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Henderson C, Virva R, Lenca L, Butzer JF, Lovell L, Roth E, Hornby TG, Moore JL. Gait and Balance Outcome Measures are Responsive in Severely Impaired Individuals Undergoing Inpatient Stroke Rehabilitation. Arch Phys Med Rehabil 2022; 103:1210-1212.e1. [PMID: 35093332 DOI: 10.1016/j.apmr.2022.01.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To investigate whether gait and balance outcome measures in patients with severe gait and balance impairments at admission to inpatient rehabilitation provided additional and meaningful information beyond customary measures. Specifically, this study investigated whether individuals who obtained low scores at admission exhibited improvements that exceeded the established minimal detectable change (MDC) during inpatient rehabilitation. We also investigated whether gait outcomes would capture changes in function not identified by customary measures. DESIGN Secondary analysis of a knowledge translation project aimed at increasing the systematic collection of these outcome measures in a poststroke cohort. SETTING Subacute inpatient rehabilitation facility. PARTICIPANTS Individuals <2 months poststroke (n=157) with 34-43 with severe deficits including Berg Balance Scale ≤5, 10-meter walk test =0 m/s, or 6-minute walk test =0 m. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Berg Balance Scale, 10-meter walk test, 6-minute walk test RESULTS: After one week of rehabilitation, 41%-53% of severely impaired individuals had changes above MDCs in gait and balance outcomes, which increased to 68%-84% at discharge. Across the entire cohort, Functional Independence Measure locomotion scores failed to identify changes in gait function for 35% of participants after one week of rehabilitation. CONCLUSIONS Routine assessment of gait and balance outcome measures with patients with severe deficits early poststroke may be beneficial. These measures were responsive after one week of rehabilitation and detected changes not captured by customary measures. Routine use of a standardized gait and balance assessments may provide clinicians with important information to guide clinical decision-making.
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Affiliation(s)
- Christopher Henderson
- Indiana University School of Medicine, Indianapolis, IN; Institute for Knowledge Translation, Carmel IN.
| | - Roberta Virva
- Mary Free Bed Rehabilitation Hospital, Grand Rapids MI
| | - Lauren Lenca
- Mary Free Bed Rehabilitation Hospital, Grand Rapids MI
| | - John F Butzer
- Mary Free Bed Rehabilitation Hospital, Grand Rapids MI
| | | | - Elliot Roth
- Shirley Ryan AbilityLab, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
| | - T George Hornby
- Indiana University School of Medicine, Indianapolis, IN; Institute for Knowledge Translation, Carmel IN
| | - Jennifer L Moore
- Institute for Knowledge Translation, Carmel IN; South Eastern Norway Regional Center of Knowledge Translation in Rehabilitation, Oslo, Norway
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Jacobs M, Ellis C. Estimating the cost and value of functional changes in communication ability following telepractice treatment for aphasia. PLoS One 2021; 16:e0257462. [PMID: 34534254 PMCID: PMC8448307 DOI: 10.1371/journal.pone.0257462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 09/01/2021] [Indexed: 12/02/2022] Open
Abstract
Context Aphasia is a post-stroke condition that can dramatically impact a person with aphasia’s (PWA) communication abilities. To date, few if any studies have considered the cost and cost-effectiveness of functional change in aphasia nor considered measures of patient’s value for aphasia treatment. Objective To assess the cost, cost-effectiveness, and perceived value associated with improved functional communication in individuals receiving telerehabilitation treatment for aphasia. Design Twenty PWA completed between 5 and 12 telehealth rehabilitation sessions of 45–60 minutes within a 6-week time frame using a Language-Oriented Treatment (LOT) designed to address a range of language issues among individuals with aphasia. National Outcomes Measures (NOMS) comprehension and verbal expression and the ASHA Quality of Communication Life (QCL) were completed prior to and at the completion of rehabilitation to obtain baseline and treatment measures. Results Age, education, and race are significantly correlated with improvement in the NOMS verbal expression. African Americans (OR = 2.0917) are twice as likely as Whites to experience improvement after treatment. The likelihood of improvement also increases with each additional year of education (OR = 1.002) but decrease with age (OR = 0.9463). A total of 15 PWA showed improvement in NOMS comprehension and nine patients showed improvement in NOMS verbal expression. Improving patients attended between five and 12 treatment sessions. The average cost of improvement in NOMS comprehension was $1,152 per patient and NOMS verbal expression was $1,128 per patient with individual treatment costs varying between $540 and $1,296. However, on average, the monetary equivalent in patient’s improved QCL was between $1,790.39 to $3,912,54—far exceeding the financial cost of treatment. Conclusions When measuring the functional improvement of patients with aphasia, patient’s quality of communication life received from treatment exceeded financial cost of services provided.
