1
|
Mangone E, Shahriary E, Bosch P. Role of inpatient rehabilitation facility functional measures to predict community discharge after stroke. PM R 2024. [PMID: 39319640 DOI: 10.1002/pmrj.13266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 07/03/2024] [Accepted: 07/18/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND This study investigated the association between stroke severity, functional status measured by the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI), and community discharge from IRF. OBJECTIVES Aim one examined the association between National Institutes of Health Stroke Scale (NIHSS) scores measured during the acute care stay and IRF admission functional status, measured by the admission IRF-PAI self-care and mobility functional measures, to deduce if functional measures can serve as a proxy for stroke severity. Aim two investigated the ability of the NIHSS and IRF-PAI admission functional measures to predict community discharge from IRF after stroke. DESIGN Retrospective cohort study using electronic health records and Uniform Data System. Medical Record file data from January 1, 2018, to December 30, 2019. SETTING Academic hospital-based IRF. PARTICIPANTS Five hundred forty-four patients transferred from acute care hospital to IRF after an ischemic or hemorrhagic stroke. Exclusion criteria included a transient ischemic attack, discharge against medical advice, death during IRF stay, or readmission to acute care within 48 hours of IRF admission. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Admission IRF-PAI self-care and mobility scores and discharge status from IRF. RESULTS Of the 544 patients, 76.7% had community discharge. NIHSS scores were significantly associated with IRF-PAI admission self-care scores across each NIHSS stroke category. There was no statistically significant association between NIHSS and IRF-PAI admission mobility score. IRF admission self-care and mobility scores were each statistically significant predictors of community discharge (odds ratio [OR] = 1.10, 95% confidence interval [CI]: 1.03-1.17; OR = 1.10, CI: 1.03-1.18, respectively). NIHSS scores were not a statistically significant predictor of community discharge (OR = 0.70, CI: 0.47-1.04) from IRF. CONCLUSIONS IRF-PAI self-care functional measure is associated with the NIHSS and can serve as a proxy for stroke severity. IRF-PAI self-care and mobility measures each predict community discharge.
Collapse
Affiliation(s)
- Elizabeth Mangone
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Eashan Shahriary
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Pamela Bosch
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
- Department of Physical Therapy and Athletic Training, College of Health and Human Services, Northern Arizona University, Phoenix Bioscience Core, Phoenix, Arizona, USA
| |
Collapse
|
2
|
Shin D, Razzouk J, Thomas J, Nguyen K, Cabrera A, Bohen D, Lipa SA, Bono CM, Shaffrey CI, Cheng W, Danisa O. Social determinants of health and disparities in spine surgery: a 10-year analysis of 8,565 cases using ensemble machine learning and multilayer perceptron. Spine J 2024:S1529-9430(24)00890-8. [PMID: 39033881 DOI: 10.1016/j.spinee.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 06/28/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND CONTEXT The influence of SDOH on spine surgery is poorly understood. Historically, researchers commonly focused on the isolated influences of race, insurance status, or income on healthcare outcomes. However, analysis of SDOH is becoming increasingly more nuanced as viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDOH on healthcare delivery. PURPOSE The aim of this study was to evaluate the effects of patient social history on length of stay (LOS) and readmission within 90 days following spine surgery using ensemble machine learning and multilayer perceptron. STUDY DESIGN Retrospective chart review. PATIENT SAMPLE 8,565 elective and emergency spine surgery cases performed from 2013 to 2023 using our institution's database of longitudinally collected electronic medical record information. OUTCOMES MEASURES Patient LOS, discharge disposition, and rate of 90-day readmission. METHODS Ensemble machine learning and multilayer perceptron were employed to predict LOS and readmission within 90 days following spine surgery. All other subsequent statistical analysis was performed using SPSS version 28. To further assess correlations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Independent sample t-tests, paired sample t-tests, one-way analysis of variance (ANOVA) with post-hoc Bonferroni and Tukey corrections, and Pearson's chi-squared test were applied where appropriate for analysis of continuous and categorical variables. RESULTS Black patients demonstrated a greater LOS compared to white patients, but race and ethnicity were not significantly associated with 90-day readmission rates. Insured patients had a shorter LOS and lower readmission rates compared to non-insured patients, as did privately insured patients compared to publicly insured patients. Patients discharged home had lower LOS and lower readmission rates, compared to patients discharged to other facilities. Marriage decreased both LOS and readmission rates, underweight patients showcased increased LOS and readmission rates, and religion was shown to impact LOS and readmission rates. When utilizing patient social history, lab values, and medical history, machine learning determined the top 5 most-important variables for prediction of LOS -along with their respective feature importances-to be insurance status (0.166), religion (0.100), ICU status (0.093), antibiotic use (0.061), and case status: elective or urgent (0.055). The top 5 most-important variables for prediction of 90-day readmission-along with their respective feature importances-were insurance status (0.177), religion (0.123), discharge location (0.096), emergency case status (0.064), and history of diabetes (0.041). CONCLUSIONS This study highlights that SDOH is influential in determining patient length of stay, discharge disposition, and likelihood of readmission following spine surgery. Machine learning was utilized to accurately predict LOS and 90-day readmission with patient medical history, lab values, and social history, as well as social history alone.
Collapse
Affiliation(s)
- David Shin
- Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, 92350 CA, USA
| | - Jacob Razzouk
- Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, 92350 CA, USA
| | - Jonathan Thomas
- Department of Ophthalmology, Loma Linda University, 11370 Anderson St #1800, 92354, Loma Linda, CA, USA
| | - Kai Nguyen
- Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, 92350 CA, USA
| | - Andrew Cabrera
- Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, 92350 CA, USA
| | - Daniel Bohen
- Information Sciences Institute, University of Southern California, 4676 Admiral Way #1001, 90292, Los Angeles, CA, USA
| | - Shaina A Lipa
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, 02114, Boston, MA, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Duke University Medical Center, 40 Duke Medicine Cir Suit 1554, 27710, Durham, NC, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis Memorial Veterans Hospital, 11201 Benton St, 92357, Loma Linda, CA, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, 11234 Anderson St, 92354, Loma Linda, CA, USA.
| |
Collapse
|
3
|
Young DL, Hannum SM, Engels R, Colantuoni E, Friedman LA, Hoyer EH. Dynamic Prediction of Post-Acute Care Needs for Hospitalized Medicine Patients. J Am Med Dir Assoc 2024; 25:104939. [PMID: 38387858 DOI: 10.1016/j.jamda.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/05/2023] [Accepted: 01/10/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVES Use patient demographic and clinical characteristics at admission and time-varying in-hospital measures of patient mobility to predict patient post-acute care (PAC) discharge. DESIGN Retrospective cohort analysis of electronic medical records. SETTING AND PARTICIPANTS Patients admitted to the two participating Hospitals from November 2016 through December 2019 with ≥72 hours in a general medicine service. METHODS Discharge location (PAC vs home) was the primary outcome, and 2 time-varying measures of patient mobility, Activity Measure for Post-Acute Care (AM-PAC) Mobility "6-clicks" and Johns Hopkins Highest Level of Mobility, were the primary predictors. Other predictors included demographic and clinical characteristics. For each day of hospitalization, we predicted discharge to PAC using the demographic and clinical characteristics and most recent mobility data within a random forest (RF) for survival, longitudinal, and multivariate (RF-SLAM) data. A regression tree for the daily predicted probabilities of discharge to PAC was constructed to represent a global summary of the RF. RESULTS There were 23,090 total patients and compared to PAC, those discharged home were younger (64 vs 71), had shorter length of stay (5 vs 8 days), higher AM-PAC at admission (43 vs 32), and average AM-PAC throughout hospitalization (45 vs 35). AM-PAC was the most important predictor, followed by age, and whether the patient lives alone. The area under the hospital day-specific receiver operating characteristic curve ranged from 0.76 to 0.79 during the first 5 days. The global summary tree explained 75% of the variation in predicted probabilities for PAC from the RF. Sensitivity (75%), specificity (70%), and accuracy (72%) were maximized at a PAC probability threshold of 40%. CONCLUSIONS AND IMPLICATIONS Daily assessment of patient mobility should be part of routine practice to help inform care planning by hospital teams. Our prediction model could be used as a valuable tool by multidisciplinary teams in the discharge planning process.
