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Arm Subscore of Motricity Index to Predict Recovery of Upper Limb Dexterity in Patients With Acute Ischemic Stroke. Am J Phys Med Rehabil 2020; 99:300-304. [PMID: 31592879 DOI: 10.1097/phm.0000000000001326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether the arm subscore of the Motricity Index 1 wk after stroke can predict recovery of upper limb function according to the Action Research Arm Test before inpatient rehabilitation facility discharge and at 3-mo outpatient follow-up. DESIGN This was a prospective cohort study of patients with acute ischemic stroke admitted to a single acute care hospital and affiliated inpatient rehabilitation facility between 2016 and 2018. Upper limb dexterity of the impaired limb was assessed using the arm subscore of the Motricity Index and Action Research Arm Test. Receiver operating characteristic curve analysis was used to determine optimal cutoffs of the initial arm subscore of the Motricity Index for a good functional outcome defined as Action Research Arm Test score of 45 or higher. RESULTS Ninety-five patients were evaluated at median 6, 26, and 98.5 days after stroke. The median (interquartile range) arm subscore of the Motricity Index at 1 wk was 77 (20.3-93). The median (interquartile range) Action Research Arm Test scores before inpatient rehabilitation facility discharge and at 3-mo outpatient follow-up were 33 (3.5-52) and 52 (34-55.8), respectively. The optimal arm subscore of the Motricity Index to predict Action Research Arm Test score of 45 or higher before inpatient rehabilitation facility discharge and at 3-mo outpatient follow-up were 71 and 58, respectively. CONCLUSIONS Early arm subscore of the Motricity Index at 1 wk predicts upper limb functional capacity before inpatient rehabilitation facility discharge and at 3-mo outpatient follow-up.
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Simić-Panić D, Bošković K, Milićević M, Rabi Žikić T, Cvjetković Bošnjak M, Tomašević-Todorović S, Jovićević M. The Impact of Comorbidity on Rehabilitation Outcome after Ischemic Stroke. Acta Clin Croat 2018; 57:5-15. [PMID: 30256006 PMCID: PMC6400340 DOI: 10.20471/acc.2018.57.01.01] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
SUMMARY – Comorbidity decreases survival but it still remains unknown to what extent functional recovery after ischemic stroke is affected. The aim of this research was to determine the prevalence of the most common comorbidities in patients with ischemic stroke and to examine their predictive value on the functional status and recovery. In order to obtain relevant information for this research, we conducted a prospective study over a two-year period. It included patients with acute/subacute ischemic stroke who had inhospital rehabilitation treatment in our institution. Functional status of the patients was evaluated by the following three aspects at the beginning and at the end of rehabilitation treatment: Rivermead Mobility Index was used for mobility, Barthel Index for independence in activities of daily living, and modified Rankin Scale for total disability. Modified Charlston Comorbidity Index was used to assess comorbidity. Multivariate analysis was applied to evaluate the impact of recorded comorbidities on the patient functional outcome. Independent predictors of rehabilitation success in our study were the value of modified Charlston Comorbidity Index, atrial fibrillation and myocardial infarction. Our study demonstrated that patients with more comorbidities had worse functional outcome after stroke, so it is important to consider the comorbidity status when planning the rehabilitation treatment.
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Affiliation(s)
| | - Ksenija Bošković
- Faculty of Medicine, University of Novi Sad, Department of Medical Rehabilitation, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Marija Milićević
- Department of Neurology, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Tamara Rabi Žikić
- Faculty of Medicine, University of Novi Sad, Department of Neurology, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Mina Cvjetković Bošnjak
- Faculty of Medicine, University of Novi Sad, Department of Psychiatry, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Snežana Tomašević-Todorović
- Faculty of Medicine, University of Novi Sad, Department of Medical Rehabilitation, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Mirjana Jovićević
- Faculty of Medicine, University of Novi Sad, Department of Neurology, Clinical Center of Vojvodina, Novi Sad, Serbia
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Taiwo W, Wressle A, Bradley L. Predicting length of stay in specialist neurological rehabilitation. Disabil Rehabil 2016; 40:548-552. [PMID: 27976930 DOI: 10.1080/09638288.2016.1261419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS A retrospective case series was performed to determine which measures of complexity, dependency and function most accurately predict inpatient neurorehabilitation length of stay for individuals with post-acute neurological disorders. METHODS Sociodemographic, medical and functional variables were extracted from data submitted to the UK Rehabilitation Outcomes Collaborative. Length of stay was calculated as the total number of inpatient days, functional status was measured using Barthel Index, rehabilitation complexity was measured using Extended Rehabilitation Complexity Scale, and nursing dependency was measured using the Northwick Park Dependency Scale. RESULTS The mean rehabilitation length of stay was 70.9 days, with length of stay being 35.1 days higher in inpatients with acquired brain injury than inpatients with spinal cord injury. Diagnostic category, Barthel Index scores, Extended Rehabilitation Complexity Scale scores and Northwick Park Dependency Scale scores at admission independently predicted length of stay. Multiple regressions including diagnostic group, Barthel Index, Extended Rehabilitation Complexity Scale and Northwick Park Dependency Scale statistically significantly predicted 37.9% of the variability in length of stay (p < 0.005). Northwick Park Dependency Scale on admission was most closely correlated with inpatient length of stay. CONCLUSIONS In conclusion, inpatient length of stay is predicted by diagnostic category, Extended Rehabilitation Complexity Scale, Northwick Park Dependency Scale and Barthel Index. The most influential predictor of rehabilitation length of stay was Northwick Park Dependency Scale score at admission. These results may help facilitate rehabilitation resource planning and implementation of effective commissioning plans. Implications for Rehabilitation The most accurate predicting variable for length of stay in inpatient neurological rehabilitation was nursing need as measured by the Northwick Park Dependency Scale score on admission. Service users and commissioners can be provided with more realistic predictions of length of stay derived from admission variables that can be used in planning inpatient rehabilitation. Age and gender do not seem to have an effect on the total length of stay in rehabilitation.
