medicine, Weill Cornell Medical College
- NewYork-Presbyterian Hospital, New York, NY
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29
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So C, Lage DE, Slocum CS, Zafonte RD, Schneider JC. Utility of Functional Metrics Assessed During Acute Care on Hospital Outcomes: A Systematic Review. PM R 2019; 11:522-532. [PMID: 30758920 PMCID: PMC10108704 DOI: 10.1002/pmrj.12013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/10/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Traditionally, illness severity, social factors, and comorbid conditions have been examined as predictors of hospital outcomes. However, recent research in the rehabilitation setting demonstrated that physical function outperformed comorbidity indices as a predictor of 30-day readmission. The purpose of this study was to review the literature examining the association between acute hospital physical function and various hospital outcomes and health care utilization. TYPE: Systematic review. LITERATURE SURVEY A review of the MEDLINE database was performed. Search terms included acute functional outcomes and frailty outcomes. Studies up to September 2017 were included if they were in English and examined how functional metrics collected at acute care hospitalization affected hospital outcomes. METHODOLOGY Cohort characteristics and measures of associations were extracted from the studies. Outcomes include hospital readmission, length of stay, mortality, discharge location, and physical function post acute care. The studies were assessed for potential confounders as well as selection, attrition, and detection bias. SYNTHESIS A total of 30 studies were identified (hospital readmissions: 6; discharge location: 11; length of stay: 4; mortality: 15; function: 6). Thirteen different metrics assessed function during acute care. Lower function during acute care was associated with statistically significant higher odds of hospital readmission, lower likelihood of discharge to home, longer hospital length of stay, increased mortality, and worse functional recovery when compared to patients with higher function during acute care, when adjusted for age and gender. The Barthel Index may be a useful marker for mortality in the elderly whereas the Functional Independence Measure instrument may be valuable for examining discharge location. CONCLUSIONS There is increasing evidence that function measured during acute care predicts a broad array of meaningful clinical outcomes. Further research would help direct the use of practical, yet parsimonious functional metrics that effectively screen high-need, high-cost patients to deliver optimal care. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Conan So
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,University of Maryland School of Medicine, Baltimore, MD
| | - Daniel E Lage
- Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Chloe S Slocum
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Abstract
Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.
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Affiliation(s)
- Anjail Sharrief
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, United States.
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31
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Magdon-Ismail Z, Ledneva T, Sun M, Schwamm LH, Sherman B, Qian F, Bettger JP, Xian Y, Stein J. Factors associated with 1-year mortality after discharge for acute stroke: what matters? Top Stroke Rehabil 2018; 25:576-583. [PMID: 30281414 DOI: 10.1080/10749357.2018.1499303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate factors associated with 1-year mortality after discharge for acute stroke. METHODS In this retrospective cohort study, we studied 305 patients with ischemic stroke or intracerebral hemorrhage discharged in 2010/2011. We linked Get With The Guidelines®-Stroke clinical data with New York State administrative data and used multivariate regression models to examine variables related to 1-year all-cause mortality poststroke. RESULTS The mean age was 68.6 ± 14.8 years and 51.1% were women. A total of 146 (47.9%) were discharged directly home, 96 (31.5%) to inpatient rehabilitation facilities (IRFs), and 63 (20.7%) to skilled nursing facilities (SNFs). Overall, 24 (7.9%) patients died within 1-year post-discharge. Older age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), higher National Institutes of Health Stroke Scale (NIHSS) on admission (OR 1.10, 95% CI 1.03-1.17), and discharge destination (IRF vs. home, OR 0.10, 95% CI 0.01-0.94; and SNF vs. home, OR 2.22, 95% CI 0.71-6.95) were factors associated with 1-year all-cause mortality. When ambulation status at discharge was added to the model, ambulation with assistance and non-ambulation were significantly associated with mortality (ambulatory with assistance vs. ambulatory, OR 9.42, 95% CI 1.87-47.61; nonambulatory vs. ambulatory, OR 12.65, 95% CI 1.89-84.89). CONCLUSIONS While age and NIHSS on admission are important predictors of long-term outcomes, factors at discharge - ambulation status at discharge and discharge destination - are associated with 1-year mortality post-discharge for acute stroke and therefore could represent therapeutic targets to improve long-term survival in future studies.
