Poststroke Discharge Destination: Functional Independence and Sociodemographic Factors in Urban Japan

The cutoff values of functional independence measure scores for predicting discharge destination in the early stroke phase

This study aimed to determine cutoff values of functional independence measure (FIM) scores to predict the discharge destinations of patients with acute stroke. The sample included 318 patients with acute stroke (mean age, 72.0 years; women, 39%). The discharge destination was categorized into three groups: home, postacute rehabilitation (hospital with convalescent rehabilitation wards), and postacute care (institution without convalescent rehabilitation wards). We assessed FIM after lifting bed restriction. Multinomial logistic regression analyses were used to estimate odds ratios (OR) and 95% confidence intervals (CI) of the FIM scores for predicting discharge destinations, with postacute rehabilitation as a reference. Cutoff values of motor and cognitive FIM scores for distinguishing home from postacute rehabilitation and postacute care from postacute rehabilitation were determined using receiver operating characteristic curves. The proportion of home, postacute rehabilitation, and postacute care were 34.6%, 41.8%, and 23.6%, respectively. After adjustments for clinical variables, the ORs (95% CIs) for motor and cognitive FIM scores for home versus postacute rehabilitation were 1.08 (1.04-1.11) and 1.05 (0.98-1.12). Furthermore, those for postacute care versus postacute rehabilitation were 1.01 (0.98-1.04) and 0.92 (0.87-0.98). The cutoff values of the motor and cognitive FIM scores for distinguishing home from postacute rehabilitation were 37.5 (sensitivity: 0.92; specificity: 0.64) and 23.5 (sensitivity: 0.78; specificity: 0.67). Furthermore, those for distinguishing postacute care from postacute rehabilitation were 15.5 (sensitivity, 0.81; specificity, 0.51) and 12.5 (sensitivity, 0.74; specificity, 0.64). The identified cutoff values may serve as early indicators for predicting discharge destinations from acute stroke care.

Development and Validation of a Decision Tree Analysis Model for Predicting Home Discharge in a Convalescent Ward: A Single Institution Study

OBJECTIVES

Accurately predicting the likelihood of inpatients' home discharge in a convalescent ward is crucial for assisting patients and families in decision-making. While logistic regression analysis has been commonly used, its complexity limits practicality in clinical settings. We focused on decision tree analysis, which is visually straightforward. This study aimed to develop and validate the accuracy of a prediction model for home discharge for inpatients in a convalescent ward using a decision tree analysis.

METHODS

The cohort consisted of 651 patients admitted to our convalescent ward from 2018 to 2020. We collected data from medical records, including disease classification, sex, age, duration of acute hospitalization, discharge destination (home or nonhome), and Functional Independence Measure (FIM) subitems at admission. We divided the cohort data into training and validation sets and developed a prediction model using decision tree analysis with discharge destination as the target and other variables as predictors. The model's accuracy was validated using the validation data set.

RESULTS

The decision tree model identified FIM grooming as the first single discriminator of home discharge, diverging at four points and identifying subsequent branching for the duration of acute hospitalization. The model's accuracy was 86.7%, with a sensitivity of 0.96, specificity of 0.52, positive predictive accuracy of 0.88, and negative predictive accuracy of 0.80. The area under the receiver operating characteristic curve was 0.75.

CONCLUSION

The predictive model demonstrated more than moderate predictive accuracy, suggesting its utility in clinical practice. Grooming emerged as a variable with the highest explanatory power for determining home discharge.

Impact of functional independence and sociodemographic factors on post-stroke discharge destination in a super-aged rural community in Japan

Objective: This study aimed to clarify the factors influencing the discharge destination of stroke patients in a super-aged rural community in Japan, focusing on functional independence and sociodemographic factors. Patients and Methods: We enrolled patients recovering from stroke with supratentorial lesions who were admitted to our convalescent rehabilitation hospital. The motor components of the Functional Independence Measure (FIM-motor) were assessed for each patient at admission and discharge as explanatory variables. An increase in the FIM-motor scores during hospitalization was also recorded. Additionally, sociodemographic data such as sex, age, and clinical characteristics, such as type of stroke, history of stroke, days from stroke onset to transfer to our convalescent rehabilitation hospital, total duration of hospital stay including acute care, number of co-resident household members, living with a spouse, and number of children were collected. As target values, discharge outcomes were categorized into two groups: returning home and going to a nursing home. Logistic regression analysis was performed. Results: The study sample comprised 160 patients (mean age ± standard deviation, 74.80 ± 12.19 years). Of these, 114 were discharged to their homes, and 46 were transferred to nursing homes. The results of multivariate logistic regression analysis indicated that higher FIM-motor scores at discharge, greater number of co-resident household members, and living with one's spouse were the most powerful predictors of a higher probability of returning home. Conclusion: This study demonstrated that functional independence levels and the number of co-resident household members were crucial factors in predicting the discharge destination of patients after stroke in a super-aged rural community in Japan. These findings imply that for older patients with lower functional independence, supportive social networks are essential for home discharge, offering clues for providing long-term healthcare in super-aged rural communities worldwide.

Association of functional and cognitive impairment severity with discharge to long-term care facilities in older patients admitted to a general acute care hospital from home

BACKGROUND

The early recognition of hospitalized patients at risk of being discharged to long-term care facilities (LTCFs) may help to identify those who require transitional care programs and interventions that support discharge to home. We examined the association of functional and cognitive impairment severity with discharge to LTCFs among older hospitalized patients.

METHODS

In this retrospective cohort study, we used an administrative claims database linked with geriatric assessment data from a general acute care hospital in Japan. We analyzed patients aged ≥65 years discharged between July 2016 and December 2018. The severity of functional and cognitive impairments was assessed using the Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) scale. Based on their DASC-8 scores, patients were designated as Category I (no impairment), Category Ⅱ (mild impairment), or Category III (moderate/severe impairment). We conducted logistic regression analyses to examine the association between the severity of impairments and discharge to LTCFs after adjusting for patient-level factors.

RESULTS

We analyzed 9,060 patients (mean age: 79.4 years). Among the 112 patients (1.2%) discharged to LTCFs, 62.3%, 18.6%, and 19.2% fell under Category I, Category Ⅱ, and Category III, respectively. Category II was not significantly associated with discharge to LTCFs. However, Category III had a significantly higher odds of discharge to LTCFs than Category I (Adjusted odds ratio: 2.812, 95% confidence interval: 1.452-5.449).