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Affiliation(s)
- Molly Jacobs
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Charles Ellis
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, United States of America
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Simmonds KP, Burke J, Kozlowski AJ, Andary M, Luo Z, Reeves MJ. Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities. Arch Phys Med Rehabil 2021; 103:1213-1221. [PMID: 34480886 DOI: 10.1016/j.apmr.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Abstract
In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.
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Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - James Burke
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Allan J Kozlowski
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI
| | - Michael Andary
- Department of Physical Medicine & Rehabilitation, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI.
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Jordan N, Deutsch A. Why and How to Demonstrate the Value of Rehabilitation Services. Arch Phys Med Rehabil 2021; 103:S172-S177. [PMID: 34407445 DOI: 10.1016/j.apmr.2021.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/29/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
Abstract
The health care delivery landscape in the United States is changing as payment models consider both costs and health outcomes, which are key components of value in health care. Without evidence about the effectiveness and costs of rehabilitation interventions, it is difficult to judge the value of rehabilitation interventions. Understanding the short- and long-term costs associated with implementing a rehabilitation intervention and the intervention's cost-effectiveness compared with other alternatives is critical to supporting decision-making by policymakers, health care administrators, and other decision makers. This article describes the policy context for considering the costs and outcomes of postacute care and rehabilitation interventions, introduces methods for assessing the value of rehabilitation interventions, and summarizes the challenges and opportunities associated with applying value measurement to rehabilitation services. Assessing the value of rehabilitation interventions is critical as we continue to identify, implement, and sustain evidence-based interventions that promote the health and function of people with disabilities.
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Affiliation(s)
- Neil Jordan
- Northwestern University Feinberg School of Medicine, Chicago, IL; Edward J Hines Jr Hospital VA, Hines, IL.
| | - Anne Deutsch
- Northwestern University Feinberg School of Medicine, Chicago, IL; Shirley Ryan AbilityLab, Chicago, IL; RTI International, Chicago, IL
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Commentary on the Challenges and Benefits of Implementing Standardized Outcome Measures. Arch Phys Med Rehabil 2020; 103:S246-S251. [PMID: 33248124 DOI: 10.1016/j.apmr.2020.10.132] [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: 07/16/2020] [Revised: 09/09/2020] [Accepted: 10/01/2020] [Indexed: 11/23/2022]
Abstract
The Institute of Medicine (now the National Academy of Medicine) has proposed a Learning Heath system (LHS) as a model to improve health care. A LHS focuses on capturing data from the clinical encounter and applying those data to improve practice. The process can be described as an iterative learning cycle composed of 3 areas: performance to data, data to knowledge, and knowledge to performance or often knowledge translation. Adoption of new knowledge in medicine is notoriously slow, and the relatively new field of knowledge translation is systematically examining the critical success factors. In this issue of the Archives, Moore reports a knowledge translation project in a key aspect of rehabilitation: implementing standardized outcome measures. We report on the challenges and benefits of that project from a practical perspective and identify the critical success ingredient, leadership for implementation, which was composed of 3 key behaviors: setting clear expectations, engaging stakeholders, and providing support. Furthermore, the additional benefits, challenges, and costs are addressed.
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Butzer JF, Virva R, Kozlowski AJ, Cistaro R, Perry ML. Participation by design: Integrating a social ecological approach with universal design to increase participation and add value for consumers. Disabil Health J 2020; 14:101006. [PMID: 32994140 DOI: 10.1016/j.dhjo.2020.101006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/10/2020] [Accepted: 09/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Physical activity is an essential component of a healthy lifestyle. Health clubs encourage sustained healthy lifestyles but are still largely not accessible to people with disabilities. Cost is a barrier for accessibility enhancements. HYPOTHESIS We postulate that: (A) universal design coupled with a social ecological approach improves measured accessibility compared with existing fitness facilities constructed since the adoption of the ADA; (B) increased accessibility coupled with an environment friendly to people with disabilities attracts more participants to a YMCA than predicted by traditional industry market research producing a recovery of the cost of increased accessibility; and (C) attitudes of facility members toward people with disabilities may improve if an accessible facility facilitates more personal interactions between people with and without disabilities. METHODS Accessibility is measured with the Accessibility Instruments Measuring Fitness and Recreation Environments (AIMFREE). Cost recovery is determined by comparing excess membership revenue to the cost of universal design elements beyond regulatory requirements, and attitudes toward people with disabilities are measured with the Attitudes Toward Disabled Persons Scale. RESULTS AIMFREE scores were significantly higher than comparison facilities in all areas except for equipment, parking, training, and programs. Excess revenue exceeded the extra cost of accessibility enhancements and attitudes toward people with disabilities did not change. CONCLUSIONS Universal design coupled with a social ecological approach improves accessibility in fitness facilities and results in a reasonable payback time. Attitudes toward people with disabilities did not change in a YMCA designed to accommodate people with disabilities.