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Affiliation(s)
- Whitney Taiwo
- a Brighton and Sussex Medical School , Brighton , UK
| | - Alexandra Wressle
- b Donald Wilson House Neurological Rehabilitation Centre , Western Sussex Hospitals NHS Trust , Chichester, UK
| | - Lloyd Bradley
- b Donald Wilson House Neurological Rehabilitation Centre , Western Sussex Hospitals NHS Trust , Chichester, UK
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Schönenberger S, Niesen WD, Fuhrer H, Bauza C, Klose C, Kieser M, Suarez JI, Seder DB, Bösel J. Early tracheostomy in ventilated stroke patients: Study protocol of the international multicentre randomized trial SETPOINT2 (Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial 2). Int J Stroke 2016; 11:368-79. [PMID: 26763913 DOI: 10.1177/1747493015616638] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/03/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tracheostomy is a common procedure in long-term ventilated critical care patients and frequently necessary in those with severe stroke. The optimal timing for tracheostomy is still unknown, and it is controversial whether early tracheostomy impacts upon functional outcome. METHOD The Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial 2 (SETPOINT2) is a multicentre, prospective, randomized, open-blinded endpoint (PROBE-design) trial. Patients with acute ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage who are so severely affected that two weeks of ventilation are presumed necessary based on a prediction score are eligible. It is intended to enroll 190 patients per group (n = 380). Patients are randomized to either percutaneous tracheostomy within the first five days after intubation or to ongoing orotracheal intubation with consecutive weaning and extubation and, if the latter failed, to percutaneous tracheostomy from day 10 after intubation. The primary endpoint is functional outcome defined by the modified Rankin Scale (mRS, 0-4 (favorable) vs. 5 + 6 (unfavorable)) after six months; secondary endpoints are mortality and cause of mortality during intensive care unit-stay and within six months from admission, intensive care unit-length of stay, duration of sedation, duration of ventilation and weaning, timing and reasons for withdrawal of life support measures, relevant intracranial pressure rises before and after tracheostomy. CONCLUSION The necessity and optimal timing of tracheostomy in ventilated stroke patients need to be identified. SETPOINT2 should clarify whether benefits in functional outcome can be achieved by early tracheostomy in these patients.
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Affiliation(s)
| | - Wolf-Dirk Niesen
- Department of Neurology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hannah Fuhrer
- Department of Neurology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Colleen Bauza
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - José I Suarez
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, Maine, USA
| | - Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Chen CM, Ke YL. Predictors for total medical costs for acute hemorrhagic stroke patients transferred to the rehabilitation ward at a regional hospital in Taiwan. Top Stroke Rehabil 2015; 23:59-66. [PMID: 26094779 DOI: 10.1179/1945511915y.0000000006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND One-third of the acute stroke patients in Taiwan receive rehabilitation. It is imperative for clinicians who care for acute stroke patients undergoing inpatient rehabilitation to identify which medical factors could be the predictors of the total medical costs. OBJECTIVES The aim of this study was to identify the most important predictors of the total medical costs for first-time hemorrhagic stroke patients transferred to inpatient rehabilitation using a retrospective design. METHODS All data were retrospectively collected from July 2002 to June 2012 from a regional hospital in Taiwan. A stepwise multivariate linear regression analysis was used to identify the most important predictors for the total medical costs. RESULTS The medical records of 237 patients (137 males and 100 females) were reviewed. The mean total medical cost per patient was United States dollar (USD) 5939.5 ± 3578.5.The following were the significant predictors for the total medical costs: impaired consciousness [coefficient (B), 1075.7; 95% confidence interval (CI) = 138.5-2012.9], dysphagia [coefficient (B), 1025.8; 95% CI = 193.9-1857.8], number of surgeries [coefficient (B), 796.4; 95% CI = 316.0-1276.7], pneumonia in the neurosurgery ward [coefficient (B), 2330.1; 95% CI = 1339.5-3320.7], symptomatic urinary tract infection (UTI) in the rehabilitation ward [coefficient (B), 1138.7; 95% CI = 221.6-2055.7], and rehabilitation ward stay [coefficient (B), 64.9; 95% CI = 31.2-98.7] (R(2) = 0.387). CONCLUSIONS Our findings could help clinicians to understand that cost reduction may be achieved by minimizing complications (pneumonia and UTI) in these patients.
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Affiliation(s)
- Chien-Min Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital , Chiayi, Taiwan
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Camicia M, Wang H, DiVita M, Mix J, Niewczyk P. Length of Stay at Inpatient Rehabilitation Facility and Stroke Patient Outcomes. Rehabil Nurs 2015; 41:78-90. [PMID: 26009865 DOI: 10.1002/rnj.218] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2015] [Indexed: 11/08/2022]
Abstract
PURPOSE To examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes. DESIGN A secondary data analysis of the Uniform Data System for Medical Rehabilitation database. METHODS Stroke patients discharged from IRFs in the United States between 2009 and 2011 were identified and divided into mild (n = 639), moderate (n = 2,065), and severely (n = 2,077) impaired groups. Study outcomes included cognition and motor functional gains measured by the Functional Independence Measure (FIM) instrument and discharge to the community. FINDINGS The average LOS was 8.9, 13.9, and 22.2 days for mild, moderate, and severely impaired stroke patients, respectively. After controlling for FIM admission and other important covariates, a longer LOS was associated with a modest increase in cognition gain (β = 0.038, p = .0045) for the moderately impaired patients, and a modest increase in cognition (β = 0.13, p < .0001) and motor gains (β = 0.25, p < .0001) as well as a tendency for discharge to the community (OR = 1.01, 95% CI = 1.00-1.02) among the severely impaired patients. However, a longer LOS showed a negative association with functional gains among the mildly impaired patients as well as discharge to community for both mild and moderately impaired patients. CONCLUSION The association of IRF LOS and patient outcomes varied by stroke impairment severity, positively for more severely impaired patients and negatively for mildly impaired patients. CLINICAL RELEVANCE The study provides evidence for the care of stroke patients at the IRF setting.