Collapse
Affiliation(s)
- Daniel L Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA.
| | - Susan M Hannum
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rebecca Engels
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa Aronson Friedman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA; Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
4
|
French MA, Hayes H, Johnson JK, Young DL, Roemmich RT, Raghavan P. The effect of post-acute rehabilitation setting on 90-day mobility after stroke: A difference-in-difference analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.08.24301026. [PMID: 38260437 PMCID: PMC10802638 DOI: 10.1101/2024.01.08.24301026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background After discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge. Methods In this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health. Results We included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services (β=-3.5 (1.4), p=0.01 and β=-8.2 (1.3), p=<0.001, respectively). Conclusions These findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.
Collapse
Affiliation(s)
- Margaret A. French
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
| | - Heather Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Joshua K. Johnson
- Department of Physical Medicine & Rehabilitation, Cleveland Clinic, Cleveland, OH
| | - Daniel L. Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV
| | - Ryan T. Roemmich
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MD
| | - Preeti Raghavan
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
5
|
Scharp D, Hobensack M, Davoudi A, Topaz M. Natural Language Processing Applied to Clinical Documentation in Post-acute Care Settings: A Scoping Review. J Am Med Dir Assoc 2024; 25:69-83. [PMID: 37838000 PMCID: PMC10792659 DOI: 10.1016/j.jamda.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVES To determine the scope of the application of natural language processing to free-text clinical notes in post-acute care and provide a foundation for future natural language processing-based research in these settings. DESIGN Scoping review; reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. SETTING AND PARTICIPANTS Post-acute care (ie, home health care, long-term care, skilled nursing facilities, and inpatient rehabilitation facilities). METHODS PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched in February 2023. Eligible studies had quantitative designs that used natural language processing applied to clinical documentation in post-acute care settings. The quality of each study was appraised. RESULTS Twenty-one studies were included. Almost all studies were conducted in home health care settings. Most studies extracted data from electronic health records to examine the risk for negative outcomes, including acute care utilization, medication errors, and suicide mortality. About half of the studies did not report age, sex, race, or ethnicity data or use standardized terminologies. Only 8 studies included variables from socio-behavioral domains. Most studies fulfilled all quality appraisal indicators. CONCLUSIONS AND IMPLICATIONS The application of natural language processing is nascent in post-acute care settings. Future research should apply natural language processing using standardized terminologies to leverage free-text clinical notes in post-acute care to promote timely, comprehensive, and equitable care. Natural language processing could be integrated with predictive models to help identify patients who are at risk of negative outcomes. Future research should incorporate socio-behavioral determinants and diverse samples to improve health equity in informatics tools.
Collapse
Affiliation(s)
| | | | - Anahita Davoudi
- VNS Health, Center for Home Care Policy & Research, New York, NY, USA
| | - Maxim Topaz
- Columbia University School of Nursing, New York, NY, USA
| |
Collapse
|
6
|
Yedavalli V, Koneru M, Hoseinyazdi M, Copeland K, Xu R, Luna L, Caplan J, Dmytriw A, Guenego A, Heit J, Albers G, Wintermark M, Gonzalez F, Urrutia V, Huang J, Leigh R, Marsh E, Llinas R, Hernandez MG, Hillis A. Excellent Recanalization and Small Core Volumes Are Associated With Favorable AM-PAC Score in Patients With Acute Ischemic Stroke Secondary to Large Vessel Occlusion. Arch Rehabil Res Clin Transl 2023; 5:100306. [PMID: 38163017 PMCID: PMC10757189 DOI: 10.1016/j.arrct.2023.100306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Objective To assess pretreatment and interventional parameters as predictors of favorable Activity Measure for Post-Acute Care (AM-PAC) scores for optimal discharge planning. Design In this prospectively collected, retrospectively reviewed multicenter study from 9/1/2017 to 9/22/2022, patients were dichotomized into favorable and unfavorable AM-PAC. Multivariate logistic regression and receiver operator characteristics analyses were performed for the identified significant variables. A P value of ≤.05 was significant. Setting Hospitalized care. Participants In total, 229 patients (mean ±SD 70.65 ±15.2 [55.9% women]) met our inclusion criteria. Inclusion criteria were (a) computed tomography (CT) angiography confirmed LVO from 9/1/2017 to 9/22/2022; (b) diagnostic CT perfusion; and (c) available AM-PAC scores. Interventions None. Main Outcome Measures Favorable AM-PAC, defined as a daily activity score ≥19 and basic mobility score of ≥17. Results Patients with favorable AM-PAC were younger (61.3 vs 70.7, P<.001), had lower admission glucose (mean, 124 vs 136, P=.042), lower blood urea nitrogen (mean, 15.59 vs 19.11, P<.001), and lower admission National Institutes of Health Stroke Scale (NIHSS) (mean, 10.58 vs 16.15, P<.001). No differences in sex were noted. Multivariate regression analyses revealed age, admission NIHSS, relative cerebral blood flow (rCBF) <30% volume, and modified thrombolysis in cerebral infarction (mTICI) score to be independent predictors of favorable AM-PAC (P<.047 for all predictors). The combined model revealed an area under the curve (AUC) of 0.83 (IQR 0.75-0.86). Conclusion Excellent recanalization, smaller core volumes, younger age, and lower stroke severity independently predict favorable outcomes as measured by AM-PAC.
Collapse
Affiliation(s)
- Vivek Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | - Justin Caplan
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Adam Dmytriw
- Department of Neuroradiology, Massachusetts General Hospital & Harvard Medical School, Cambridge, MA
| | - Adrien Guenego
- Department of Radiology, Université Libre De Bruxelles Hospital Erasme, Brussels, BE
| | - Jeremy Heit
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA
| | - Gregory Albers
- Department of Neurology, Stanford University School of Medicine, Baltimore, MD
| | - Max Wintermark
- Department of Radiology, University of Texas MD Anderson Center, Houston, TX
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Richard Leigh
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elisabeth Marsh
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Rafael Llinas
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Argye Hillis
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
7
|
Young DL, Johnson JK, Guo N, Tereshchenko LG, Martinez M, Rothberg MB. Association between physical therapy frequency and postacute care for a national cohort of patients hospitalized with pneumonia. J Hosp Med 2023; 18:803-811. [PMID: 37545436 DOI: 10.1002/jhm.13186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Annually more than 300,000 patients hospitalized for pneumonia need postacute care. Patients and systems prefer home discharge, but physical limitations often necessitate postacute care. It is unknown whether frequency of physical therapy in the hospital affects postacute care discharges. OBJECTIVE Examine the relationship between physical therapy visit frequency and disposition among a national sample of patients hospitalized with pneumonia. DESIGNS Observational cohort study. SETTING Acute care hospital. PARTICIPANTS Adult patients with primary diagnosis of pneumonia in the Premier Data Set who received physical therapy in the hospital during a 5-day window, with therapy on at least days 1 and 5. INTERVENTION Physical therapy visit frequency. MAIN OUTCOME AND MEASURES Discharge disposition (home or postacute care). RESULTS We included 18,886 patients from 595 hospitals. Just over half were discharged home (n = 9638; 51.0%) and 558 (2.95%) died. Patients getting more frequent therapy were older, non-Hispanic white, treated in small non-teaching rural hospitals in the West, Midwest, or South, and had fewer severe illness indicators. In adjusted models, patients who received physical therapy on 100% of days were 7% [(95% confidence interval, 4.3-9.7), p < .0001] more likely to go home than patients who received physical therapy on 40% of days. As a falsification test, we found that there was no relationship between physical therapy frequency and all-cause mortality. Physical therapy visit frequency was positively associated with discharge to home. Increasing visit frequency of physical therapy in hospitals might reduce the need for postacute care, but randomized controlled trials are needed to confirm the effect.