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Affiliation(s)
- Zainab Magdon-Ismail
- a American Heart Association/American Stroke Association, Founders Affiliate , Albany , NY.,b School of Public Health , University at Albany, State University of New York , Rensselaer , NY
| | | | - Mingzeng Sun
- c The New York State Department of Health , Albany , NY
| | - Lee H Schwamm
- d Department of Neurology , Massachusetts General Hospital , Boston , MA.,e Harvard Medical School , Boston , MA
| | - Barry Sherman
- b School of Public Health , University at Albany, State University of New York , Rensselaer , NY
| | - Feng Qian
- b School of Public Health , University at Albany, State University of New York , Rensselaer , NY
| | | | - Ying Xian
- f Duke Clinical Research Institute , Durham , NC
| | - Joel Stein
- g Department of Rehabilitation and Regenerative Medicine , Columbia University College of Physicians and Surgeons , New York , NY.,h Department of Rehabilitation Medicine , Weill Cornell Medical College , New York , NY.,i New York-Presbyterian Hospital , New York , NY
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Dewilde S, Annemans L, Peeters A, Hemelsoet D, Vandermeeren Y, Desfontaines P, Brouns R, Vanhooren G, Cras P, Michielsens B, Redondo P, Thijs V. The relationship between Home-time, quality of life and costs after ischemic stroke: the impact of the need for mobility aids, home and car modifications on Home-time. Disabil Rehabil 2018; 42:419-425. [DOI: 10.1080/09638288.2018.1501438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Sarah Dewilde
- Department of Public Health, University of Ghent, Ghent, Belgium
- Services in Health Economics (SHE), Brussels, Belgium
| | - Lieven Annemans
- Interuniversity Centre for Health Economics Research, University of Ghent, VUB, Belgium
| | - Andre Peeters
- Department of Neurology Universitaires Saint Luc, Brussels, Belgium
| | | | | | | | - Raf Brouns
- ZorgSaam Hospital, Terneuzen, The Netherlands
| | | | - Patrick Cras
- Born Bunge Institute, University Hospital, Antwerp, Belgium
| | | | | | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne and Austin Health, Victoria, Australia
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33
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The Transformation of the Rehabilitation Paradigm Across the Continuum of Care. PM R 2018; 10:S264-S271. [DOI: 10.1016/j.pmrj.2018.08.381] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
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Castiglia SF, Galeoto G, Lauta A, Palumbo A, Tirinelli F, Viselli F, Santilli V, Sacchetti ML. The culturally adapted Italian version of the Barthel Index (IcaBI): assessment of structural validity, inter-rater reliability and responsiveness to clinically relevant improvements in patients admitted to inpatient rehabilitation centers. FUNCTIONAL NEUROLOGY 2018; 22:221-228. [PMID: 29306359 PMCID: PMC5762108 DOI: 10.11138/fneur/2017.32.4.221] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Barthel Index (BI) is widely used to determine eligibility criteria for inpatient rehabilitation and to monitor patients' recovery, irrespective of the illnesses that affect them. The culturally adapted Italian version of the Barthel Index (IcaBI) was recently validated. This paper reports the structural validity and inter-rater reliability of the IcaBI and its responsiveness to the results of inpatient rehabilitation. The IcaBI was administered to a cohort of 264 patients hospitalized in two rehabilitation centers in Rome, Italy. Factor analysis using principal component analysis revealed a monofactorial structure for neurological patients and, after removal of item 1 "feeding", also for orthopedic patients. Substantial to optimal inter-rater reliability was found (0.74 > intraclass correlation coefficient < 0.96). The IcaBI was found to be accurate (area under the curve= 0.72) with a minimal clinically important change score of 35 points. This work confirms that IcaBI is a useful tool for measuring disability in health and social care settings along the continuum of care. Further studies are needed to assess its criterion validity, interpretability and responsiveness in other specific disease conditions.