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Affiliation(s)
- Michelle Camicia
- Kaiser Foundation Rehabilitation Center, Kaiser Permanente Medical Center, Vallejo, CA, USA
| | - Hua Wang
- Kaiser Foundation Rehabilitation Center, Kaiser Permanente Medical Center, Vallejo, CA, USA
| | - Margaret DiVita
- Health Department, State University of New York at Cortland, Cortland, NY, USA
| | - Jacqueline Mix
- Uniform Data System for Medical Rehabilitation, Amherst, NY, USA
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Roth EJ, Lovell L. Seven-Year Trends in Stroke Rehabilitation: Patient Characteristics, Medical Complications, and Functional Outcomes. Top Stroke Rehabil 2015; 9:1-9. [PMID: 14523695 DOI: 10.1310/plfl-ubhj-jnr5-e0fc] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Studies of stroke trends have focused primarily on incidence, mortality, and hospitalization rates. There has been little evaluation of changes over time in the common patient characteristics, medical comorbidities, and functional outcomes of patients. The present study evaluated changes during a 7-year period. We found that while demographic variables, stroke severity, and most stroke characteristics remained relatively stable, disability levels at admission and discharge decreased and frequencies of both medical tube usage and many secondary medical complications increased over time. These changes have important implications for the clinical management of stroke patients in rehabilitation and for the organization and financing of stroke rehabilitation programs.
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Affiliation(s)
- Elliot J Roth
- Rehabilitation Institute of Chicago and Rehabilitation Research, Training Center on Enhancing the Quality of Life of Stroke Survivors, and Physical Medicine and Rehabilitation, Northwestern University's Feinberg School of Medicine, Chicago, Illinois, USA
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Grant C, Goldsmith CH, Anton HA. Inpatient Stroke Rehabilitation Lengths of Stay in Canada Derived From the National Rehabilitation Reporting System, 2008 and 2009. Arch Phys Med Rehabil 2014; 95:74-8. [DOI: 10.1016/j.apmr.2013.08.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 05/30/2013] [Accepted: 08/16/2013] [Indexed: 11/25/2022]
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Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehabil 2013; 94:1951-8. [PMID: 23810355 DOI: 10.1016/j.apmr.2013.05.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 04/24/2013] [Accepted: 05/26/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine whether functional status on admission to a Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) is associated with unplanned readmission to acute care. DESIGN Retrospective cohort study. SETTING Academic hospital-based CIIRP. PARTICIPANTS Consecutive patients (N=1515) admitted to a CIIRP between January 2009 and June 2012. INTERVENTIONS Patients' functional status, the primary exposure variable, was assessed using tertiles of the total FIM score at CIIRP admission, with secondary analyses using the FIM motor and cognitive domains. A propensity score, consisting of 25 relevant clinical and demographic variables, was used to adjust for confounding in the analysis. MAIN OUTCOME MEASURES Readmission to acute care was categorized as (1) readmission before planned discharge from the CIIRP, (2) readmission within 30 days of discharge from the CIIRP, and (3) total readmissions from both groups, with total readmissions being the a priori primary outcome. RESULTS Among the 1515 patients, there were 347 total readmissions. Total readmissions were significantly associated with FIM scores, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the lowest and middle FIM tertiles versus the highest tertile (AOR=2.6; 95% CI, 1.9-3.7; P<.001 and AOR=1.7; 95% CI, 1.2-2.4; P=.002, respectively). There were similar findings for secondary analyses of readmission before planned discharge from the CIIRP (AOR=3.5; 95% CI, 2.2-5.8; P<.001 and AOR=2.1; 95% CI, 1.3-3.5l P=.002, respectively), and a weaker association for readmissions after discharge from the CIIRP (AOR=1.6; 95% CI, 1.0-2.4; P=.047 and AOR=1.3; 95% CI, 0.8-1.9; P=.28, respectively). The FIM motor domain score was more strongly associated with readmissions than the FIM cognitive score. CONCLUSIONS Functional status on admission to the CIIRP is strongly associated with readmission to acute care, particularly for motor aspects of functional status and readmission before planned discharge from the CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.
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Affiliation(s)
- Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.
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In-Hospital Predictors of Falls in Community-Dwelling Individuals After Stroke in the First 6 Months After a Baseline Evaluation: A Prospective Cohort Study. Arch Phys Med Rehabil 2012; 93:2244-50. [DOI: 10.1016/j.apmr.2012.06.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 06/11/2012] [Accepted: 06/20/2012] [Indexed: 10/28/2022]
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Haines TP, Kuys S, Clarke J, Morrison G, Bew P. Dose-response relationship between physiotherapy resource provision with function and balance improvements in patients following stroke: a multi-centre observational study. J Eval Clin Pract 2011; 17:136-42. [PMID: 20825535 DOI: 10.1111/j.1365-2753.2010.01380.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Inpatient rehabilitation of patients following stroke can be resource intensive, with optimal models of service delivery unclear. This study investigates the dose-response curves between physiotherapy service delivery variables and balance and function clinical outcomes. METHOD This was a multi-centre (15 sites), prospective, cohort study involving patients (n = 288) admitted for rehabilitation following stroke conducted across two states in Australia. Physiotherapy department resource provision variables were collected and examined for association with change in patient function and balance outcomes (Functional Independence Measure, step test, functional reach test) measured at admission and discharge from inpatient care. RESULTS A greater amount of log-transformed physiotherapy department resource provision was associated with greater improvement in the functional independence measure [Regression coefficient (95% CI): 4.05 (1.15, 6.95)] and functional reach test [46.43 (17.03, 75.84)], while physiotherapist time provided to patients was associated with greater improvement for the step test [0.15 (0.03, 0.28)], and functional reach [0.35 (0.19, 0.52)]. CONCLUSION Receiving a higher rate of physiotherapist input is an important factor in attaining a greater amount of recovery in function and balance outcomes; however, the improvement by patients who received the greatest amount of input was highly variable.
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Affiliation(s)
- Terry P Haines
- Allied Health Clinical Research Unit, Southern Health, Cheltenham, Victoria, Australia.