CONCLUSION

Patients identified as Category III by the DASC-8 on admission may benefit from enhanced transitional care and interventions that promote discharge to home.

Physical functioning factors predicting a return home after stroke rehabilitation: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis sought to identify the physical functioning factors associated with home discharge after inpatient stroke rehabilitation.

DATA SOURCES

A search of PubMed, Embase, CINHAL, The Cochrane Library (Trials), Web of Science, and PEDro were conducted up until May 2023.

METHODS

Two independent reviewers selected studies for population (patients with stroke), predictive factors (physical functioning), outcome (discharge destination), setting (inpatient rehabilitation), and study designs (observational and experimental studies). Predictive factors were identified among assessments of the "body function" and "activity" components of the International Classification of Functioning. Methodological quality was assessed with the Newcastle-Ottawa Scale. The findings used quantitative and narrative syntheses. Meta-analyses were performed with the inverse variance method and the random-effects model using included studies with sufficient data.

RESULTS

Forty-five studies were included with 204,787 participants. Included studies assessed the association of independence in activities of daily living, walking, rolling, transferring, and balance on admission with a probability of returning home. Motor (odds ratio = 1.23, 95% confidence interval: 1.12-1.35, p < .001) and total (odds ratio = 1.34, 95% confidence interval: 1.14-1.57, p < .001) Functional Independence Measure scores on admission were significantly associated with home discharge in meta-analyses. Additionally, included studies showed that independence in motor activities, such as sitting, transferring, and walking, and scores above thresholds for the Functional Independence Measure and Berg Balance Scale on admission were associated with discharge destination.

CONCLUSION

This review showed that higher independence in activities of daily living on admission is associated with home discharge after inpatient stroke rehabilitation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICALTRIAL

Inpatient Rehabilitation After Acute Severe Stroke: Predictive Value of the National Institutes of Health Stroke Scale Among Other Potential Predictors for Discharge Destination

Background

Research focusing on predictors for discharge destination after rehabilitation of inpatients recovering from severe stroke is scarce. The predictive value of rehabilitation admission NIHSS score among other potential predictors available on admission to rehabilitation has not been studied.

Aim

The aim of this retrospective interventional study was to determine the predictive accuracy of 24 hours and rehabilitation admission NIHSS scores among other potential socio-demographic, clinical and functional predictors for discharge destination routinely collected on admission to rehabilitation.

Material and Methods

On a university hospital specialized inpatient rehabilitation ward 156 consecutive rehabilitants with 24 hours NIHSS score ⩾15 were recruited. On admission to rehabilitation, routinely collected variables potentially associated with discharge destination (community vs institution) were analyzed using logistic regression.

Results

70 (44.9%) of rehabilitants were discharged to community, and 86 (55.1%) were discharged to institutional care. Those discharged home were younger and more often still working, had less often dysphagia/tube feeding or DNR decision in the acute phase, shorter time from stroke onset to rehabilitation admission, less severe impairment (NIHSS score, paresis, neglect) and disability (FIM score, ambulatory ability) on admission, and faster and more significant functional improvement during the in-stay than those institutionalized.

Conclusion

The most influential independent predictors for community discharge on admission to rehabilitation were lower admission NIHSS score, ambulatory ability and younger age, NIHSS being the most powerful. The odds of being discharged to community decreased with 16.1% for every 1 point increase in NIHSS. The 3-factor model explained 65.7% of community discharge and 81.9% of institutional discharge, the overall predictive accuracy being 74.7%. The corresponding figures for admission NIHSS alone were 58.6%, 70.9% and 65.4%.

Length of Stay and Home Discharge for Patients with Inpatient Stroke Rehabilitation

OBJECTIVE

To examine temporal trends and geographic variations and predict inpatient rehabilitation (IPR) length of stay (LOS) and home discharge for stroke patients.

METHODS

Patients aged ≥18 years who were admitted to an IPR facility in Alberta, Canada, between 04/2014 and 03/2018 (years 2014-2017) were included. Predictors of LOS and home discharge were examined using 2014-2016 data and validated using 2017 data. Multivariable linear regression (MLR), multivariable negative binomial (MNB), and multivariable quantile regressions (MQR) were used to examine LOS, and logistic regression was used for home discharge.

RESULTS

We included 2686 rehabilitation admissions between 2014 and 2017. The mean LOS decreased (2014: 71 days; 2017: 62.1 days; p = 0.003) during the study period and was shortest in Edmonton (59.1 days) compared to Calgary (66 days) or other localities (70.8 days; p < 0.001). Three-quarters of patients were discharged home and this proportion remained unchanged between 2014 and 2017. Calgary patients were more likely to be discharged home than those in Edmonton (OR = 0.62; p = 0.019) or other localities (OR = 0.39; p = 0.011). The MLR and MNB models provided accurate prediction for the mean LOS (predicted = 59.9 and 60.8 days, respectively, vs. actual = 62.1 days; both p > 0.5), while the MQR model did so for the median LOS (predicted = 44.3 days vs. actual = 44 days; p = 0.09). The logistic regression resulted in 82.4% of correct prediction, a sensitivity of 91.6%, and a specificity of 50.7% for home discharge.

CONCLUSIONS

Rehabilitation LOS decreased while the proportion of home discharge remained unchanged during the study period. Both varied across health zones. Identifiable statistical models provided accurate prediction with a separate patient cohort.

Clinical Items for Geriatric Patients with Post-Stroke at Discharge or Transfer after Rehabilitation Therapy in a Chronic-Phase Hospital: A Retrospective Pilot Study

Clinical factors related to destination after rehabilitation therapy for geriatric patients with post-stroke in chronic-phase hospitals have not been elucidated. This study analyzed the clinical characteristics of geriatric patients with post-stroke at discharge/transfer after rehabilitation therapy in a chronic-phase hospital. Fifty-three patients (20 men, 33 women; mean age 81.36 ± 8.14 years) were recruited (the period analyzed: October 2013−March 2020). Clinical data were statistically analyzed among patients discharged to homes or facilities for older adults or transferred to another hospital. In addition, we analyzed the clinical items at discharge and transfer after rehabilitation therapy using a decision tree analysis. Twelve patients were discharged, eighteen were discharged to facilities for older adults, and twenty-three were transferred to another hospital. There were significant differences in the modified Rankin Scale, admission dates, functional independence measure (FIM) score, and Barthel Index score in the three groups (p < 0.05). Patients with motor subtotal functional independence scores of ≥14 (chronologically improved ≥5) after rehabilitation therapy for <291 days were more likely to be discharged home. Patients in a chronic-phase hospital who improved within a limited period were discharged to their homes, whereas those who were bedridden tended to be transferred to another hospital.