Collapse
Affiliation(s)
- Daniel L Young
- Department of Physical Therapy, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Joshua K Johnson
- Department of Physical Medicine & Rehabilitation, Cleveland Clinic, Cleveland, Ohio, USA
- Rehabilitation and Sports Therapy, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ning Guo
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Maylyn Martinez
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Lee SB, Oh YT, Yang SW, Kim JB. Data-Driven Smart Living Lab to Promote Participation in Rehabilitation Exercises and Sports Programs for People with Disabilities in Local Communities. SENSORS (BASEL, SWITZERLAND) 2023; 23:2761. [PMID: 36904962 PMCID: PMC10006891 DOI: 10.3390/s23052761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 06/18/2023]
Abstract
Patients discharged from hospitals after an inpatient course of medical treatment for any ailment or traumatic injury that results in disabling conditions and are rendered mobility impaired require ongoing systematic sports and exercise programs to maintain healthy lifestyles. Under such circumstances, a rehabilitation exercise and sports center, accessible throughout local communities, is critical for promoting beneficial living and community participation for these individuals with disabilities. An innovative data-driven system equipped with state-of-the-art smart and digital equipment, set up in architecturally barrier-free infrastructures, is essential for these individuals to promote health maintenance and overcome secondary medical complications following an acute inpatient hospitalization or suboptimal rehabilitation. A federally funded collaborative research and development (R&D) program proposes to build a multi-ministerial data-driven system of exercise programs using a smart digital living lab as a platform to provide pilot services in physical education and counseling with exercise and sports programs for this patient population. We describe the social and critical aspects of rehabilitating such a population of patients by presenting a full study protocol. A modified sub-dataset of the previously generated 280-item full dataset is applied using a data-collecting system-"The Elephant"-as an example of how data acquisition will be achieved to assess the effects of lifestyle rehabilitative exercise programs for people with disabilities.
Collapse
Affiliation(s)
- Seung Bok Lee
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
- Korea Wheelchair Rugby Association, Seoul 05540, Republic of Korea
| | - Yim Taek Oh
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
- Korea Wheelchair Rugby Association, Seoul 05540, Republic of Korea
- Frontier Research Institute for Convergence Sports Science, Yonsei University, Seoul 03722, Republic of Korea
| | - Seung Wan Yang
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
| | - Jong Bae Kim
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
- Korea Wheelchair Rugby Association, Seoul 05540, Republic of Korea
- Department of Occupational Therapy, College of Health Sciences, Yonsei University, Wonju 26493, Republic of Korea
| |
Collapse
|
11
|
Lee SB, Oh YT, Yang SW, Kim JB. Data-Driven Smart Living Lab to Promote Participation in Rehabilitation Exercises and Sports Programs for People with Disabilities in Local Communities. SENSORS 2023; 23:2761. [DOI: https:/doi.org/10.3390/s23052761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2023]
Abstract
Patients discharged from hospitals after an inpatient course of medical treatment for any ailment or traumatic injury that results in disabling conditions and are rendered mobility impaired require ongoing systematic sports and exercise programs to maintain healthy lifestyles. Under such circumstances, a rehabilitation exercise and sports center, accessible throughout local communities, is critical for promoting beneficial living and community participation for these individuals with disabilities. An innovative data-driven system equipped with state-of-the-art smart and digital equipment, set up in architecturally barrier-free infrastructures, is essential for these individuals to promote health maintenance and overcome secondary medical complications following an acute inpatient hospitalization or suboptimal rehabilitation. A federally funded collaborative research and development (R&D) program proposes to build a multi-ministerial data-driven system of exercise programs using a smart digital living lab as a platform to provide pilot services in physical education and counseling with exercise and sports programs for this patient population. We describe the social and critical aspects of rehabilitating such a population of patients by presenting a full study protocol. A modified sub-dataset of the previously generated 280-item full dataset is applied using a data-collecting system—“The Elephant”—as an example of how data acquisition will be achieved to assess the effects of lifestyle rehabilitative exercise programs for people with disabilities.
Collapse
Affiliation(s)
- Seung Bok Lee
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
- Korea Wheelchair Rugby Association, Seoul 05540, Republic of Korea
| | - Yim Taek Oh
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
- Korea Wheelchair Rugby Association, Seoul 05540, Republic of Korea
- Frontier Research Institute for Convergence Sports Science, Yonsei University, Seoul 03722, Republic of Korea
| | - Seung Wan Yang
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
| | - Jong Bae Kim
- Yonsei Enabling Science and Technology Research Center, Seoul 26493, Republic of Korea
- Korea Wheelchair Rugby Association, Seoul 05540, Republic of Korea
- Department of Occupational Therapy, College of Health Sciences, Yonsei University, Wonju 26493, Republic of Korea
| |
Collapse
|
12
|
Reistetter TA, Dean JM, Haas AM, Prochaska JD, Jupiter DC, Eschbach K, Kuo YF. Development and Evaluation of Rehabilitation Service Areas for the United States. BMC Health Serv Res 2023; 23:204. [PMID: 36859285 PMCID: PMC9976368 DOI: 10.1186/s12913-023-09184-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/15/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Geographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries. METHODS A patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward's clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries. RESULTS The method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care. CONCLUSIONS Rehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.
Collapse
Affiliation(s)
- Timothy A Reistetter
- University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.
| | - Julianna M Dean
- University of Houston-Clear Lake, 2700 Bay Area Blvd, Houston, TX, 77058, USA
| | - Allen M Haas
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - John D Prochaska
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Daniel C Jupiter
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Karl Eschbach
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Yong-Fang Kuo
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| |
Collapse
|
13
|
Uddin T, Ahmed B, Shoma FK. Relations between indoor rehabilitation and basic health services in a developing country. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1001084. [PMID: 36761089 PMCID: PMC9905241 DOI: 10.3389/fresc.2023.1001084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023]
Abstract
Background and Introduction: Physical rehabilitation is vital for patients to regain maximum function. Approximately 80% of people with a disability live in developing countries, where they face multiple challenges in rehabilitation. The goal of the study was to conduct an analysis of indoor rehabilitation programs based on the demographics and medical conditions of the admitted patients and to relate to the available basic health and rehabilitation facilities. Methods This was a mixed method study conducted in an inpatient rehabilitation ward of a tertiary level academic university hospital in a developing country. All admitted patients who stayed for a period of minimum two weeks were included in the study. Demographic and clinical data were obtained by means of a retrospective medical record review utilizing a standardized data extraction form. The study was further strengthened by an online literature search for the available documents for analysis, relation, and discussion. Results Among the 1,309 admitted patients was male- female ratio was 10:7, with the majority (31.4%) cases falling between the ages of 46 and 60yrs. Rehabilitation outpatient department was the principal mode of admission (78%), and musculoskeletal and neurological conditions represented the maximum number (79.8%). Majority of patients (60.8%) were discharged home on completion of the rehabilitation program with a large number of patients who were absconded. Poor health budget allocation and lack of prioritization of the rehabilitation sector face multiple challenges, including the rehabilitation team functioning resources, space crisis for expansion which was further impacted by the COVID-19 pandemic. Conclusions The country's current health-related rehabilitation process and socio-demographic variables have a negative relationship. There was a large number of missing data in the medical records and many patients were lost prematurely from the indoor rehabilitation program. Musculoskeletal disorders were common, and the majority of patients were discharged home once the program was completed.