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Wei JW, Heeley EL, Jan S, Huang Y, Huang Q, Wang JG, Cheng Y, Xu E, Yang Q, Anderson CS. Variations and determinants of hospital costs for acute stroke in China. PLoS One 2010; 5. [PMID: 20927384 PMCID: PMC2946911 DOI: 10.1371/journal.pone.0013041] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 08/31/2010] [Indexed: 12/04/2022] Open
Abstract
Background The burden of stroke is high and increasing in China. We modelled variations in, and predictors of, the costs of hospital care for patients with acute stroke in China. Methods and Findings Baseline characteristics and hospital costs for 5,255 patients were collected using the prospective register-based ChinaQUEST study, conducted in 48 Level 3 and 14 Level 2 hospitals in China during 2006–2007. Ordinary least squares estimation was used to determine factors associated with hospital costs. Overall mean cost of hospitalisation was 11,216 Chinese Yuan Renminbi (CNY) (≈US$1,602) per patient, which equates to more than half the average annual wage in China. Variations in cost were largely attributable to stroke severity and length of hospital stay (LOS). Model forecasts showed that reducing LOS from the mean of 20 days for Level 3 and 18 days for Level 2 hospitals to a duration of 1 week, which is common among Western countries, afforded cost reductions of 49% and 19%, respectively. Other lesser determinants varied by hospital level: in Level 3 hospitals, health insurance and the occurrence of in-hospital complications were each associated with 10% and 18% increases in cost, respectively, whilst treatment in a teaching hospital was associated with approximately 39% decrease in cost on average. For Level 2 hospitals, stroke due to intracerebral haemorrhage was associated with a 19% greater cost than for ischaemic stroke. Conclusions Changes to hospital policies to standardise resource use and reduce the variation in LOS could attenuate costs and improve efficiencies for acute stroke management in China. The success of these strategies will be enhanced by broader policy initiatives currently underway to reform hospital reimbursement systems.
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Affiliation(s)
- Jade W Wei
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia.
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Calderón SAL, Zurakowski D, Davis JS, Ring D. Quantitative Adjustment of the Influence of Depression on the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire. Hand (N Y) 2010; 5:49-55. [PMID: 19495887 PMCID: PMC2820631 DOI: 10.1007/s11552-009-9205-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 05/19/2009] [Indexed: 11/29/2022]
Abstract
Upper extremity specific disability as measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire varies more than expected based upon variations in objective impairment influenced by depression. We tested the hypothesis that adjusting for depression can reduce the mean and variance of DASH scores. Five hundred and sixteen patients (352 men, 164 women) with an average of 58 years of age (range, 18-100) were asked to simultaneously complete the DASH and Center for Epidemiologic Studies Depression Scale (CES-D) scores at their initial visit to a hand surgeon. Pearson's correlations between each of the DASH items and the CES-D score were obtained. The DASH score was then adjusted for the influence of Depression for women and men using ordinary least-squares regression and subtracting the product of the regression coefficient and the CES-D score from the raw DASH score. The average DASH score was 24 points (SD, 19; range, 0-91), and the average CES-D score was 10 points (SD, 8; range, 0-42). Thirteen of the 30 items of the DASH demonstrated correlation greater than r = 0.20. Adjustment of these DASH items for the depression effect led to significant reductions in the mean (5.5 points; p < 0.01) and standard deviation (0.8 points; p < 0.01) of DASH scores. Adjustment for depression alone had a significant but perhaps clinically marginal effect on the variance of DASH scores. Additional research is merited to determine if DASH score adjustments for the most important subjective and psychosocial aspects of illness behavior can improve correlation between DASH scores and objective impairment.
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Affiliation(s)
| | - David Zurakowski
- Harvard Medical School, Boston, MA USA ,Department of Surgery, Children’s Hospital Boston, Boston Children’s Hospital, Boston, MA USA
| | - James S. Davis
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA USA
| | - David Ring
- Harvard Medical School, Boston, MA USA ,Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
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Re: Length of Stay in Rehabilitation Is Associated With Admission Neurologic Deficits and Discharge Destination. PM R 2009; 1:783; author reply 784. [DOI: 10.1016/j.pmrj.2009.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Accepted: 05/20/2009] [Indexed: 11/18/2022]
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Tan WS, Heng BH, Chua KSG, Chan KF. Factors Predicting Inpatient Rehabilitation Length of Stay of Acute Stroke Patients in Singapore. Arch Phys Med Rehabil 2009; 90:1202-7. [DOI: 10.1016/j.apmr.2009.01.027] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Revised: 01/13/2009] [Accepted: 01/20/2009] [Indexed: 11/29/2022]
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Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: a case-control study. Am J Phys Med Rehabil 2009; 88:30-8. [PMID: 19096289 DOI: 10.1097/phm.0b013e3181909b73] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To assess the association of selected clinical factors and specific medication use (proton pump inhibitors, H2 receptor antagonists [H2 blockers], and angiotensin-converting enzyme inhibitors) with presence of pneumonia in patients with stroke undergoing acute inpatient rehabilitation. DESIGN Matched case-control study in a freestanding urban academic inpatient acute rehabilitation hospital. Participants were 72 stroke survivors, consisting of 36 patients who developed pneumonia during rehabilitation hospitalization individually matched in order of decreasing priority on age, sex, stroke side, depth, and severity with 36 patients with stroke not developing pneumonia. Potential risk factors, including severe dysphagia, dietary interventions, presence of tracheostomy or feeding tube, and specific medications, were assessed for association with pneumonia during rehabilitation using separate univariate and multivariate analyses. Functional change was assessed using the functional independence measure. RESULTS Although pneumonia was associated with proton pump inhibitors or H2 blockers (odds ratio, 3.3; 95% confidence interval, 1.0-13.7), any feeding tube (odds ratio: 5.0; 95% confidence interval, 1.4-27.0), severe dysphagia (odds ratio: 15.0; 95% confidence interval, 2.3-631), and tracheostomy (odds ratio: 10; 95% confidence interval, 1.4-434.0) on univariate evaluation, none of these individual factors was significantly associated with pneumonia in a multivariate model. Risk factors were found to be highly related to each other. Odds of pneumonia did not significantly decrease with angiotensin-converting enzyme inhibitors (odds ratio: 0.9; 95% confidence interval, 0.2-3.0). Patients with pneumonia had a significantly lower functional independence measure score at discharge. CONCLUSIONS A reduction in pneumonia was not found with the use of angiotensin-converting enzyme inhibitors. Although tracheostomies, feeding tubes, proton pump inhibitor or H2 blocker use, and the presence of dysphagia were identified as risk factors for pneumonia on univariate analyses, none of these factors demonstrated an independent association with pneumonia on multivariate analyses. It may be more that the underlying impairment, rather than the assessed interventions, may confer greater risk of pneumonia in the poststroke patient.