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Affiliation(s)
- Stefano Filippo Castiglia
- Department of Human Neurosciences, “Sapienza” University of Rome, Rome, Italy
- Department of Neuromotor and Orthopedic Rehabilitation, Institute of Neurosciences, Neurological Centre of Latium (NCL), Rome, Italy
| | - Giovanni Galeoto
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Antonella Lauta
- Department of Neuromotor and Orthopedic Rehabilitation, Institute of Neurosciences, Neurological Centre of Latium (NCL), Rome, Italy
| | - Andrea Palumbo
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Franca Tirinelli
- UO Lepanto, San Giovanni Battista Hospital ACI SMOM, Rome, Italy
| | - Fabio Viselli
- UO Lepanto, San Giovanni Battista Hospital ACI SMOM, Rome, Italy
| | - Valter Santilli
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, “Sapienza” University of Rome, Rome, Italy
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Dutta D, Thornton D, Bowen E. Using population-based routinely collected data from the Sentinel Stroke National Audit Programme to investigate factors associated with discharge to care home after rehabilitation. Clin Rehabil 2017; 32:1108-1118. [DOI: 10.1177/0269215517748715] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We investigated factors associated with Care Home (CH) discharge following stroke using routinely collected data in unselected patients and assessed the relevance of previous research findings to such patients seen in routine clinical practice. Design: Retrospective analysis of data from the Sentinel Stroke National Audit Programme using univariate analysis and logistic regression. Setting: A large acute and rehabilitation UK stroke unit with access to early supported discharge. Subjects: All patients with stroke treated from 1 January 2014 to 1 January 2017. Main measures: National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). Results: Of 2584 patients (median age 78 years, interquartile range (IQR) 69–86; 50.6% male; 86.7% infarcts; median admission NIHSS 4, IQR 2–9), 401 (15.5%) died in hospital and 203 patients (7.9%) were permanently discharged to CH for the first time. Most had pre-discharge mRS scores of 4/5. Factors (odds ratios; 95% confidence intervals) associated with CH discharge included age (1.07; 1.05–1.10), incontinence (11.5; 7.13–19.25), dysphagia (2.13; 1.39–3.29), severe weakness (1.93; 1.28–2.92), pneumonia (1.68; 1.13–2.50), urinary tract infection (UTI) (1.70; 1.04–2.75) and depression (1.65; 1.00–2.72). In a subgroup of all patients with a pre-discharge mRS of 4/5, age (1.04; 1.02–1.06), incontinence (4.87; 2.39–11.02), UTI (2.0; 1.09–3.71) and pneumonia (1.59; 1.02–2.50) were the only factors associated with CH discharge. Conclusion: Potentially modifiable variables like incontinence, UTI and pneumonia were associated with CH discharge, particularly in the severely disabled.
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Affiliation(s)
- Dipankar Dutta
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Daniel Thornton
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Emily Bowen
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
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Xian Y, Thomas L, Liang L, Federspiel JJ, Webb LE, Bushnell CD, Duncan PW, Schwamm LH, Stein J, Fonarow GC, Hoenig H, Montalvo C, George MG, Lutz BJ, Peterson ED, Bettger JP. Unexplained Variation for Hospitals’ Use of Inpatient Rehabilitation and Skilled Nursing Facilities After an Acute Ischemic Stroke. Stroke 2017; 48:2836-2842. [DOI: 10.1161/strokeaha.117.016904] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 07/14/2017] [Accepted: 08/01/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Laine Thomas
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Li Liang
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Jerome J. Federspiel
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Laura E. Webb
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Cheryl D. Bushnell
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Pamela W. Duncan
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Lee H. Schwamm
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Joel Stein
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Gregg C. Fonarow
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Helen Hoenig
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Cris Montalvo
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Mary G. George
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Barbara J. Lutz
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Eric D. Peterson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
| | - Janet Prvu Bettger
- From the Duke Clinical Research Institute, Durham, NC (Y.X., L.T., L.L., J.J.F., L.E.W., E.D.P., J.P.B.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD (J.J.F.); Department of Neurology, Wake Forest Baptist Health, Winston Salem, NC (C.D.B., P.W.D.); Stroke Service and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.); Department of
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Cho JS, Hu Z, Fell N, Heath GW, Qayyum R, Sartipi M. Hospital Discharge Disposition of Stroke Patients in Tennessee. South Med J 2017; 110:594-600. [PMID: 28863224 PMCID: PMC5774648 DOI: 10.14423/smj.0000000000000694] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Early determination of hospital discharge disposition status at an acute admission is extremely important for stroke management and the eventual outcomes of patients with stroke. We investigated the hospital discharge disposition of patients with stroke residing in Tennessee and developed a predictive tool for clinical adoption. Our investigational aims were to evaluate the association of selected patient characteristics with hospital discharge disposition status and predict such status at the time of an acute stroke admission. METHODS We analyzed 127,581 records of patients with stroke hospitalized between 2010 and 2014. Logistic regression was used to generate odds ratios with 95% confidence intervals to examine the factor outcome association. An easy-to-use clinical predictive tool was built by using integer-based risk scores derived from coefficients of multivariable logistic regression. RESULTS Among the 127,581 records of patients with stroke, 86,114 (67.5%) indicated home discharge and 41,467 (32.5%) corresponded to facility discharge. All considered patient characteristics had significant correlations with hospital discharge disposition status. Patients were at greater odds of being discharged to another facility if they were women; older; black; patients with a subarachnoid or intracerebral hemorrhage; those with the comorbidities of diabetes mellitus, heart disease, hypertension, chronic kidney disease, arrhythmia, or depression; those transferred from another hospital; or patients with Medicare as the primary payer. A predictive tool had a discriminatory capability with area under the curve estimates of 0.737 and 0.724 for derivation and validation cohorts, respectively. CONCLUSIONS Our investigation revealed that the hospital discharge disposition pattern of patients with stroke in Tennessee was associated with the key patient characteristics of selected demographics, clinical indicators, and insurance status. These analyses resulted in the development of an easy-to-use predictive tool for early determination of hospital discharge disposition status.