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Sleep Disturbances Following Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022. [DOI: 10.1007/s40141-022-00351-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
16
|
Suzuki K, Sugiyama R, Katano T, Shigehara H, Takagiwa T, Katafuchi I, Tanabe M, Ozaki H, Numao S, Aoki J, Nishiyama Y, Kimura K. The safety of rapid administration of enteral nutrition in acute stroke patients. J Neurol Sci 2022; 437:120270. [DOI: 10.1016/j.jns.2022.120270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022]
|
17
|
A Post-Acute Care Function Process Quality Measure for the Collection of Standardized Self-Care and Mobility Data: Development, Implementation, and Quality Measure Scores. Arch Phys Med Rehabil 2022; 103:1061-1069. [DOI: 10.1016/j.apmr.2022.01.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/18/2022]
|
18
|
Whitlock KC, Mandala M, Bishop KL, Moll V, Sharp JJ, Krishnan S. Lower AM-PAC 6-Clicks Basic Mobility Score Predicts Discharge to a Postacute Care Facility Among Patients in Cardiac Intensive Care Units. Phys Ther 2022; 102:6413902. [PMID: 34723327 DOI: 10.1093/ptj/pzab252] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 08/19/2021] [Accepted: 10/02/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The objective of this study was to determine the ability of the Activity Measure for Post-Acute Care "6-Clicks" Basic Mobility Short Form to predict patient discharge destination (home vs postacute care [PAC] facility) from the cardiac intensive care unit (ICU), including patients from the cardiothoracic surgical ICU and coronary care unit. METHODS This retrospective cohort study utilized electronic medical records of patients in cardiac ICU (n = 359) in an academic teaching hospital in the southeastern region of United States from September 1, 2017, through August 31, 2018. RESULTS The median interquartile range age of the sample was 68 years (75-60), 55% were men, the median interquartile range 6-Clicks score was 16 (20-12) at the physical therapist evaluation, and 79% of the patients were discharged to home. Higher score on 6-Clicks indicates improved function. A prediction model was constructed based on a machine learning approach using a classification tree. The classification tree was constructed and evaluated by dividing the sample into a train-test split using the Leave-One-Out cross-validation approach. The classification tree split the data into 4 distinct groups along with their predicted outcomes. Patients with a 6-Clicks score >15.5 and a score between 11.5 and 15.5 with primary insurance other than Medicare were discharged to home. Patients with a 6-Clicks score between 11.5 and 15.5 with Medicare insurance and those with a score ≤11.5 were discharged to a PAC facility. CONCLUSION Patients with lower 6-Clicks scores were more likely to be discharged to a PAC facility. Patients without Medicare insurance had to be significantly lower functioning, as indicated by lower 6-Clicks scores for PAC facility placement than those with Medicare insurance. IMPACT The ability of 6-Clicks along with primary insurance to determine discharge destination allows for early discharge planning from cardiac ICUs.
Collapse
Affiliation(s)
- Katelyn C Whitlock
- Department of Rehabilitation Therapy, Emory University Hospital, Atlanta, Georgia, USA
| | - Mahender Mandala
- School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, Georgia, USA.,Apollo Neuroscience, Inc, Pittsburgh, Pennsylvania, USA
| | - Kathy Lee Bishop
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vanessa Moll
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Jennifer J Sharp
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shilpa Krishnan
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta, Georgia, USA.,Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, U.S. Department of Veterans Affairs, Decatur, Georgia, USA
| |
Collapse
|
19
|
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.
Collapse
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.)
| | | |
Collapse
|
20
|
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.
Collapse
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.
| |
Collapse
|
21
|
Cho J, Place K, Salstrand R, Rahmat M, Mansouri M, Fell N, Sartipi M. Developing a Predictive Tool for Hospital Discharge Disposition of Patients Poststroke with 30-Day Readmission Validation. Stroke Res Treat 2021; 2021:5546766. [PMID: 34457232 PMCID: PMC8390171 DOI: 10.1155/2021/5546766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 08/10/2021] [Indexed: 11/17/2022] Open
Abstract
After short-term, acute-care hospitalization for stroke, patients may be discharged home or other facilities for continued medical or rehabilitative management. The site of postacute care affects overall mortality and functional outcomes. Determining discharge disposition is a complex decision by the healthcare team. Early prediction of discharge destination can optimize poststroke care and improve outcomes. Previous attempts to predict discharge disposition outcome after stroke have limited clinical validations. In this study, readmission status was used as a measure of the clinical significance and effectiveness of a discharge disposition prediction. Low readmission rates indicate proper and thorough care with appropriate discharge disposition. We used Medicare beneficiary data taken from a subset of base claims in the years of 2014 and 2015 in our analyses. A predictive tool was created to determine discharge disposition based on risk scores derived from the coefficients of multivariable logistic regression related to an adjusted odds ratio. The top five risk scores were admission from a skilled nursing facility, acute heart attack, intracerebral hemorrhage, admission from "other" source, and an age of 75 or older. Validation of the predictive tool was accomplished using the readmission rates. A 75% probability for facility discharge corresponded with a risk score of greater than 9. The prediction was then compared to actual discharge disposition. Each cohort was further analyzed to determine how many readmissions occurred in each group. Of the actual home discharges, 95.7% were predicted to be there. However, only 47.8% of predictions for home discharge were actually discharged home. Predicted discharge to facility had 15.9% match to the actual facility discharge. The scenario of actual discharge home and predicted discharge to facility showed that 186 patients were readmitted. Following the algorithm in this scenario would have recommended continued medical management of these patients, potentially preventing these readmissions.
Collapse
Affiliation(s)
- Jin Cho
- Department of Computer Science and Engineering, University of Tennessee at Chattanooga, USA
- Center for Urban Informatics and Progress, University of Tennessee at Chattanooga, USA
| | - Krystal Place
- Department of Physical Therapy, University of Tennessee at Chattanooga, USA
| | - Rebecca Salstrand
- Department of Physical Therapy, University of Tennessee at Chattanooga, USA
| | - Monireh Rahmat
- Department of Computer Science and Engineering, University of Tennessee at Chattanooga, USA
- Center for Urban Informatics and Progress, University of Tennessee at Chattanooga, USA
| | - Misagh Mansouri
- Center for Urban Informatics and Progress, University of Tennessee at Chattanooga, USA
| | - Nancy Fell
- Department of Physical Therapy, University of Tennessee at Chattanooga, USA
| | - Mina Sartipi
- Department of Computer Science and Engineering, University of Tennessee at Chattanooga, USA
- Center for Urban Informatics and Progress, University of Tennessee at Chattanooga, USA
| |
Collapse
|
22
|
Ifejika NL, Vahidy FS, Reeves M, Xian Y, Liang L, Matsouaka R, Fonarow GC, Grotta JC. Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage. J Am Heart Assoc 2021; 10:e020528. [PMID: 34387132 PMCID: PMC8475024 DOI: 10.1161/jaha.120.020528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals. Conclusions The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.