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Luengo-Fernandez R, Gray AM, Rothwell PM. Costs of stroke using patient-level data: a critical review of the literature. Stroke 2008; 40:e18-23. [PMID: 19109540 DOI: 10.1161/strokeaha.108.529776] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria. METHODS A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups. RESULTS A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs. CONCLUSIONS This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.
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Affiliation(s)
- Ramon Luengo-Fernandez
- Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, USA.
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Cieza A, Geyh S, Chatterji S, Kostanjsek N, Üstün BT, Stucki G. Identification of candidate categories of the International Classification of Functioning Disability and Health (ICF) for a Generic ICF Core Set based on regression modelling. BMC Med Res Methodol 2006; 6:36. [PMID: 16872536 PMCID: PMC1569864 DOI: 10.1186/1471-2288-6-36] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Accepted: 07/27/2006] [Indexed: 11/16/2022] Open
Abstract
Background The International Classification of Functioning, Disability and Health (ICF) is the framework developed by WHO to describe functioning and disability at both the individual and population levels. While condition-specific ICF Core Sets are useful, a Generic ICF Core Set is needed to describe and compare problems in functioning across health conditions. Methods The aims of the multi-centre, cross-sectional study presented here were: a) to propose a method to select ICF categories when a large amount of ICF-based data have to be handled, and b) to identify candidate ICF categories for a Generic ICF Core Set by examining their explanatory power in relation to item one of the SF-36. The data were collected from 1039 patients using the ICF checklist, the SF-36 and a Comorbidity Questionnaire. ICF categories to be entered in an initial regression model were selected following systematic steps in accordance with the ICF structure. Based on an initial regression model, additional models were designed by systematically substituting the ICF categories included in it with ICF categories with which they were highly correlated. Results Fourteen different regression models were performed. The variance the performed models account for ranged from 22.27% to 24.0%. The ICF category that explained the highest amount of variance in all the models was sensation of pain. In total, thirteen candidate ICF categories for a Generic ICF Core Set were proposed. Conclusion The selection strategy based on the ICF structure and the examination of the best possible alternative models does not provide a final answer about which ICF categories must be considered, but leads to a selection of suitable candidates which needs further consideration and comparison with the results of other selection strategies in developing a Generic ICF Core Set.
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Affiliation(s)
- Alarcos Cieza
- ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), IHRS, Ludwig-Maximilian University, Munich, Germany
- Swiss Paraplegic Research, Nottwil, Switzerland
| | - Szilvia Geyh
- ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), IHRS, Ludwig-Maximilian University, Munich, Germany
| | - Somnath Chatterji
- Classification, Assessment, Surveys and Terminology Team, World Health Organization, Geneva, Switzerland
| | - Nenad Kostanjsek
- Classification, Assessment, Surveys and Terminology Team, World Health Organization, Geneva, Switzerland
| | - Bedirhan T Üstün
- Classification, Assessment, Surveys and Terminology Team, World Health Organization, Geneva, Switzerland
| | - Gerold Stucki
- ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), IHRS, Ludwig-Maximilian University, Munich, Germany
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Physical Medicine and Rehabilitation, Ludwig-Maximilian University, Munich, Germany
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Austin PC, Tu JV, Daly PA, Alter DA. The use of quantile regression in health care research: a case study examining gender differences in the timeliness of thrombolytic therapy. Stat Med 2005; 24:791-816. [PMID: 15532082 DOI: 10.1002/sim.1851] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Investigators are frequently interested in determining patient and system characteristics associated with delays in the provision of essential medical treatment. Investigators have typically used either multiple linear regression or Cox proportional hazards models to assess the impact of patient and system characteristics on the timeliness of medical treatment. A drawback to the use of these two methods is that they allow, at best, a partial exploration of how a distribution of delays in treatment or of waiting times changes with patient characteristics. In contrast, quantile regression models allow one to assess how any quantile of a conditional distribution changes with patient characteristics. We illustrate the utility of quantile regression by examining gender differences in the delivery of thrombolysis in patients with an acute myocardial infarction. We demonstrate that richer inferences can be drawn through the use of quantile regression. Females were more likely to experience delays in treatment compared to males. Furthermore, gender had a greater impact upon those patients who had the greatest delays in treatment. Investigators who want to determine how a distribution of delays in treatment or of waiting times changes with patient or system characteristics should consider complementing their analyses with the use of quantile regression.
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MacKay-Lyons MJ, Howlett J. Exercise capacity and cardiovascular adaptations to aerobic training early after stroke. Top Stroke Rehabil 2005; 12:31-44. [PMID: 15735999 DOI: 10.1310/rdqm-jtgl-whaa-xybw] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Clinicians are becoming increasingly interested in the use of aerobic training to enhance functional outcomes after stroke. Several studies have demonstrated the effectiveness of training among individuals in the chronic poststroke period. However, there is limited information on the response to training in earlier stages of recovery. The purpose of this article is to review what is known regarding the capacity of people early after stroke (<4 months) to respond to the physiological demands of exercise (exercise capacity) as well as their ability to make long-term cardiovascular adaptations to aerobic exercise. There is evidence that exercise capacity, as measured by peak oxygen consumption on maximal exercise tests, is reduced in this population. There is also evidence, albeit limited, that exercise trainability soon after stroke can be both feasible and safe, if appropriate screening and monitoring are used. Moreover, there are early indications that activity-level functions such as walking speed, mobility, and balance may be enhanced through such programs. Further research is necessary to elucidate the most appropriate timing and design of fitness programs for people early after stroke.