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Affiliation(s)
- Jin S Cho
- From the Departments of Computer Science and Engineering, Physical Therapy, Health and Human Performance, University of Tennessee, Chattanooga, and Erlanger Health System, Chattanooga, Tennessee
| | - Zhen Hu
- From the Departments of Computer Science and Engineering, Physical Therapy, Health and Human Performance, University of Tennessee, Chattanooga, and Erlanger Health System, Chattanooga, Tennessee
| | - Nancy Fell
- From the Departments of Computer Science and Engineering, Physical Therapy, Health and Human Performance, University of Tennessee, Chattanooga, and Erlanger Health System, Chattanooga, Tennessee
| | - Gregory W Heath
- From the Departments of Computer Science and Engineering, Physical Therapy, Health and Human Performance, University of Tennessee, Chattanooga, and Erlanger Health System, Chattanooga, Tennessee
| | - Rehan Qayyum
- From the Departments of Computer Science and Engineering, Physical Therapy, Health and Human Performance, University of Tennessee, Chattanooga, and Erlanger Health System, Chattanooga, Tennessee
| | - Mina Sartipi
- From the Departments of Computer Science and Engineering, Physical Therapy, Health and Human Performance, University of Tennessee, Chattanooga, and Erlanger Health System, Chattanooga, Tennessee
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Lindsay LR, Lercher K, O'Dell MW. Should This Patient With Global Aphasia After a Left Cerebral Stroke Be Admitted to Your Hospital-Based Inpatient Rehabilitation Unit? PM R 2017; 9:629-635. [DOI: 10.1016/j.pmrj.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022]
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Faux SG, Arora P, Shiner CT, Thompson-Butel AG, Klein LA. Rehabilitation and education are underutilized for mild stroke and TIA sufferers. Disabil Rehabil 2017; 40:1480-1484. [DOI: 10.1080/09638288.2017.1295473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Steven G. Faux
- Department of Rehabilitation Medicine, St Vincent’s Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Pooja Arora
- Department of Rehabilitation Medicine, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Christine T. Shiner
- Department of Rehabilitation Medicine, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | | | - Linda A. Klein
- Sydney Medical School, University of Sydney, New South Wales, Australia
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Cormier DJ, Frantz MA, Rand E, Stein J. Physiatrist referral preferences for postacute stroke rehabilitation. Medicine (Baltimore) 2016; 95:e4356. [PMID: 27537563 PMCID: PMC5370790 DOI: 10.1097/md.0000000000004356] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 06/13/2016] [Accepted: 07/03/2016] [Indexed: 11/26/2022] Open
Abstract
This study was intended to determine if there is variation among physiatrists in referral preferences for postacute rehabilitation for stroke patients based on physician demographic characteristics or geography.A cross-sectional survey study was developed with 5 fictional case vignettes that included information about medical, social, and functional domains. Eighty-six physiatrist residents, fellows, and attendings were asked to select the most appropriate postacute rehabilitation setting and also to rank, by importance, 15 factors influencing the referral decision. Chi-square bivariate analysis was used to analyze the data.Eighty-six surveys were collected over a 3-day period. Bivariate analysis (using chi-square) showed no statistically significant relationship between any of the demographic variables and poststroke rehabilitation preference for any of the cases. The prognosis for functional outcome and quality of postacute facility had the highest mean influence ratings (8.63 and 8.31, respectively), whereas location of postacute facility and insurance had the lowest mean influence ratings (5.74 and 5.76, respectively).Physiatrists' referral preferences did not vary with any identified practitioner variables or geographic region; referral preferences only varied significantly by case.