Clarification of Factors Determining Discharge Destination Among Elderly Patients After Stroke With Low Levels of Independence in Activities of Daily Living: A Retrospective Study

Objective

To determine factors influencing discharge destination of elderly patients after stroke with low levels of independence in activities of daily living (ADL).

Design

Cross-sectional study.

Setting

A community-based public hospital in a rural area in Japan.

Participants

A total of 67 patients with low daily function among 205 elderly patients with stroke screened for eligibility (N=67).

Interventions

Not applicable.

Main Outcome Measures

Motor component of functional independence measure (M-FIM) at discharge and discharge destination-home or long-term care facility (LCF).

Results

Among the 205 eligible patients, 147 were discharged home and 58 were discharged to LCFs. Patients with an M-FIM score of ≤30 at discharge were defined as patients deemed difficult to discharge home because of low independence levels in ADL. Of the 147 patients discharged home, 24 (16.3%) had M-FIM scores of ≤30. Of the 58 patients discharged to LCFs, 43 (74.1%) had M-FIM scores of ≤30. Patients with an M-FIM score of ≤30 at discharge significantly tended to be discharged home if they obtained oral intake vs tube feeding as a nutritional method (P=.047) and higher cognitive component of FIM scores at discharge (P=.002). All six patients who lived alone among patients with an M-FIM score of ≤30 were discharged to LCFs. Two patients on tube feeding were discharged home.

Conclusions

Nutritional method, cognitive function at discharge, and the prestroke living situation with or without household caregivers are important factors of discharge among elderly patients after stroke with low independence levels in ADL. However, only a small number of severely disabled patients were successfully discharged home.

Functional Independence Measure Subtypes among Inpatients with Subacute Stroke: Classification via Latent Class Analysis

Objectives:

Using Functional Independence Measure (FIM) records, this study used latent class analysis (LCA) to clarify the structure of activities of daily living (ADL) status in patients following stroke.

Methods:

In this retrospective, single-center study, we extracted the medical records of patients with stroke who were admitted to a rehabilitation hospital in Japan between April 2018 and March 2020. LCA was used to determine classes of ADL status based on response patterns in FIM items converted from the original seven levels to three levels: Complete Dependence, FIM1–2; Modified Dependence, FIM3–5; Independence, FIM6–7. We compared the length of stay and discharge destinations among subgroups of patients with different ADL status at admission.

Results:

From 373 patients, 1592 FIM records were analyzed. These were classified into six ADL status classes based on “Complete Dependence,” “Modified Dependence,” and “Independence” in the motor and cognitive domains. Significant differences were observed among the six admission ADL subgroups for the length of stay (median values in patient subgroups based on admission ADL status: 126, 146, 90, 65, 44, and 29 days in the Motor Complete/Cognitive Complete, Motor Complete/Cognitive Modified, Motor Modified/Cognitive Modified, Motor Modified/Cognitive Independent, Motor Independent/Cognitive Modified, and Motor Independent/Cognitive Independent groups, respectively) and discharge destinations (patients discharged home: 27%, 62%, 81%, 92%, 95%, and 98%, respectively, and to acute care hospitals: 18%, 14%, 8%, 8%, 2%, and 2%, respectively).

Conclusions:

LCA successfully stratified ADL status in patients with stroke undergoing rehabilitation and may aid in determining an appropriate treatment regimen.

Socio-environmental predictive factors for discharge destination after inpatient rehabilitation in patients with stroke: a systematic review and meta-analysis

PURPOSE

To identify which of the socio-environmental factors of patients with stroke are predictive for discharge to their home after inpatient rehabilitation. Because discharge planning is a key component of rehabilitation, it is important to recognize the predictive factors for a discharge home. Other systematic reviews demonstrated the value of functional outcome measures. This review adds to the current literature by assessing the predictive value of socio-environmental factors, which shape the context in which a person lives.

METHODS

We performed a systematic search in seven databases. Two independent reviewers selected studies and assessed them for methodological quality. We extracted data to estimate pooled odds ratio for household situation, social support, ethnicity and socioeconomic status.

RESULTS

Forty studies were included. Significant estimates were found for living with others (OR 2.60; 95%CI 1.84-3.68), having support at home (OR 11.48; 95%CI 6.52-20.21), being married (OR 2.05; 95%CI 1.80-2.33) and living at home before stroke (OR 31.01; 95%CI 7.38-130.18).

CONCLUSION

Living at home and benefiting from social support, including living with others, are important factors to consider during discharge planning after stroke. Further research should consider the impact of socioeconomic status.IMPLICATIONS FOR REHABILITATIONEvaluating the social and environmental factors of patients with stroke plays an important role in discharge planning.Next to functional status, caregiver availability (support at home) is among the strongest predictive factors for discharge home.To assess caregiver availability, the presence of a willing and able caregiver should be surveyed at admission.Further predictive factors for discharge home are cohabitation and marital status.

Identification of Functional Limitations and Discharge Destination in Patients With COVID-19

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.

Can I Discharge My Stroke Patient Home After Inpatient Neurorehabilitation? LIMOS Cut-Off Scores for Stroke Patients "Living Alone" and "Living With Family"