Collapse
Affiliation(s)
- Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation UT Southwestern Medical Center Dallas TX.,Department of Neurology UT Southwestern Medical Center Dallas TX.,Department of Population and Data Sciences UT Southwestern Medical Center Dallas TX
| | - Farhaan S Vahidy
- Centers for Outcomes Research Houston Methodist Research Institute Houston TX
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics College of Human Medicine Michigan State University Lansing MI
| | - Ying Xian
- Department of Neurology Duke University Hospital Durham NC.,Duke Clinical Research Institute Durham NC
| | - Li Liang
- Duke Clinical Research Institute Durham NC
| | | | - Gregg C Fonarow
- Division of Cardiology Ahmanson-UCLA Cardiomyopathy CenterUniversity of CaliforniaLos Angeles, Medical Center Los Angeles CA
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit Memorial Hermann Hospital-Texas Medical Center Houston TX
| |
Collapse
|
23
|
Plys E, Morrow CD, Portz JD, Jones CD, Piper C, Boxer RS. Psychological interventions with older adults during inpatient postacute rehabilitation: A systematic review. Rehabil Psychol 2021; 66:233-247. [PMID: 34472922 PMCID: PMC8622202 DOI: 10.1037/rep0000383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Older adults in inpatient postacute care settings report high rates of depression and anxiety. Psychological interventions address these symptoms through educational, cognitive, behavioral, relaxation, and/or psychosocial approaches. The purpose of this study was to systematically evaluate the quality of existing literature on psychological interventions for depression and/or anxiety among older adults during an inpatient postacute care stay. Method: Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Google Scholar were searched for key concepts. Studies were included that (a) sampled skilled nursing facility or inpatient rehabilitation facility patients, (b) evaluated a psychological intervention, (c) measured depression and/or anxiety symptoms before and after interventions, and (d) had a mean or median age of 65+. Two raters assessed articles for inclusion and risk of bias. Results: Search strategies identified 7,506 articles for screening; nine met inclusion criteria. Included studies varied by study design, intervention type, and methodological quality. Only one study had low overall risk of bias. Four studies demonstrated preliminary treatment benefits for depression symptoms; none reported benefits for anxiety symptoms. Conclusions: Most of the included studies were limited by small sample size and high risk of bias. Thus, currently, there is insufficient evidence to support the effectiveness of psychological interventions for depression or anxiety among older adults during an inpatient postacute care stay. The authors offer a detailed discussion of methodological limitations, empirical gaps, and future directions to develop this body of literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Collapse
Affiliation(s)
- Evan Plys
- Department of Psychiatry, University of Colorado School of Medicine
| | - Cynthia D Morrow
- Health Systems Management and Policy, Colorado School of Public Health
| | - Jennifer D Portz
- Division of General Internal Medicine, University of Colorado School of Medicine
| | - Christine D Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System
| | - Christi Piper
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente of Colorado
| |
Collapse
|
24
|
Executive Function Moderates Functional Outcomes of Engagement Strategies During Rehabilitation in Older Adults. Am J Phys Med Rehabil 2021; 100:635-642. [PMID: 34131093 DOI: 10.1097/phm.0000000000001739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study examined cognitive, affective, and medical impairments and their impact on rehabilitation approaches for improving functional outcome after hospitalization in older adults. DESIGN A secondary analysis of a randomized clinical trial in 229 adults 65 yrs or older admitted to two skilled nursing facilities undergoing rehabilitation services was conducted. Patients were randomized to receive physical and occupational therapy by therapists trained in systematic approaches to engage patients, called Enhanced Medical Rehabilitation, or standard of care. The outcome of interest was functional improvement, defined as Barthel Index at discharge (controlling for Barthel Index upon admission). This study analyzed the relationship of measures of cognition, depression, and medical comorbidities as predictors of functional outcome and as moderators interacting with treatment group. RESULTS Clock drawing score moderated treatment effect size; the functional improvement of Enhanced Medical Rehabilitation over standard of care therapy reduced with increasing executive impairment. In contrast, general cognitive abilities, depression, medical comorbidities, and readiness for rehabilitation were neither predictors nor moderators of functional improvement. CONCLUSIONS For older adults undergoing rehabilitation, greater functional improvement with the motivational techniques of Enhanced Medical Rehabilitation was contingent on patients having intact executive function. Given that executive function impairments are common in rehabilitation populations, new strategies are needed to improve treatment outcomes in physical/occupational therapy. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES Upon completion of this article, the reader should be able to (1) Discuss the role of baseline affective, cognitive, and medical impairments in impacting functional outcomes of older adults undergoing rehabilitation; (2) Describe the behavioral change and motivational approaches that are core features of the novel intervention known as Enhanced Medical Rehabilitation (E-MR); and (3) Determine the role of baseline executive function in moderating the effect of rehabilitation intervention on functional outcomes in older adults. LEVEL Advanced. ACCREDITATION The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Collapse
|
25
|
Evans E, Krebill C, Gutman R, Resnik L, Zonfrillo MR, Lueckel SN, Zhang W, Kumar RG, Dams-O'Connor K, Thomas KS. Functional motor improvement during inpatient rehabilitation among older adults with traumatic brain injury. PM R 2021; 14:417-427. [PMID: 34018693 DOI: 10.1002/pmrj.12644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/21/2021] [Accepted: 05/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Older adults comprise an increasingly large proportion of patients with traumatic brain injury (TBI) receiving care in inpatient rehabilitation facilities (IRF). However, high rates of comorbidities and evidence of declining preinjury health among older adults who sustain TBI raise questions about their ability to benefit from IRF care. OBJECTIVES To describe the proportion of older adults with TBI who exhibited minimal detectable change (MDC) and a minimally clinically important difference (MCID) in motor function from IRF admission to discharge; and to identify characteristics associated with clinically meaningful improvement in motor function and better discharge functional status. DESIGN This retrospective cohort study used Medicare administrative data probabilistically linked to the National Trauma Data Bank to estimate the proportion of patients whose motor function improved during inpatient rehabilitation and identify factors associated with meaningful improvement in motor function and motor function at discharge. SETTING Inpatient rehabilitation facilities in the United States. PATIENTS Fee-for-service Medicare beneficiaries with TBI. MAIN OUTCOME MEASURES Minimal Detectable Change (MDC) and Minimally Clinically Important Difference (MCID) in the Functional Independence Measure motor (FIM-M) score from admission to discharge, and FIM-M score at IRF discharge. RESULTS From IRF admission to discharge 84% of patients achieved the MDC threshold, and 68% of patients achieved the MCID threshold for FIM-M scores. Factors associated with a higher probability of achieving the MCID for FIM-M scores included better admission motor and cognitive function, lower comorbidity burden, and a length of stay longer than 10 days but only among individuals with lower admission motor function. Older age was associated with a lower FIM-M discharge score, but not the probability of achieving the MCID in FIM-M score. CONCLUSION Older adults with TBI have the potential to improve their motor function with IRF care. Baseline functional status and comorbidity burden, rather than acute injury severity, should be used to guide care planning.
Collapse
Affiliation(s)
- Emily Evans
- Department of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cicely Krebill
- Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Linda Resnik
- Department of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health and Providence VA Medical Center, Providence, Rhode Island, USA
| | - Mark R Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Stephanie N Lueckel
- Division of Acute Care Surgery and Surgical Critical Care, Rhode Island Hospital, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Wenhan Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Raj G Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kali S Thomas
- Department of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health and Providence VA Medical Center, Providence, Rhode Island, USA
| |
Collapse
|
26
|
Abrams LR, Hoffman GJ. Skilled Nursing Facilities Modify the Relationship Between Depressive Symptoms and Hospital Readmissions but Not Health Outcomes Among Older Adults. J Aging Health 2021; 33:817-827. [PMID: 33929271 DOI: 10.1177/08982643211013127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Despite detrimental effects of depressive symptoms on self-care and health, hospital discharge practices and the benefits of different discharge settings are poorly understood in the context of depression. Methods: This retrospective cohort study comprised 23,485 hospitalizations from Medicare claims linked to the Health and Retirement Study (2000-2014). Results: Respondents with depressive symptoms were no more likely to be referred to home health, whereas the probability of discharge to skilled nursing facilities (SNFs) went up a half percentage point with each increasing symptom, even after adjusting for family support and health. Rehabilitation in SNFs, compared to routine discharges home, reduced the positive association between depressive symptoms and 30-day hospital readmissions (OR = 0.95, p = 0.029) but did not prevent 30-day falls, 1-year falls, or 1-year mortality associated with depressive symptoms. Discussion: Depressive symptoms were associated with discharges to SNFs, but SNFs do not appear to address depressive symptoms to enhance functioning and survival.