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Affiliation(s)
- David J. Cormier
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
- Division of Rehabilitation Medicine, Weill Cornell Medical College
- New York-Presbyterian Hospital, New York, NY
| | - Megan A. Frantz
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
- Division of Rehabilitation Medicine, Weill Cornell Medical College
- New York-Presbyterian Hospital, New York, NY
| | - Ethan Rand
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
- Division of Rehabilitation Medicine, Weill Cornell Medical College
- New York-Presbyterian Hospital, New York, NY
| | - Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
- Division of Rehabilitation Medicine, Weill Cornell Medical College
- New York-Presbyterian Hospital, New York, NY
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Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 47:e98-e169. [PMID: 27145936 DOI: 10.1161/str.0000000000000098] [Citation(s) in RCA: 1516] [Impact Index Per Article: 189.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. CONCLUSIONS As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).
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Mees M, Klein J, Yperzeele L, Vanacker P, Cras P. Predicting discharge destination after stroke: A systematic review. Clin Neurol Neurosurg 2016; 142:15-21. [DOI: 10.1016/j.clineuro.2016.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 11/19/2015] [Accepted: 01/03/2016] [Indexed: 10/22/2022]
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Raj VS, Fu JB, O'Dell MW. Hospital-Based Rehabilitation for Recurrent Glioblastoma. PM R 2015; 7:1182-1188. [PMID: 26608717 DOI: 10.1016/j.pmrj.2015.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/04/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Vishwa S Raj
- Department of Physical Medicine & Rehabilitation, Carolinas Rehabilitation, and Levine Cancer Institute, Charlotte, NC
| | - Jack B Fu
- Department of Palliative, Rehabilitation & Integrative Medicine, MD Anderson Cancer Center, University of Texas, Houston, TX
| | - Michael W O'Dell
- Department of Rehabilitation Medicine, Weill Cornell Medical Center, 525 E 68th St, F-1600, New York, NY 10065
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Teo K, Slark J. A systematic review of studies investigating the care of stroke survivors in long-term care facilities. Disabil Rehabil 2015; 38:715-723. [PMID: 26104106 DOI: 10.3109/09638288.2015.1059496] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The burden of stroke is immense, with approximately 30 million stroke survivors globally. Approximately one-quarter of residents in long-term care (LTC) facilities are stroke survivors. This review aims to integrate the existing knowledge from the literature and elucidate themes around the care of stroke survivors in LTC facilities. METHOD A systematic search was performed in PubMed, Ovid MEDLINE, the Cochrane Library and CINAHL. Articles that met the eligibility criteria were selected. Synthesis of results according to similar themes was performed. RESULTS A total of 1920 articles were screened for eligibility, of which 22 met the eligibility criteria. Of the 22 articles selected, five and 17 articles comprised interventional and observational studies, respectively. Three themes were identified: rehabilitation, stroke specific care and secondary stroke drug prevention. These were found to be lacking within LTC facilities. There is also a dearth of interventional studies in stroke survivors from LTC facilities. CONCLUSIONS The care of stroke survivors in LTC facilities is lacking in rehabilitation, stroke specific care and secondary stroke prevention. This needs to be addressed through conducting further research to build a strong body of evidence to influence change in the care of this vulnerable group of patients. Implications for Rehabilitation Care of stroke survivors in long-term care facilities Stroke survivors make up almost a quarter of residents in long-term care facilities. They suffer from functional impairments and many other disabilities as a result of more severe stroke, precluding them from living in their own homes. Rehabilitation, stroke-specific care and secondary stroke prevention for stroke survivors are lacking in long-term care facilities despite strong evidence showing benefits for these interventions in stroke survivors living in the community. Interventions to address the unmet need in stroke survivors living in long-term care facilities are vital for optimal care of this vulnerable group of patients.
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Affiliation(s)
- Keith Teo
- a The School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland , New Zealand and
| | - Julia Slark
- b The School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland , New Zealand
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