Background: Discharge planning of stroke patients during inpatient neurorehabilitation is often difficult since it depends both on the patient's ability to perform activities of daily living (ADL) and the social context. The aim of this study was to define ADL cut-off scores using the Lucerne ICF-based multidisciplinary observation scale (LIMOS) that allow the clinicians to decide whether stroke patients who "live alone" and "live with a family" can be discharged home or must enter a nursing home. Additionally, we investigated whether age and gender factors influence these cut-off scores. Methods: A single-center retrospective cohort study was conducted to establish cut-off discharge scores for the LIMOS. Receiver-operating-characteristics curves were calculated for both patient groups "living alone" and "living with family" to illustrate the prognostic potential of the LIMOS total score with respect to their discharge goals (home alone or nursing home; home with family or nursing home). A logistic regression model was used to determine the (age- and gender-adjusted) odds ratios of being released home if the LIMOS total score was above the cut-off. A single-center prospective cohort study was then conducted to verify the adequacy of the cut-off values for the LIMOS total score. Results: A total of 687 stroke inpatients were included in both studies. For the group "living alone" a LIMOS total score above 158 indicated good diagnostic accuracy in predicting discharge home (sensitivity 93.6%; specificity 95.4%). A LIMOS total cut-off score above 130 points was found for the group "living with family" (sensitivity 92.0%; specificity 88.6%). The LIMOS total score odds ratios, adjusted for age and gender, were 292.5 [95% CI: (52.0-1645.5)] for the group "living alone" and were 89.4 [95% CI: (32.3-247.7)] for the group "living with family." Conclusion: Stroke survivors living alone needed a higher ADL level to return home than those living with a family. A LIMOS total score above 158 points allows a clinician to discharge a patient that lives alone, whereas a lower LIMOS score above 130 points can be sufficient in a patient that lives with a family. Neither age nor gender played a significant role.

Psychometric properties of the Care Dependency Scale in stroke survivors in Indonesian hospitals

Purpose

This study aimed to evaluate the psychometric properties of the Indonesian version of the Care Dependency Scale (CDS) among stroke survivors.

Methods

The study was undertaken in four hospitals. We analysed datasets obtained from 109 stroke survivors on inpatient wards and in outpatient clinics, who were rated by nurses to determine the CDS reliability coefficients. The Cronbach's α and Cohen's kappa coefficients were applied. Concurrent validity was conducted for the data on care dependency, which werecollected from 49 of these 109 participants on inpatient wards by nurses using the CDS and the Barthel Index. A Spearman's rank correlation analysis was conducted to measure the association between the CDS and the Barthel Index results.

Results

An analysis of the results of the CDS tested on the inpatient ward and in the outpatient clinic revealed a high level of internal consistency. The reliability analysis yielded the same Cronbach's α coefficient of 0.98 for both the inpatient and outpatient data. A significant, moderate correlation was observed between the CDS and Barthel Index results.

Conclusion

The CDS can be recommended for use as a tool for the assessment and evaluation of stroke survivors who are receiving acute or long-term care.

Systematic review and meta-analysis of the effect of cognitive impairment on the risk of admission to long-term care after stroke

Introduction: Admission to long-term care (LTC) post-stroke can be a significant source of costs. Studies evaluating the effect of cognitive impairment (CI) and dementia on risk of LTC admission post-stroke have not been systematically reviewed. The aim of this paper was to conduct a systematic review and meta-analysis of studies of the association between post-stroke CI/dementia and admission to LTC. Patients and methods: PubMed, PsycInfo and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for peer-review articles in English published January 2000-June 2018. Included studies were population-based or hospital-based studies assessing the relationship between CI or dementia, and admission to LTC post-stroke. Abstracts were screened, followed by full-text review of potentially relevant articles. Relevant data was extracted using a standard form and the Crowe Critical Appraisal Tool was used for quality appraisal. Results were pooled using random-effects meta-analysis and heterogeneity was assessed using the I² statistic. Results: 18 articles were included in the review and 12 in a meta-analysis. 14/18 studies adjusted for covariates including functional impairment. Increased odds of admission to LTC was associated with post-stroke CI [Odds Ratio (CI 95%): 2.36 (1.18, 4.71), I²=77%] and post-stroke dementia [Odds Ratio (CI 95%): 2.58 (1.38 to 4.82), I²=60%]. Discussion and conclusion: Post-stroke CI and dementia increase odds of admission to LTC post-stroke, independent of functional impairment. This indicates the potential for interventions that reduce post-stroke CI and dementia to also reduce risk of admission to LTC post-stroke, and ultimately costs.

Effects of nutritional status on prognosis in patients with severe hemiplegia who were recently admitted to a rehabilitation hospital

[Purpose] The purpose of this study was to examine the effect of nutritional status on the prognosis of patients with severe hemiplegia who were recently admitted to a convalescent rehabilitation hospital. [Participants and Methods] Eighty patients with stroke and severe hemiplegia were divided into two groups based on their serum albumin levels: normal (serum albumin 3.5 g/dL or more) and undernourished group (serum albumin 3.4 g/dL or less). Background characteristics, cognitive function, neurological symptoms, physical function at admission, and outcome were compared between groups. [Results] There were no differences found between groups in terms of cognitive function, neurological symptoms, physical function at admission, destination, and length of stay at the hospital. In contrast, age and duration from onset to admission were significantly lower in the normal group than in the undernourished group. The ability to walk and perform activities of daily living (ADL) at discharge was significantly higher in the normal group than in the undernourished group. [Conclusion] As a result, the findings of the present study suggest that in patients with severe hemiplegia, nutritional status at the time of admission determines the improved walking and ADL ability at the time of discharge.

Exploring discharge destination following severe stroke

Background:

Patients with severe stroke frequently present with substantial impairments but are often not prioritised for post-discharge rehabilitation. There is a need to determine where these patients are discharged to in order to facilitate appropriate allocation of post-discharge pathway resources.

Aim:

The present study aimed to describe the discharge pathways of patients with severe stroke and to identify predictors of discharge destination for these patients.

Method:

A descriptive, retrospective design was utilised to determine the discharge destination for 770 patients with severe stroke in Queensland, Australia. Binomial logistic regression was used to determine the variables that predicted discharge destination.

Results:

The results indicated that 58.44% of patients were discharged home (n = 450). Age, length of stay, discharge ward and geographical region emerged as significant predictors of discharge destination. The full model containing all predictors was statistically significant and, as a whole, explained 36.50% of the variance in discharge destination.

Conclusion:

These results highlight the importance of these variables in influencing the outcomes of patients with severe stroke, which may assist post-hospital discharge services in allocating resources for patients with severe stroke.

Factors Affecting the Discharge Destination of Patients With Spinal Bone Metastases

Objective

To investigate the factors affecting the discharge destination of patients with spinal bone metastases.

Methods

We reviewed the medical records of patients admitted to our institute with a diagnosis of skeletalrelated events secondary to malignant disease. Exclusion criteria comprised decreased cognitive function and hypercalcemia, brain metastasis, peritoneal dissemination, and pleural dissemination. The factors examined included the discharge destination, age, sex, the Barthel Index (BI) at admission and discharge, pain at admission and discharge, number of co-resident household members, length of hospital stay, treatment strategy, spinal instability neoplastic score, vertebral body collapse, spinal level of bone metastases, and motor paralysis. For the discharge destination, patients at discharge were grouped into two categories. The home group included patients discharged to their own homes, and the non-home group included patients discharged to other hospitals.