Collapse
Affiliation(s)
- Leah R Abrams
- Harvard Center for Population and Development Studies, 1857Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - Geoffrey J Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
| |
Collapse
|
27
|
Roberts P, Wertheimer J, Park E, Nuño M, Riggs R. Identification of Functional Limitations and Discharge Destination in Patients With COVID-19. Arch Phys Med Rehabil 2021; 102:351-358. [PMID: 33278363 PMCID: PMC7709477 DOI: 10.1016/j.apmr.2020.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/15/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The objectives of this study were to identify functional limitations in patients with coronavirus 2019 (COVID-19) admitted to acute care hospitals; to evaluate functional limitations by demographic, medical, and encounter characteristics; and to examine functional limitations in relation to discharge destination. DESIGN and Setting:This is a cross-sectional, retrospective study of adult patients with COVID-19 who were discharged from 2 different types of hospitals (academic medical center and a community hospital) within 1 health care system from January 1 to April 30, 2020. PARTICIPANTS Patients were identified from the Cedars-Sinai COVID-19 data registry who had a new-onset positive test for severe acute respiratory syndrome coronavirus 2. A total of 273 patients were identified, which included 230 patients who were discharged alive and 43 patients who died and were excluded from the study sample. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Functional limitations in patients with COVID-19 in acute care hospitals and the predictors for discharge disposition. RESULTS A total of 230 records were analyzed including demographic, encounter, medical, and functional variables. In a propensity score-matched cohort based on age and comorbidity, 88.2% had functional physical health deficits, 72.5% had functional mental health deficits, and 17.6% experienced sensory deficits. In the matched cohort, individuals discharged to an institution experienced greater physical (62.7% vs 25.5%, P<.001) and mental health (49.0% vs 23.5%, P=.006) deficits than patients discharged home. Marital status (odds ratio, 3.17; P=.011) and physical function deficits (odds ratio, 3.63; P=.025) were associated with an increase odds ratio of discharge to an institution. CONCLUSIONS This research highlights that functional status is a strong predictor for discharge destination to an institution for patients with COVID-19. Patients who were older, in the acute care hospital longer, and with comorbidities were more likely to be discharged to an institution. Rehabilitation is a significant aspect of the health care system for these vulnerable patients. The challenges of adjusting the role of rehabilitation providers and systems during the pandemic needs further exploration. Moreover, additional research is needed to look more closely at the many facets and timing of functional status needs, to shed light in use of interdisciplinary rehabilitation services, and to guide providers and health care systems in facilitating optimal recovery and patient outcomes.
Collapse
Affiliation(s)
- Pamela Roberts
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, California; Department of Enterprise Information Services, Cedars-Sinai, Los Angeles, California; Department of Medical Affairs, Cedars-Sinai, Los Angeles, California.
| | - Jeffrey Wertheimer
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, California
| | - Eunice Park
- Department of Enterprise Information Services, Cedars-Sinai, Los Angeles, California
| | - Miriam Nuño
- University of California, Davis, Department of Public Health Sciences, Davis, California
| | - Richard Riggs
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, California; Department of Medical Affairs, Cedars-Sinai, Los Angeles, California
| |
Collapse
|
28
|
Daras LC, Deutsch A, Ingber MJ, Hefele JG, Perloff J. Inpatient rehabilitation facilities' hospital readmission rates for medicare beneficiaries treated following a stroke. Top Stroke Rehabil 2020; 28:61-71. [PMID: 32657256 DOI: 10.1080/10749357.2020.1771927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Stroke is the leading cause for admission to the nearly 1,200 Inpatient Rehabilitation Facilities (IRFs) nationally in the US. For many patients, post-acute care is an important component of their rehabilitation. Several quality measures have been publicly reported for post-acute care providers, including hospital readmissions. However, to date none have focused on specific medical conditions, limiting the usability for patients and quality improvement. OBJECTIVE To assess hospital readmission rates for Medicare patients receiving inpatient rehabilitation following stroke and to identify risk factors in order to evaluate the feasibility of a stroke-specific hospital readmission measure. METHODS Observational study analyzing national Medicare inpatient claims and administrative data to assess hospital readmissions. Using logistic regression, we calculated unadjusted and risk-standardized readmission rates, which adjusted for patient characteristics, including type of stroke and admission function, to capture stroke severity. RESULTS Our national study included 116,073 fee-for-service Medicare beneficiary discharged from IRFs in 2013-2014 following stroke from 1,162 IRFs nationally. The observed hospital readmission rate among IRF patients following stroke was 11.6% and varied by patients' admission motor function. Patients with greater functional dependence had higher readmission rates on average. Lower admission function, hemorrhagic and other stroke types (relative to ischemic) were significantly associated with higher odds of hospital readmission. CONCLUSION Results suggest it is feasible to assess hospital readmission rates among a stroke-cohort treated in IRFs. Stroke-focused quality measures would be useful to patients in selecting a provider and for providers in evaluating their stroke rehabilitation program outcomes. Secondary results suggest that admission function (FIM) capture stroke severity, a limitation with other claims-based stroke measures.
Collapse
Affiliation(s)
| | - Anne Deutsch
- eHealth, Quality and Analytics, RTI International , Durham, NC, USA.,Shirley Ryan AbilityLab , Chicago,IL, USA.,School of Medicine, Northwestern University Feinberg
| | - Melvin J Ingber
- eHealth, Quality and Analytics, RTI International , Durham, NC, USA
| | - Jennifer Gaudet Hefele
- Heller School for Social Policy & Management, Brandeis University , Waltham, MA, USA.,Booz Allen Hamilton , Chicago,IL, USA.,Gerontology Institute, University of Massachusetts-Boston , Chicago,IL, USA
| | - Jennifer Perloff
- Heller School for Social Policy & Management, Brandeis University , Waltham, MA, USA
| |
Collapse
|
29
|
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.
Collapse
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
| | | |
Collapse
|
30
|
Abstract
In the United States, we are blessed with many options for postacute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports.
Collapse
Affiliation(s)
- Robert Samuel Mayer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA.
| | - Amira Noles
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA
| | - Dominique Vinh
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA
| |
Collapse
|
31
|
Hong I, Goodwin JS, Reistetter TA, Kuo YF, Mallinson T, Karmarkar A, Lin YL, Ottenbacher KJ. Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities. JAMA Netw Open 2019; 2:e1916646. [PMID: 31800069 PMCID: PMC6902754 DOI: 10.1001/jamanetworkopen.2019.16646] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
IMPORTANCE Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. OBJECTIVE To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. EXPOSURES Inpatient rehabilitation received in IRFs vs SNFs. MAIN OUTCOMES AND MEASURES Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. RESULTS Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. CONCLUSIONS AND RELEVANCE In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.
Collapse
Affiliation(s)
- Ickpyo Hong
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston
| | - James S. Goodwin
- University of Texas Medical Branch, School of Medicine, Sealy Center on Aging, Department of Internal Medicine, Galveston
| | - Timothy A. Reistetter
- University of Texas Health Science Center at San Antonio, School of Health Professions, Department of Occupational Therapy, San Antonio
| | - Yong-Fang Kuo
- University of Texas Medical Branch, School of Medicine, Sealy Center on Aging, Department of Preventive Medicine and Population Health, Galveston
| | - Trudy Mallinson
- George Washington University, School of Medicine and Health Sciences, Clinical Research and Leadership, Washington, DC
| | - Amol Karmarkar
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston; now with Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
| | - Yu-Li Lin
- University of Texas Medical Branch, School of Medicine, Department of Preventive Medicine and Population Health, Galveston
| | - Kenneth J. Ottenbacher
- University of Texas Medical Branch, School of Health Professions, Sealy Center on Aging, Division of Rehabilitation Sciences, Galveston
| |
Collapse
|
32
|
Kaufman BG, O'Brien EC, Stearns SC, Matsouaka R, Holmes GM, Weinberger M, Song PH, Schwamm LH, Smith EE, Fonarow GC, Xian Y. The Medicare Shared Savings Program and Outcomes for Ischemic Stroke Patients: a Retrospective Cohort Study. J Gen Intern Med 2019; 34:2740-2748. [PMID: 31452032 PMCID: PMC6854149 DOI: 10.1007/s11606-019-05283-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/10/2019] [Accepted: 07/25/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care. OBJECTIVE To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke. DESIGN Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605). MAIN MEASURES Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated. KEY RESULTS For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed. CONCLUSIONS Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted. REGISTRATION None.