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Ward A, Payne KA, Caro JJ, Heuschmann PU, Kolominsky-Rabas PL. Care needs and economic consequences after acute ischemic stroke: the Erlangen Stroke Project. Eur J Neurol 2005; 12:264-7. [PMID: 15804242 DOI: 10.1111/j.1468-1331.2004.00949.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objective was to determine the functional outcome, location of care and economic consequences in the first 3 months after ischemic stroke. As part of the Erlangen Stroke Project, (ESPro) information was collected on patients suffering a first-ever ischemic stroke. Three months after the stroke, location of care, dependence on caregivers and function based on Barthel Index: poor (0-55), moderate (60-90) or good function (95-100) were recorded. Data about health services used were combined with cost estimates for Germany (2000 Euros, undiscounted). Of 491 patients hospitalized, 383 were alive 3 months afterwards, 79% residing in the community. The majority of patients with poor function (60%) were still in institutional care. Patients with good function typically accrued the lowest costs, whether in an institution (17 965) or not (11 032) compared with poorer function who were living in an institution (poor: 26 370; moderate: 28,121), or community (poor: 27,207; moderate: 19,350). Hospitalization and rehabilitation services were the major costs accrued at each level of function. Many patients were left requiring a substantial amount of care and the costs associated with providing institutional care has a major impact on the economic consequences of a stroke.
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Affiliation(s)
- A Ward
- Caro Research Institute, Concord, MA 01742, USA.
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Dobrez DG, Lo Sasso AT, Heinemann AW. The effect of prospective payment on rehabilitative care. Arch Phys Med Rehabil 2004; 85:1909-14. [PMID: 15605325 DOI: 10.1016/j.apmr.2004.06.064] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To estimate the difference between cost and prospective payment system (PPS) reimbursements for rehabilitation care and to simulate potential consequences of cost-reducing strategies. DESIGN A retrospective study to estimate costs and functional status at discharge from care. SETTING An academic, urban, rehabilitation hospital. PARTICIPANTS Stroke patients on their first admission to a rehabilitation hospital between 1994 and 1998. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Cost was estimated from billing databases. Function was measured using the motor and cognitive components of the FIM instrument. RESULTS PPS reimbursements were 10,825 dollars (37%) lower than costs. No matter how much therapy was reduced, the costs were still greater than the mean PPS reimbursement. A reduction in length of stay by 9.6 days was required to bring costs in line with the PPS reimbursement, reducing discharge cognitive function by 1.1 points (P <.01). Use of group therapy brought costs close to PPS reimbursement amount and improved discharge cognitive function by 0.5 points (P <.10). CONCLUSIONS Our study shows the large difference between costs and expected PPS reimbursements that would have been observed before the PPS. Institutions have many options that reduce costs, with little effect on function at discharge. Future studies should determine the impact of evolving reimbursement rules on facilities financial status, and on patient outcomes.
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Affiliation(s)
- Deborah G Dobrez
- Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Northwestern University, Chicago, IL 60611, USA.
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Abstract
OBJECTIVE To determine if stroke patients without specific aerobic training experience a change in the first 6 months after stroke. DESIGN Descriptive, longitudinal study with repeated measures of exercise capacity at 1, 2, 3, and 6 months after stroke. SETTING Exercise testing laboratory in a tertiary care hospital. PARTICIPANTS Consecutive sample of 25 patients (mean age +/- standard deviation, 64.1+/-13.6 y) 1 month after first ischemic stroke. INTERVENTIONS Not applicable. Main Outcome Measures Peak oxygen consumption (Vo(2)peak) was measured by open-circuit spirometry during maximal effort treadmill walking with 15% body-weight support. RESULTS Mean Vo(2)peak increased from 14.8+/-5.3 mL x kg(-1). min(-1) at 1 month to 17.3+/-7.0 mL x kg(-1).min(-1) at 6 months after stroke (P=.003) or from 61.7%+/-16% to 71.3%+/-23% of age- and sex-related normative values for sedentary healthy adults (P=.008). CONCLUSIONS Despite improvements in Vo(2)peak and other indices of cardiovascular training between 1 and 6 months poststroke, substantial limitations in exercise capacity persisted. Further study is needed to determine the extent to which these limitations can be modified through aerobic conditioning.
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Valach L, Selz B, Signer S. Length of stay in the rehabilitation center, the admission functional independence measure and the functional independence measure gain. Int J Rehabil Res 2004; 27:135-43. [PMID: 15167111 DOI: 10.1097/01.mrr.0000131577.55940.80] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The decision to discharge is an important factor determining the length of stay (LOS) in a rehabilitation center and should be scrutinized. The purpose of this study was to analyse the predictive power of the individual items of the admission functional independence measure (FIM) for the LOS indicating their relevance in the decision to discharge and to expose the assumptions driving this decision. The data of all consecutive in-patients of 5 years in a rehabilitation center were analysed (n=1047). The regression analysis of FIM item values on admission and FIM item gains as independent variables and the LOS as the dependent variable showed a number of criteria operational in the decision to discharge patients with different diagnoses. The criteria were identified as 'aiming for certain standards' (for example, bed/chair/WC transfer), 'aiming for optimal improvement', 'dealing with different rates of improvement' and 'giving benefit of learning potential'. It is proposed that these criteria should be discussed and evaluated.
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Affiliation(s)
- Ladislav Valach
- Rehabilitation Center, Buerger Hospital Solothurn, Faculty of Philosophy, University of Zurich, Switzerland.