Results

Of 140 patients, the home group comprised 120 patients and the non-home group comprised 20 patients. Activities of daily living (ADL) and pain at rest and during motion improved significantly in the home group, whereas only pain at rest and during motion improved significantly in the non-home group. The results indicated that discharge BI and motor paralysis were the best predictors of the discharge destination; a BI cut-off value of 72.5 predicted discharge to home.

Conclusion

This study showed that the ADL level on discharge and motor paralysis affected the discharge destination of patients with spinal bone metastases. These results are likely to be helpful in predicting the discharge destination of patients with spinal bone metastases.

Defining discharge-readiness from subacute care from all stakeholders' perspectives: a systematic review

Purpose: Research to date has focused on clinicians' views on patients' discharge readiness from acute hospital settings.This study aims to synthesise the literature on discharge readiness from sub-acute (rehabilitation) hospital settings from all stakeholders' perspectives.Methods: Electronic databases (MEDLINE, CINAHL, Ageline, AMED and Global Health) were systematically searched for post-2000 publications on discharge readiness of adult inpatients in sub-acute settings. After screening, quantitative and qualitative studies were assessed for bias using the Downs and Black checklist and McMaster critical assessment tool respectively, and narrative analysis conducted.Results: From the 3516 papers identified, 23 were included in the review. Overall quality of articles was rated as adequate. Narrative synthesis identified three main themes: the importance of functional outcomes; confounding factors impact on discharge destination and length of stay and barriers and facilitators to discharge.Conclusion: Despite limited literature defining sub-acute patients' discharge-readiness from all stakeholders' perspectives, synthesis of available findings identified major themes for consideration when determining when a patient is ready to leave hospital. Limitations include the heterogeneity of the studies located impacted on data extraction and quality appraisal.IMPLICATIONS FOR REHABILITATIONDischarging patients from hospital is complex, discharge too early may lead to poor medical outcomes or readmission, while discharge too late may increase the risk of hospital-based adverse events.Multiple factors need to be considered when considering the discharge readiness of an inpatient.Ensuring adequate social support is key to maximising transition from hospital to home.Combining the use of functional outcome measures with clinical decision-making allows for quantifying readiness for discharge.

Premorbid instrumental activities of daily living predicts discharge home following stroke

Background and purpose

Stroke survivors who remain dependent require multiple healthcare resources, including rehabilitation and nursing care. The effect of premorbid instrumental ADL (IADL) on the discharge destination, which has not been studied previously in detail, is analyzed.

Materials and methods

Between April and September 2015, 40 stroke patients admitted to hospital were enrolled prospectively in the present study. The ADL (Barthel index) and IADL (Frenchay activities index: FAI) scores in their premorbid status were recorded. Baseline demographic data, stroke severity (NIHSS) and type of stroke, and whether they lived with family were also recorded. Simple univariate regression was performed between the two discharge destination groups (Home or Not Home). Significant factors were then included in multivariate logistic regression in order to determine the adjusted odds ratio for the discharge destination. A P value <.05 was taken as significant.

Results

25 patients (64.1%) returned home. According to univariate analysis, NIHSS on admission and premorbid FAI were significantly associated with the discharge destination. Multivariate analysis found that NIHSS (OR, 0.71; 95% CI0.56–0.92; p = .008) and premorbid FAI (OR, 1.17; 95% CI1.03–1.33; p = .01) were independent predictors of the discharge destination.

Conclusions

Severity of stroke upon admission and premorbid IADL are associated with discharge destination following stroke.

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Predictors of discharge disposition after acute stroke were investigated in a Japanese rural community hospital.

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Stroke severity on admission and premorbid IADL are both correlated with the discharge destination following acute stroke.

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Improvement in the premorbid IADL of community dwellers might assist in reducing the consumption of healthcare resources.

Development and validation of a prediction model for home discharge in patients with moderate stroke: The Korean stroke cohort for functioning and rehabilitation study

BACKGROUND

Previous studies have investigated the predictors for home discharge without considering stroke severity.

OBJECTIVES

To develop a practical assessment tool that predicts home discharge for moderate stroke patients after subacute rehabilitation therapy in the tertiary hospitals.

METHODS

Stroke patients with National Institutes of Health Stroke Scale scores of 6 to 13 were included in this prospective cohort study. Various demographic, clinical, and functional factors were analyzed as potential predictive factors. A weighted scoring model was developed through the following three-step process: 1) selection of the factors by logistic regression analyses, 2) development of a weighted scoring model, and 3) validation of the generalizability of the model.

RESULTS

The home discharge rate was 51% (n = 372), and the overall mean length of stay of hospitalization was 32.5 days. 1) The Cognitive Functional Independence Measure, 2) the Functional Ambulation Categories, 3) the modified Charlson Comorbidity Index, and 4) marital status were independent predictors of home discharge. The coefficient value for marital status was adjusted to 1 in the scoring system, and the values of the other parameters were proportionally converted to the nearest integer. Possible total scores ranged from 0 to 13 in the model, with a higher score indicating a higher probability of home discharge. With a cutoff point of 7, this model showed 87.0% sensitivity and 86.2% specificity (area under the curve = 0.90).

CONCLUSIONS

This novel assessment tool can be useful in predicting home discharge after subacute rehabilitation of moderate stroke patients.

Risk factors for long-term care after hemiplegia from cancer-related brain surgery: a pilot study for new prediction model

BACKGROUND

Hemiplegia is a worldwide-represented neurological condition leading to long-term disability. The most common cause of hemiplegia is stroke; 25% to 50% of stroke survivors require some assistance after hospital discharge; approximately half of them become dependent, while only 14% achieve full recovery of activities of daily living (ADL). Cancer and cancer-related surgery are other causes of hemiplegia and rehabilitation in cancer patients has been recognized as important factor in order to help maintaining quality of life as long as possible. Many studies have been done in order to assess a reliable prediction about outcome of hemiplegia from stroke, but outcome prediction for cancer-related hemiplegia still remains a challenge and no clinical prediction tool has been developed being better than physician's informal prediction.