Collapse
Affiliation(s)
- Brystana G Kaufman
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - G Mark Holmes
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula H Song
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Gregg C Fonarow
- Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC, USA
| |
Collapse
|
33
|
Pappadis MR, Krishnan S, Hay CC, Jones B, Sander AM, Weller SC, Reistetter TA. Lived experiences of chronic cognitive and mood symptoms among community-dwelling adults following stroke: a mixed-methods analysis. Aging Ment Health 2019; 23:1227-1233. [PMID: 30369243 PMCID: PMC6486878 DOI: 10.1080/13607863.2018.1481927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objectives: Few studies have explored the lived experiences of chronic cognitive and mood symptoms following stroke using a racially/ethnically diverse sample. Therefore, we aimed to explore the perceptions of chronic post-stroke cognition and mood symptoms and goals among a racially/ethnically diverse sample of community-dwelling adults aging with stroke. Method: This qualitative study using mixed-methods analysis included semi-structured interviews regarding perceived post-stroke cognitive and mood symptoms among community-dwelling stroke survivors at least one-year post stroke. Transcripts were subjected to thematic content analysis, and differences in theme usage patterns by age, gender, race/ethnicity, and post-acute rehabilitation setting were assessed using an inferential clustering technique. Results: The majority of participants (93%) reported cognition-related themes, including language and communication, memory, thinking abilities, comprehension, visual-spatial processing, and cognitive assessments and training. Nearly half of participants mentioned mood-related themes, including depression, aggression and anger, mood fluctuations, anxiety, and psychological services and medication. Nearly half reported an unmet need for cognition or mood-related treatment. Inferential clustering analysis revealed that older participants reported a different pattern of cognitive and mood symptoms than those aged younger than 65 (p = 0.02). Older adults were more likely to describe post-stroke language/communication changes, while younger adults described post-stroke mood changes. Conclusion: Stroke survivors experienced cognitive and mood-related symptoms beyond one-year post stroke, which has implications for long-term assessment and management. Incorporation of continued symptom monitoring into existing community-based services is needed to address chronic cognitive and mood symptoms affecting the quality of life of persons with stroke.
Collapse
Affiliation(s)
- Monique R. Pappadis
- Division of Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch at Galveston (UTMB), Galveston, TX, USA;,Sealy Center on Aging, UTMB, 301 University Blvd., Galveston, TX, USA;,Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA
| | - Shilpa Krishnan
- Sealy Center on Aging, UTMB, 301 University Blvd., Galveston, TX, USA;,Department of Occupational Therapy, School of Health Professions, UTMB, Galveston, TX, USA
| | - Catherine C. Hay
- Division of Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch at Galveston (UTMB), Galveston, TX, USA
| | - Beata Jones
- Division of Clinical Neuropsychology and Psychology, University of Gdansk, Gdansk, Poland
| | - Angelle M. Sander
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA;,Departments of Physical Medicine and Rehabilitation & Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA;,Center for Neurotrauma Rehabilitation, Department of Physical Medicine & Rehabilitation, Harris Health System, Houston, TX, USA
| | - Susan C. Weller
- Sealy Center on Aging, UTMB, 301 University Blvd., Galveston, TX, USA;,Department of Preventive Medicine and Community Health, UTMB, Galveston, TX, USA;,Department of Family Medicine, UTMB, TX, USA
| | - Timothy A. Reistetter
- Division of Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch at Galveston (UTMB), Galveston, TX, USA;,Sealy Center on Aging, UTMB, 301 University Blvd., Galveston, TX, USA;,Department of Occupational Therapy, School of Health Professions, UTMB, Galveston, TX, USA
| |
Collapse
|
34
|
Stulberg EL, Dong L, Zheutlin AR, Kim S, Claflin ES, Skolarus LE, Morgenstern LB, Lisabeth LD. Associations of Self-Reported History of Depression and Antidepressant Use Before Stroke Onset With Poststroke Post-Acute Rehabilitation Care-An Exploratory Study: The BASIC (Brain Attack Surveillance in Corpus Christi) Project. J Am Heart Assoc 2019; 8:e013382. [PMID: 31423875 PMCID: PMC6759886 DOI: 10.1161/jaha.119.013382] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Prestroke depression status and post–acute rehabilitation care (PARC) are determinants of poststroke depression and function. However, little is known on how prestroke depression status affects PARC placement, a possible pathway for upstream intervention. We examined how prestroke depression status affects PARC in a population‐based study. Methods and Results Incident ischemic stroke cases were from the BASIC (Brain Attack Surveillance in Corpus Christi) Project from 2008 to 2012. Prestroke depression status was self‐reported and categorized as (1) never depressed, (2) history of depression without antidepressant use before stroke onset, or (3) antidepressant use before stroke onset. PARC included home, a skilled nursing facility, or an inpatient rehabilitation facility. Confounder‐adjusted multinomial regression models were used to examine the association between prestroke depression status and PARC. Adjustment for stroke severity was deferred in the main analyses because it may lie on the causal pathway. There were 548 stroke survivors (mean age 65.3 years, 48.3% female, 62.6% Mexican‐American). The adjusted odds ratios comparing home discharge to a skilled nursing facility were 1.88 (95% CI: 0.86‐4.11) for those with a history of depression and 2.55 (95% CI: 1.11‐5.83) for those using an antidepressant at stroke onset, relative to those never depressed. The adjusted odds ratios comparing an inpatient rehabilitation facility to a skilled nursing facility were 1.17 (95% CI 0.40‐3.42) and 3.28 (95% CI 1.24‐8.67) for those with a history of depression and those using an antidepressant at stroke onset, respectively, relative to those never depressed. Conclusions Antidepressant use before stroke onset may increase odds of home and inpatient rehabilitation facility discharge compared with skilled nursing facility discharge.
Collapse
Affiliation(s)
- Eric L Stulberg
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,Northwestern University Feinberg School of Medicine Chicago IL
| | - Liming Dong
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI
| | - Alexander R Zheutlin
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,University of Michigan School of Medicine Ann Arbor MI
| | - Sehee Kim
- Department of Biostatistics University of Michigan School of Public Health Ann Arbor MI
| | - Edward S Claflin
- Department of Physical Medicine and Rehabilitation University of Michigan School of Medicine Ann Arbor MI
| | - Lesli E Skolarus
- Department of Neurology University of Michigan School of Medicine Ann Arbor MI
| | - Lewis B Morgenstern
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,Department of Neurology University of Michigan School of Medicine Ann Arbor MI
| | - Lynda D Lisabeth
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,Department of Neurology University of Michigan School of Medicine Ann Arbor MI
| |
Collapse
|
35
|
Multidiscipline Stroke Post-Acute Care Transfer System: Propensity-Score-Based Comparison of Functional Status. J Clin Med 2019; 8:jcm8081233. [PMID: 31426354 PMCID: PMC6724215 DOI: 10.3390/jcm8081233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 12/19/2022] Open
Abstract
Few studies have investigated the characteristics of stroke inpatients after post-acute care (PAC) rehabilitation, and few studies have applied propensity score matching (PSM) in a natural experimental design to examine the longitudinal impacts of a medical referral system on functional status. This study coupled a natural experimental design with PSM to assess the impact of a medical referral system in stroke patients and to examine the longitudinal effects of the system on functional status. The intervention was a hospital-based, function oriented, 12-week to 1-year rehabilitative PAC intervention for patients with cerebrovascular diseases. The average duration of PAC in the intra-hospital transfer group (31.52 days) was significantly shorter than that in the inter-hospital transfer group (37.1 days) (p < 0.001). The intra-hospital transfer group also had better functional outcomes. The training effect was larger in patients with moderate disability (Modified Rankin Scale, MRS = 3) and moderately severe disability (MRS = 4) compared to patients with slight disability (MRS = 2). Intensive post-stroke rehabilitative care delivered by per-diem payment is effective in terms of improving functional status. To construct a vertically integrated medical system, strengthening the qualified local hospitals with PAC wards, accelerating the inter-hospital transfer, and offering sufficient intensive rehabilitative PAC days are the most essential requirements.