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Ploughman M, Corbett D. Can forced-use therapy be clinically applied after stroke? an exploratory randomized controlled trial11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Arch Phys Med Rehabil 2004; 85:1417-23. [PMID: 15375810 DOI: 10.1016/j.apmr.2004.01.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the efficacy, safety, and compliance with forced-use therapy (FUT) applied without additional "shaping" therapy during the rehabilitation phase of stroke. DESIGN Prospective, randomized controlled trial. SETTING Tertiary mixed rehabilitation center. PARTICIPANTS Consecutive sample of 30 inpatients or outpatients with first stroke showing minimal movement of the arm and hand. Subjects who scored below 26 on the Mini-Mental State Examination were excluded. Seven subjects either did not provide consent or withdrew from the study. The remaining subjects were randomized into the control group (n=13) and the FUT group (n=10). INTERVENTION FUT involved wearing a thick constraint mitten on the sound arm for as many as 6 hours a day. MAIN OUTCOME MEASURES The Chedoke McMaster Impairment Inventory for arm, hand, postural control, and shoulder pain; Action Research Arm Test; grip strength; and FIM instrument. RESULTS FUT subjects experienced 20% more recovery of the arm than did control subjects and more recovery of postural control (P=.04). Men benefited most from the program, and there was a tendency for FUT subjects to have more shoulder pain. Compliance was related to cognitive status. CONCLUSIONS FUT, without shaping therapy, appears to augment arm recovery, but a larger sample is required to confirm these findings. The FUT mitten was safe and well tolerated; however, more research is needed to determine the relation between FUT and hemiplegic shoulder pain.
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Affiliation(s)
- Michelle Ploughman
- Div. of Basic Medical Sciences, Faculty of Medicine, Memorial University, St. John's, NL, Canada.
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Roig RL, Worsowicz GM, Stewart DG, Cifu DX. Geriatric rehabilitation. 3. Physical medicine and rehabilitation interventions for common disabling disorders1∗1No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated.∗Key references. Arch Phys Med Rehabil 2004; 85:S12-7; quiz S27-30. [PMID: 15221717 DOI: 10.1016/j.apmr.2004.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
UNLABELLED This self-directed learning module highlights physical medicine and rehabilitation (PM and R) interventions for common disorders that cause disability in older adults. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in PM and R and geriatric medicine. This article specifically focuses on PM and R interventions for arthritides, fractures, cardiovascular disorders, peripheral vascular disease, amputations, pulmonary disorders, cancer, stroke, traumatic brain injury, Parkinson's disease, spinal cord injury, peripheral neuropathies, and diabetic complications. OVERALL ARTICLE OBJECTIVE To summarize the physical medicine and rehabilitation interventions for commonly disabling conditions of older adults.
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Affiliation(s)
- Randolph L Roig
- Department of Physical Medicine and Rehabilitation, Northlake Rehabilitation Professionals, Hammond, LA 70403, USA.
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Falcão IV, Carvalho EMFD, Barreto KML, Lessa FJD, Leite VMM. Acidente vascular cerebral precoce: implicações para adultos em idade produtiva atendidos pelo Sistema Único de Saúde. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2004. [DOI: 10.1590/s1519-38292004000100009] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVOS: conhecer as incapacidades e identificar se há diferenças de gênero, em sobreviventes de primeiro episódio de acidente vascular cerebral (AVC), entre 20 e 59 anos de idade, na cidade do Recife e que tenham sido hospitalizados pelo Sistema Único de Saúde. MÉTODOS: entrevista domiciliar com uma amostra de sobreviventes, investigando-se as incapacidades referidas na vida funcional e produtiva deles. RESULTADOS: amostra equilibrada entre os sexos, média de idade de 52 anos, com nível elementar de estudos ou analfabeto e trabalhando no setor de serviços, informal ou doméstico. Menos de 20% informam recuperação total após o AVC. Aproximadamente 80% apresentam algum déficit, sendo os problemas de comunicação e os sintomas depressivos mais freqüentes entre as mulheres. Após o AVC aumentou o número de desempregados e aposentados e as incapacidades repercutem negativamente na satisfação de vida de mais de 70% dos entrevistados. CONCLUSÕES: é expressivo o percentual de casos, ainda jovens, com seqüelas pós AVC, sendo este mais precoce e o quadro de incapacidades mais freqüente e/ou grave entre as mulheres. A prevenção e a reabilitação após o AVC são desejáveis, com a implantação de programas, considerando as condições de gênero, para o controle dos riscos e para as seqüelas resultantes do AVC.
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Tu F, Anan M, Kiyohara Y, Okada Y, Nobutomo K. Analysis of hospital charges for ischemic stroke in Fukuoka, Japan. Health Policy 2004; 66:239-46. [PMID: 14637009 DOI: 10.1016/s0168-8510(03)00080-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Stroke is a heavy economic burden on individuals, society, and health services in Japan, where health expenditures are rising rapidly. The objective of the present study was to examine medical services and demographic factors associated with increased inpatient charges for ischemic stroke in Japan. SUBJECTS AND METHODS The study subjects were 316 patients with a principal diagnosis of acute ischemic stroke who were discharged from the National Kyushu Medical Center Hospital from 1 July 1995 through 31 June 1999. Demographic, clinical, and administrative data were retrospectively collected from medical records and the hospital Clinical Financial Information System (CFIS). The influence of social and medical factors on total charges was analyzed using the stepwise multiple regression model. RESULTS Among the total subjects, the mean (median) length of hospital stay (LOHS) was 33 (30) days (range, 2-155 days). The mean (median) hospital charge per patient was US dollars 9020 (dollars 7974) with a range of dollars 336-54,509. The distribution of charges was 42% for fundamental, 17% for injection therapies, 13% for radiological test, 11% for other laboratory examinations, 3% for drugs, and 3% for operations. Stepwise multiple regression analysis revealed that LOHS was the key determinant of the hospital charge (partial R2=0.5993, P=0.0001). Operations (P=0.0001) and angiography (P=0.03) were also independent but less contributory determinants of the hospital charge. CONCLUSIONS LOHS was strongly, positively associated with inpatient charges for ischemic stroke in Japan. This implies that significant charge reductions are more likely to rely on shortening LOHS, which probably can be achieved by altering reimbursement policies.