AIM

Aim of this pilot study was: a) to detect risk factors associated with need for long-term care for patients suffering from hemiplegia due to cancer-related brain surgery, b) to build an algorithm-based model from detected risk factors in order to predict the need for long-term care after rehabilitation 3) to assess the feasibility of a subsequent study on a larger sample of subjects, in order to validate of the model. The subsequent study will be considered feasible if the model developed by the pilot study will be able to correctly predict more than 85% of patients needing or not long-term care after rehabilitation.

DESIGN

Observational retrospective study.

SETTING

Neurorehabilitation Unit.

POPULATION

Inpatients affected by hemiplegia due to cancer-related surgery.

METHODS

The observational retrospective study involved 158 subjects affected by hemiplegia due to cancer-related brain surgery. All of the subjects underwent rehabilitation therapy, while radio /chemotherapy was administered if needed. Stroke prognostic factors and other clinical variables were recorded for all subjects. The endpoint variable was Functional Independence Measure (FIM®) Score at discharge after rehabilitation. Variables were then associated with patient's FIM Score <61 at discharge after rehabilitation, as predictor of long-term care at home.

RESULTS

After statistical evaluation, age, comorbidity Charlson Index >3, complete absence of motricity of the affected limbs, hypoesthesia, trunk-control deficit, dysphagia, language disorder, urinary or fecal incontinence were found to be risk factors for FIM Score <61 at discharge. From detected factors an algorithm-based model was built in order to estimate patient's overall probability to need or not an intensive long-term care after rehabilitation.

CONCLUSIONS

The model developed by the pilot study allowed correct positive or negative prediction for long-term care need after rehabilitation for 90.6% of the patients suffering from cancer-related hemiplegia. A subsequent study on a larger sample of subjects resulted therefore feasible because overall correct prediction was higher than 85%.

CLINICAL REHABILITATION IMPACT

Risk factors for intensive care at home (complete absence of motricity of affected limbs, trunk control deficit, fecal incontinence, dysphagia and comorbidity Charlson Index >3) can be useful to evaluate patients suffering from hemiplegia due to cancer-related brain surgery, at admission into Rehabilitation Unit. The algorithm-based model seems to be a promising tool to estimate the probability of intensive home care for that type of hemiplegic patients.

Classification of long-term care wards and their functional characteristics: analysis of national hospital data in Japan

Background

In a rapidly aging society that has promoted extensive reforms of the healthcare system, clarifying functional patterns in long-term care wards is important for developing regional healthcare policies. This study aimed to classify patterns of inpatient characteristics among Japanese long-term care wards and to examine hospital/ward characteristics.

Methods

We analyzed data from 1856 long-term care wards extracted from the 2014 Annual Report for Functions of Medical Institutions in Japan. We classified five clusters of long-term care wards based on inpatients’ medical acuity/activities of daily living using cluster analysis, and compared hospital/ward characteristics across the clusters with a chi-square test or analyses of variance.

Results

Cluster 1 was low medical acuity/high activities of daily living (n = 175); cluster 2, medium medical acuity/high activities of daily living (n = 340); cluster 3, medium medical acuity/low activities of daily living (n = 461); cluster 4, high medical acuity/low activities of daily living (n = 409); and cluster 5, mixed (n = 471). Although clusters 1 and 2 had similar higher proportions of home discharge (48.1% and 34.6%, respectively), there was a difference in length of hospital stay between the clusters (154.6 and 216.6 days, respectively). On the other hand, clusters 3 and 4 experienced a longer length of hospital stay (295.7 and 239.8 days, respectively) and a higher proportion of in-hospital deaths (42.7% and 50.2%, respectively). Characteristics of cluster 5 were not significantly different from the average of overall wards.

Conclusions

There were distinctive differences across hospitals in their use of long-term care wards. Wards with different functions have different support needs; the clusters with high activities of daily living needed support in promoting home discharge, while those with low activities of daily living needed support in providing quality end-of-life care. Our results can be useful for constructing the future regional healthcare system. This study also suggests introducing a standardized patient classification system in long-term care settings.

The care dependency of patients after laparoscopic abdominal surgery and associated factors in China

PURPOSE

The outcome after laparoscopic surgery is dependent on self-care behaviors. Whether or not the patients after laparoscopic abdominal surgery in China are care-dependent is still unclear. Thus, the studies try to analyze influence factors of care dependence on patients with laparoscopic abdominal surgery, to provide reference for personalized care for the patient.

METHODS

In our study, two hundreds and forty-two cases were selected and investigated by using the exercise of self-care agency scale and care dependency scale. And correlation analyses between care dependency and self-care agency, age or hospital stay duration was made by Spearman correlation analysis. The analysis of associated factors was made by multivariable linear regression model.

RESULTS

The mean age of participants is 42.12±12.67 (ranged from 18 to 73years), and 134 patients (55.37%) in the study were older than 50years. Among the 242 participants, 59.09% is male. Our data found that the average self-care agency score was 115.72±30.13. And 64.88% participates are in the median level of self-care agency. Care dependency correlated with self-care agency (r=-0.85, P=0.009), age (r=-0.71, P=0.001) and hospital stay duration (r=-0.69, P=0.003) negatively. The linear regression was found between gender, age, educational level, days of hospital stay and care dependency. The model is care dependency=99.533+5.02×(gender)-0.795×(age)+0.512×(educational level)-0.239×(days of hospital stay).

CONCLUSION

Patients after laparoscopic surgery take notice of self-care. Gender, age, educational level and days of hospital stay affect care dependence.

Predicting Discharge to Institutional Long-Term Care After Stroke: A Systematic Review and Metaanalysis

BACKGROUND/OBJECTIVES

Stroke is a leading cause of disability worldwide, and a significant proportion of stroke survivors require long-term institutional care. Understanding who cannot be discharged home is important for health and social care planning. Our aim was to establish predictive factors for discharge to institutional care after hospitalization for stroke.

DESIGN

We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42015023497) of observational studies. We searched MEDLINE, EMBASE, and CINAHL Plus to February 2017. Quantitative synthesis was performed where data allowed.

SETTING

Acute and rehabilitation hospitals.

PARTICIPANTS

Adults hospitalized for stroke who were newly admitted directly to long-term institutional care at the time of hospital discharge.

MEASUREMENTS

Factors associated with new institutionalization.