Collapse
|
36
|
Lenze EJ, Lenard E, Bland M, Barco P, Miller JP, Yingling M, Lang CE, Morrow-Howell N, Baum CM, Binder EF, Rodebaugh TL. Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e198199. [PMID: 31365113 PMCID: PMC6669784 DOI: 10.1001/jamanetworkopen.2019.8199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Enhanced medical rehabilitation (EMR) is a systematic and standardized approach for physical and occupational therapists to engage patients. Higher patient engagement in therapy might lead to improved functional recovery in rehabilitation settings, such as skilled nursing facilities (SNFs). OBJECTIVE To determine whether EMR improves older adults' functional recovery. DESIGN, SETTING, AND PARTICIPANTS A double-blind, parallel-group, randomized clinical trial was conducted from July 29, 2014, to July 13, 2018, in 229 adults aged 65 years or older admitted to 2 US SNFs. Participants were randomized to receive EMR (n = 114) vs standard-of-care rehabilitation (n = 115). Intention-to-treat analysis was used. INTERVENTIONS The intervention group received their physical and occupational therapy from therapists trained in EMR. Based on models of motivation and behavior change, EMR is a toolkit of techniques to increase patient engagement and therapy intensity. The control group received standard-of-care rehabilitation from physical and occupational therapists not trained in EMR. MAIN OUTCOMES AND MEASURES The primary outcome was change in function in activities of daily living and mobility, as assessed with the Barthel Index, which measures 10 basic activities of daily living or mobility items (scale range, 0-100), from SNF admission to discharge; secondary outcomes were gait speed for 10 m, 6-minute walk test, discharge disposition, rehospitalizations, and self-reported functional status at days 30, 60, and 90. To examine the rehabilitation process, therapists' engagement with patients and patient active time during therapy were measured for a sample of the sessions. RESULTS Of the 229 participants, 149 (65.1%) were women; 177 (77.3%) were white, and 51 (22.3%) were black; mean (SD) age was 79.3 (8.0) years. Participants assigned to EMR showed greater recovery of function than those assigned to standard of care (mean increase in Barthel Index score, 35 points; 95% CI, 31.6-38.3 vs 28 points; 95% CI, 25.2-31.7 points; P = .007). There was no evidence of a difference in the length of stay (mean [SD], 23.5 [13.1] days). However, there were no group by time differences in secondary outcome measures, including self-reported function after SNF discharge out to 90 days as measured on the Barthel Index (mean [SE] score: EMR, 83.65 [2.20]; standard of care, 84.67 [2.16]; P = .96). The EMR therapists used a median (interquartile range) of 24.4 (21.0-37.3) motivational messages per therapy session vs 2.3 (1.1-2.9) for nontrained therapists (P < .001), and EMR patients were active during a mean (SD) of 52.5 (6.6%) of the therapy session time vs 41.2 (6.8%) for nontrained therapists (P = .001). CONCLUSIONS AND RELEVANCE Enhanced medical rehabilitation modestly improved short-term functional recovery for selected older adults rehabilitating in SNFs. However, there was no evidence that the benefits persisted over the longer term. This study demonstrates the value of engaging and motivating older adults in rehabilitation therapy, but more work is needed to extend these benefits to longer-term outcomes after discharge home. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02114879.
Collapse
Affiliation(s)
- Eric J. Lenze
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Emily Lenard
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Marghuretta Bland
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Peggy Barco
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - J. Philip Miller
- Division of Biostatistics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael Yingling
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Catherine E. Lang
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nancy Morrow-Howell
- Brown School of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Carolyn M. Baum
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ellen F. Binder
- Division of Geriatrics and Nutritional Science, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas L. Rodebaugh
- Department of Psychological and Brain Sciences, Washington University in St Louis, St Louis, Missouri
| |
Collapse
|
37
|
Tse MMY, Kwan RYC, Ho SSM, Davidson PM, Cheng PPP, Yeung SSY. Frailty is associated with pain and cognitive function in older people in post-acute care settings. Geriatr Nurs 2019; 41:530-535. [PMID: 31053385 DOI: 10.1016/j.gerinurse.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/06/2019] [Accepted: 04/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND To describe pain, cognitive function, and frailty of older people in post-acute care settings and examine the association between the three elements. METHODS This cross-sectional study involved 142 participants from a rehabilitation ward and a geriatric day centre. Pain, cognitive function and frailty were assessed using Brief Pain Inventory, Abbreviated Mental Test, and 5-item Frail Scale respectively. RESULTS Participants were mostly women (51.7%) with a mean age of 76.5 (SD 7.8). Mean scores for pain, cognition, and frailty were 9.0 ± 1.0, 4.0 ± 2.8, and 2.2 ± 1.2, respectively. Cognition had a significant inverse association with frailty (β = -0.160, p = 0.047), and pain had a significant positive association with frailty (β = 5.122, p < 0.001). This linear regression model explained a variance of 0.269. CONCLUSIONS The study demonstrated the association between pain, cognitive function, and frailty. In predicting frailty, however, more studies are required to determine the predictive value and cut-off points for pain and cognitive measures.
Collapse
Affiliation(s)
- Mimi M Y Tse
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong.
| | - Rick Y C Kwan
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Simone S M Ho
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | | | | | - Suey S Y Yeung
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
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]
|
40
|
Sawabe M, Momosaki R, Hasebe K, Sawaguchi A, Kasuga S, Asanuma D, Suzuki S, Miyauchi N, Abo M. Rehabilitation Characteristics in High-Performance Hospitals after Acute Stroke. J Stroke Cerebrovasc Dis 2018; 27:2431-2435. [PMID: 29801813 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/20/2018] [Accepted: 04/26/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Rehabilitation characteristics in high-performance hospitals after acute stroke are not clarified. This retrospective observational study aimed to clarify the characteristics of high-performance hospitals in acute stroke rehabilitation. METHODS Patients with stroke discharged from participating acute hospitals were extracted from the Japan Rehabilitation Database for the period 2006-2015. We found 6855 patients from 14 acute hospitals who were eligible for analysis in this study after applying exclusion criteria. We divided facilities into high-performance hospitals and low-performance hospitals using the median of the Functional Independent Measure efficiency for each hospital. We compared rehabilitation characteristics between high- and low-performance hospitals. RESULTS High-performance hospitals had significantly shorter length of stay. More patients were discharged to home in the high-performance hospitals compared with low-performance hospitals. Patients in high-performance hospitals received greater amounts of physical, occupational, and speech therapy. Patients in high-performance hospitals engaged in more self-exercise, weekend exercise, and exercise in wards. There was more participation of board-certified physiatrists and social workers in high-performance hospitals. CONCLUSIONS Our data suggested that amount, timing, and type of rehabilitation, and participation of multidisciplinary staff are essential for high performance in acute stroke rehabilitation.
Collapse
Affiliation(s)
- Masashi Sawabe
- Department of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan; Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kiyotaka Hasebe
- Department of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Akira Sawaguchi
- Department of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Seiji Kasuga
- Department of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Daichi Asanuma
- Department of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Shoya Suzuki
- Department of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Narimi Miyauchi
- Department of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|