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Affiliation(s)
- John F Butzer
- John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, 235 Wealthy St SE, Grand Rapids, MI, USA; Division of Rehabilitation, Michigan State University College of Human Medicine, 235 Wealthy St SE, Grand Rapids, MI, USA.
| | - Roberta Virva
- John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, 235 Wealthy St SE, Grand Rapids, MI, USA; Division of Rehabilitation, Michigan State University College of Human Medicine, 235 Wealthy St SE, Grand Rapids, MI, USA
| | - Allan J Kozlowski
- John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, 235 Wealthy St SE, Grand Rapids, MI, USA; Division of Rehabilitation, Michigan State University College of Human Medicine, 235 Wealthy St SE, Grand Rapids, MI, USA; Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, 235 Wealthy St SE, Grand Rapids, MI, USA
| | - Rebecca Cistaro
- John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, 235 Wealthy St SE, Grand Rapids, MI, USA; Division of Rehabilitation, Michigan State University College of Human Medicine, 235 Wealthy St SE, Grand Rapids, MI, USA
| | - Michael L Perry
- Universal Design Consulting, 1811 4, Mile Rd NE, Grand Rapids, MI, USA
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Merlo A, Rodà F, Carnevali D, Principi N, Grimoldi L, Auxilia F, Lombardi F, Maini M, Brianti R, Castaldi S. Appropriateness of admission to rehabilitation: definition of a set of criteria and rules through the application of the Delphi method. Eur J Phys Rehabil Med 2020; 56:537-546. [PMID: 32667147 DOI: 10.23736/s1973-9087.20.06148-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Controlling inappropriateness of care is an essential issue, especially in rehabilitation medicine. In fact, admitting a patient to a rehabilitation hospital or unit is a complex decision also due to the absence of shared and objective admission criteria. AIM The aim was to define clinical admission criteria and rules in rehabilitation medicine. DESIGN Survey based on the application of the Delphi method on a sample of rehabilitation medicine experts. SETTING Administration of electronic online questionnaires concerning appropriateness of admission to intensive rehabilitation. POPULATION Volunteer sample of 53 experts with the following inclusion criteria: being members of the Italian Society of Physical and Rehabilitation Medicine, having practical experience in the research field, agreeing to the confidentiality of the information and being skilled in both rehabilitation and healthcare organization. METHODS A three-round Delphi survey was conducted according to international guidelines. The two initial rounds consisted of an electronic online questionnaire while in the third one a report of the results was provided to the participants. The experts had to score their agreement with each item in the questionnaires, based on either a Likert scale or a dichotomous statement. Consensus between the experts was assessed. RESULTS A total of 53 health professionals completed the Delphi survey. 19 out of 20 Italian regions were represented. The first round consisted of 8 multiple-choice questions. The second round was designed according to the suggestions provided by the panelists in the previous one and consisted of a twelve items questionnaire. At the end of the survey, seven criteria of appropriateness of admission to rehabilitation were identified and five rules defining an appropriate admission to a rehabilitation facility were elaborated. CONCLUSIONS This study represents an attempt to create a worthwhile and reliable tool for a more conscious clinical practice in admission to rehabilitation, based on a set of shared criteria and rules. CLINICAL REHABILITATION IMPACT To increase appropriateness of admission to rehabilitation. Improving appropriateness in healthcare delivery must be a primary goal in order to improve healthcare quality, save money and ensure system sustainability.
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Affiliation(s)
- Andrea Merlo
- LAM-Motion Analysis Laboratory, Department of Neuromotor and Rehabilitation, San Sebastiano di Correggio Hospital, USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy.,Rehabilitation Medicine Service, Department of Rehabilitation Geriatrics, NHS-University Hospital of Parma, Parma, Italy.,Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
| | - Francesca Rodà
- Rehabilitation Medicine Service, Department of Rehabilitation Geriatrics, NHS-University Hospital of Parma, Parma, Italy.,Department of Medicine and Surgery, University of Parma, Italy
| | - Davide Carnevali
- Postgraduate School in Public Health, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy -
| | - Niccolò Principi
- Postgraduate School in Public Health, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Ludovico Grimoldi
- Postgraduate School in Public Health, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Francesco Auxilia
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.,Maggiore Polyclinic Hospital, IRCCS Ca' Granda Foundation, Milan, Italy
| | - Francesco Lombardi
- Unit of Neurorehabilitation, Department of Neuromotor and Rehabilitation, San Sebastiano di Correggio Hospital, USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Rodolfo Brianti
- Rehabilitation Medicine Service, Department of Rehabilitation Geriatrics, NHS-University Hospital of Parma, Parma, Italy
| | - Silvana Castaldi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.,Maggiore Polyclinic Hospital, IRCCS Ca' Granda Foundation, Milan, Italy
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