RESULTS

From 10,420 records, we included 18 studies (n = 32,139 participants). The studies were heterogeneous and conducted in Europe, North America, and East Asia. Eight studies were at high risk of selection bias. The proportion of those surviving to discharge who were newly discharged to long-term care varied from 7% to 39% (median 17%, interquartile range 12%), and the model of care received in the long-term care setting was not defined. Older age and greater stroke severity had a consistently positive association with the need for long-term care admission. Individuals who had a severe stroke were 26 times as likely to be admitted to long-term care than those who had a minor stroke. Individuals aged 65 and older had a risk of stroke that was three times as great as that of younger individuals. Potentially modifiable factors were rarely examined.

CONCLUSION

Age and stroke severity are important predictors of institutional long-term care admission directly from the hospital after an acute stroke. Potentially modifiable factors should be the target of future research. Stroke outcome studies should report discharge destination, defining the model of care provided in the long-term care setting.

Development of a prognostic scale for severely hemiplegic stroke patients in a rehabilitation hospital

OBJECTIVES

For patients with severe hemiplegia in a rehabilitation hospital, early prediction of the functional prognosis and outcomes is challenging. The purpose of this study was to create and verify a prognostic scale in severely hemiplegic stroke patients and allowing for prediction of (1) the ability to walk at the time of hospital discharge, (2) the ability to carry out activities of daily living (ADL), and (3) feasibility of home discharge.

PATIENTS AND METHODS

The study was conducted on 80 severely hemiplegic stroke patients. A prognostic scale was created as an analysis method using the following items: mini-mental state examination (MMSE) at the time of admission, modified NIH stroke scale (m-NIHSS); trunk control test (TCT); and the ratio of the knee extensor strength on the non-paralyzed side to the body weight (KES/BW-US). We verified the reliability and validity of this scale.

RESULTS

We established a prognostic scale using the MMSE, m-NIHSS, TCT, and KES/BW-US. A score of 56.8 or higher on the prognostic scale suggested that the patient would be able to walk and that assistance with ADL would be unnecessary at the time of hospital discharge. In addition, a score of 41.3 points indicated that the patient's return home was feasible. The reliability and the results were in good agreement. These findings showed that the ability or inability to walk was predictable in 85%, the need of assistance with ADL in 82.5%, and the feasibility of home return in 76.3% of cases.

CONCLUSION

At the time of admission, four evaluation items permitted the prediction of three outcomes at time of discharge. Our formula predicts three outcomes with an accuracy of more than 76%.

Caregiver availability for severe stroke results in improved functional ability at discharge from inpatient rehabilitation

PURPOSE

To evaluate the predictive capacity of caregiver availability on functional ability at time of discharge from inpatient rehabilitation in individuals with severe first-time stroke.

METHODS

A retrospective chart review was conducted of severe stroke inpatients admitted to a stroke rehabilitation unit between April 2005 and December 2009. Follow-up telephone interviews were conducted with patients to determine caregiver availability at time of discharge. Hierarchical linear regression analysis was performed to assess the predictive capacity of caregiver availability on functional ability at discharge from an inpatient rehabilitation unit after controlling for covariates.

RESULTS

Data from 180 individuals were included in the analysis. Individuals with a caregiver had significantly higher levels of functional ability at discharge compared to those without (85.8 ± 23.6 versus 72.9 ± 20.3; p < 0.01), although both groups achieved a minimal clinically important difference. After controlling for age, gender, admission Functional Independence Measure, and length of hospital stay, caregiver availability explained 1.3% of additional variance, with the final model explaining 41.3% of total variance for functional ability at discharge (F (5,174) = 26.21, p < 0.001).

CONCLUSIONS

The presence of a caregiver at time of discharge from inpatient rehabilitation is predictive of significantly higher functional ability at discharge in individuals with severe stroke. Implications for rehabilitation The availability of a caregiver at time of discharge from inpatient rehabilitation is predictive of improved functional ability at discharge in individuals with severe stroke. The presence of an available caregiver positively influences the functional recovery of individuals with severe stroke and may be an important element to successful rehabilitation.

Prediction of destination at discharge from a comprehensive rehabilitation hospital using the home care score

[Purpose] This study investigated whether it is possible to predict return to home at discharge from a rehabilitation hospital in Japan using the home care score of patients with cerebrovascular or osteoarticular disease and low activities of daily living at admission. [Subjects and Methods] The home care score and functional independent measurement were determined for 226 patients at admission and at discharge from five hospitals, and receiver operating characteristic analyses were conducted. [Results] The home care score cutoff point for the prediction of return to home at admission and at discharge was 11, and the area under the curve was more than 0.8. The area under the curve of the home care score was 0.77 for patients with low activities of daily living and within this group, the probability of return to home was approximately 50%, as predicted by the functional independent measurement. The home care score increased after receiving intervention at a rehabilitation hospital. [Conclusion] The home care score is useful for the prediction of return to home from a rehabilitation hospital, although prediction using the functional independent measurement is difficult for patients with low activities of daily living. Moreover, comprehensive interventions provided by the rehabilitation hospitals improve the ability to provide home care of the patient’s family, which is assessed by the home care score.

Prediction of Advisability of Returning Home Using the Home Care Score

Purpose. The aim of this study was to assess whether the home care score (HCS), which was developed by the Ministry of Health and Welfare in Japan in 1992, is useful for the prediction of advisability of home care. Methods. Subjects living at home and in assisted-living facilities were analyzed. Binominal logistic regression analyses, using age, sex, the functional independence measure score, and the HCS, along with receiver operating characteristic curve analyses, were conducted. Findings/Conclusions. Only HCS was selected for the regression equation. Receiver operating characteristic curve analysis revealed that the area under the curve (0.9), sensitivity (0.82), specificity (0.83), and positive predictive value (0.84) for HCS were higher than those for the functional independence measure, indicating that the HCS is a powerful predictor for advisability of home care. Clinical Relevance. Comprehensive measurements of the condition of provided care and the activities of daily living of the subjects, which are included in the HCS, are required for the prediction of advisability of home care.

How does age affect the care dependency risk one year after stroke? A study based on claims data from a German health insurance fund

BACKGROUND

The objective of this study is to investigate the effect of age on care dependency risk 1 year after stroke. Two research questions are addressed: (1) How strong is the association between age and care dependency risk 1 year after stroke and (2) can this association be explained by burden of disease?

METHODS

The study is based on claims data from a German statutory health insurance fund. The study population was drawn from all continuously insured members with principal diagnoses of ischaemic stroke, hemorrhagic stroke, or transient ischaemic attack in 2007 who survived for 1 year after stroke and who were not dependent on care before their first stroke (n = 2864). Data were collected over a 1-year period. People are considered to be dependent on care if they, due to a physical, mental or psychological illness or disability, require substantial assistance in carrying out activities of daily living for a period of at least 6 months. Burden of disease was assessed by stroke subtype, history of stroke, comorbidities as well as geriatric multimorbidity. Regression models were used for data analysis.

RESULTS

21.6 % of patients became care dependent during the observation period. Post-stroke care dependency risk was significantly associated with age. Relative to the reference group (0-65 years), the odds ratio of care dependency was 11.30 (95 % CI: 7.82-16.34) in patients aged 86+ years and 5.10 (95 % CI: 3.88-6.71) in patients aged 76-85 years. These associations were not explained by burden of disease. On the contrary, age effects became stronger when burden of disease was included in the regression model (by between 1.1 and 28 %).

CONCLUSIONS

Our results show that age has an effect on care dependency risk that cannot be explained by burden of disease. Thus, there must be other underlying age-dependent factors that account for the remaining age effects (e.g., social conditions). Further studies are needed to explore the causes of the strong age effects observed.

Impact of spatial neglect on stroke rehabilitation: evidence from the setting of an inpatient rehabilitation facility

OBJECTIVE

To examine the impact of spatial neglect on rehabilitation outcome, risk of falls, and discharge disposition in stroke survivors.

DESIGN

Inception cohort.

SETTING

Inpatient rehabilitation facility (IRF).

PARTICIPANTS

Individuals with unilateral brain damage after their first stroke (N=108) were assessed at IRF admission and discharge. At admission, 74 of them (68.5%) demonstrated symptoms of spatial neglect as measured using the Kessler Foundation Neglect Assessment Process (KF-NAP).

INTERVENTIONS

Usual and standard IRF care.

MAIN OUTCOME MEASURES

The FIM, Conley Scale, number of falls, length of stay (LOS), and discharge disposition.

RESULTS

The greater the severity of spatial neglect (higher KF-NAP scores) at IRF admission and the lower the FIM scores at admission as well as at discharge. Higher KF-NAP scores also correlated with greater LOS and lower FIM improvement rate. The presence of spatial neglect (KF-NAP score>0), but not Conley Scale scores, predicted falls such that participants with spatial neglect fell 6.5 times more often than those without symptoms. More severe neglect, indicated by KF-NAP scores at IRF admission, reduced the likelihood of returning home at discharge. A model that took spatial neglect and other demographic, socioeconomic, and clinical factors into account predicted home discharge. Rapid FIM improvement during IRF stay and lower annual income level were significant predictors of home discharge.

CONCLUSIONS

Spatial neglect after a stroke is a prevalent problem and may negatively affect rehabilitation outcome, risk of falls, and LOS.

Derivation and validation of a discharge disposition predicting model after acute stroke

BACKGROUND

Discharge disposition planning is vital for poststroke patients. We investigated clinical factors associated with discharging patients to nursing homes, using the Taiwan Stroke Registry data collected from 39 major hospitals.

METHODS

We randomly assigned 21,575 stroke inpatients registered from 2006 to 2008 into derivation and validation groups at a 3-to-1 ratio. We used the derivation group to develop a prediction model by measuring cumulative risk scores associated with potential predictors: age, sex, hypertension, diabetes mellitus, heart diseases, stroke history, snoring, main caregivers, stroke types, and National Institutes of Health Stroke Scale (NIHSS). Probability of nursing home care and odds ratio (OR) of nursing home care relative to home care by cumulative risk scores were measured for the prediction. The area under the receiver operating characteristic curve (AUROC) was used to assess the model discrimination against the validation group.

RESULTS

Except for hypertension, all remaining potential predictors were significant independent predictors associated with stroke patient disposition to nursing home care after discharge from hospitals. The risk sharply increased with age and NIHSS. Patients with a cumulative risk score of 15 or more had an OR of 86.4 for the nursing home disposition. The AUROC plots showed similar areas under curves for the derivation group (.86, 95% confidence interval [CI], .85-.87) and for the validation group (.84, 95% CI, .83-.86).

CONCLUSIONS

The cumulative risk score is an easy-to-estimate tool for preparing stroke patients and their family for disposition on discharge.

New evidence for therapies in stroke rehabilitation

Neurologic rehabilitation aims to reduce impairments and disabilities so that persons with serious stroke can return to participation in usual self-care and daily activities as independently as feasible. New strategies to enhance recovery draw from a growing understanding of how types of training, progressive task-related practice of skills, exercise for strengthening and fitness, neurostimulation, and drug and biological manipulations can induce adaptations at multiple levels of the nervous system. Recent clinical trials provide evidence for a range of new interventions to manage walking, reach and grasp, aphasia, visual field loss, and hemi-inattention.

The role of patient demographics and clinical presentation in predicting discharge placement after inpatient stroke rehabilitation: analysis of a large, US data base

PURPOSE

To determine whether functional ability at admission and demographics predict discharge placement after inpatient rehabilitation for older adults recovering from stroke.

METHOD

In this retrospective study, we examined records of 31,910 adults 65 years of age and older who were admitted for inpatient rehabilitation post-stroke. Binary logistic regression was used with the outcome of placement and potential predictors of the admission Functional Independence Measure (FIM) score, age, sex and marital status.

RESULTS

The average admission FIM was 60.0 out of 126; the average FIM at discharge was 84.8. The mean age was 77.7 ± 7.3 years, 57% were female and 52.5% were not married. More than three quarters of the patients were discharged to home. Odds ratios (ORs) with 95% confidence intervals (CIs) showed that patients with a FIM score below the mean of our sample (OR = 5.8, CI = 5.5-6.2), older than the mean age of our sample (OR = 1.6, CI = 1.5-1.7), and who were not married (OR = 1.9, CI = 1.8-2.0) (p-values <0.001) were more likely to be discharged to residential care. Sex was not predictive of placement.

CONCLUSION

The admission FIM was an important predictor of discharge placement after rehabilitation in older adults. Age and marital status were also significant predictors of discharge placement. Sex was not a significant predictor.