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Affiliation(s)
- Feng Tu
- Department of Health Services Management and Policy, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Forrest GP. Inpatient rehabilitation of patients requiring hemodialysis11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Arch Phys Med Rehabil 2004; 85:51-3. [PMID: 14970967 DOI: 10.1016/s0003-9993(03)00366-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the outcomes of patients who require hemodialysis and are admitted to an inpatient rehabilitation unit. DESIGN Retrospective review of the data of all admissions to an inpatient rehabilitation unit in 2001. SETTING University medical center. PARTICIPANTS All inpatient rehabilitation admissions in 2001 (N=531), including 497 patients who did not require hemodialysis and 34 who required hemodialysis. INTERVENTION A comprehensive rehabilitation program including physical therapy and occupational therapy. Speech and language therapy and rehabilitation psychology were provided when necessary. MAIN OUTCOME MEASURES Length of stay (LOS), change in total score on the FIM instrument, FIM efficiency, and place of discharge. RESULTS Admission and discharge FIM scores of the patients requiring hemodialysis were virtually identical to those of the other patients admitted to the unit. The average LOS of the hemodialysis patients was 5.4 days longer than that of the other patients, and, therefore, efficiency scores of the dialysis group were less than those of the other patients. The rate of discharge to the community did not differ significantly for the dialysis group. CONCLUSIONS Patients who require hemodialysis can benefit from rehabilitation services. Their improvement on the FIM instrument is comparable to that of other patients, but their LOS may be longer than that of other patients.
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Abstract
OBJECTIVE To evaluate exercise capacity of patients with a poststroke interval of less than 1 month. DESIGN Prospective, cohort, observational study. SETTING Exercise testing laboratory in a tertiary care hospital. PARTICIPANTS Twenty-nine patients (mean age +/- standard deviation, 64.9+/-13.5 y) with a poststroke interval of 26.0+/-8.8 days. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Peak exercise capacity (VO(2)peak) was measured by open-circuit spirometry during maximal effort treadmill walking with 15% body-weight support. RESULTS Mean VO(2)peak was 14.4+/-5.1 mL. kg(-1). min(-1) or 60%+/-16% of age- and sex-related normative values for sedentary healthy adults. CONCLUSIONS Exercise capacity approximately 1 month after stroke was compromised. Further research is needed to elucidate the physiologic basis of this low capacity.
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MacKay-Lyons MJ, Makrides L. Cardiovascular stress during a contemporary stroke rehabilitation program: is the intensity adequate to induce a training effect? Arch Phys Med Rehabil 2002; 83:1378-83. [PMID: 12370872 DOI: 10.1053/apmr.2002.35089] [Citation(s) in RCA: 163] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the level of cardiovascular stress of physical therapy (PT) and occupational therapy (OT) sessions of a contemporary stroke rehabilitation program and to identify therapeutic activities that elicit heart rate responses adequate to induce a training effect. DESIGN A descriptive, longitudinal study with heart rate and activity monitoring of PT and OT sessions at biweekly intervals, 2 to 14 weeks poststroke. SETTING An acute inpatient stroke unit and inpatient and outpatient stroke rehabilitation units. PARTICIPANTS A consecutive sample of 20 patients with ischemic stroke who participated in inpatient and outpatient stroke rehabilitation. INTERVENTION Observation of routine PT and OT sessions for patients poststroke without influencing the extent and content of the sessions. MAIN OUTCOME MEASURE Time per session in which heart rate was within the calculated target heart rate zone. RESULTS Time per PT session spent in target heart rate zone was low (2.8+/-0.9 min), and per OT session was negligible (0.7+/-0.2 min) over the course of rehabilitation. CONCLUSIONS The PT and OT sessions between 2 and 14 weeks poststroke did not elicit adequate cardiovascular stress to induce a training effect.
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Evers S, Voss G, Nieman F, Ament A, Groot T, Lodder J, Boreas A, Blaauw G. Predicting the cost of hospital stay for stroke patients: the use of diagnosis related groups. Health Policy 2002; 61:21-42. [PMID: 12173495 DOI: 10.1016/s0168-8510(01)00219-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In order to provide tailor-made care, governments are considering the implementation of output-pricing based on hospital case-mix measures, such as diagnosis related groups (DRG). The question is whether the current DRG classification system can provide a satisfactory prediction of the variance of costs in stroke patients and if not, in what way other variables may enhance this prediction. In this study, data from 731 stroke patients hospitalized at University Hospital Maastricht during 1996-1998 are used in the cost analysis. The DRG classification for this group uses information--in addition to the DRG classification operation or no operation--on the patient's age combined with discharge status. The results of regression analysis show that using DRGs, the variance explained in the costs amounts to 34%. Adding other variables to the DRGs, the variance explained increases to about 61%. Additional factors highly correlating with inpatient costs are the level of functioning after stroke, comorbidity, complications, and 'days of stay for non-medical reasons'. Costs decreased for stroke patients discharged during the latter part of the years studied, and if stroke patients happened to die during their hospital stay. The results do suggest that future implementation of output-pricing based on the DRG case-mix measures is feasible for stroke patients only if it is enhanced with information on complications and the level of functioning.
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Affiliation(s)
- Silvia Evers
- Department of Health Organization Policy and Economics, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
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Eng JJ, Rowe SJ, McLaren LM. Mobility status during inpatient rehabilitation: a comparison of patients with stroke and traumatic brain injury. Arch Phys Med Rehabil 2002; 83:483-90. [PMID: 11932849 PMCID: PMC3478323 DOI: 10.1053/apmr.2002.31203] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the mobility status (admission and discharge status, change in status) between patients with stroke and traumatic brain injury (TBI) during inpatient rehabilitation and to determine the relationship between mobility status and outcome variables including length of stay (LOS). DESIGN Prospective study. SETTING Free-standing tertiary rehabilitation center. PARTICIPANTS A total of 210 patients with stroke (n = 136) and TBI (n = 74) consecutively admitted for inpatient rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Clinical Outcome Variable Scale (COVS), a 13-item scale of mobility status (measured on admission and discharge from inpatient rehabilitation), and rehabilitation LOS. RESULTS With age and time since injury controlled in the model, the TBI group showed a significantly higher mobility status on admission and discharge over the stroke group, but the change (improvement) in mobility status did not differ. The admission mobility status accounted for 61% and 60% of variability of the discharge mobility status for the stroke and TBI groups, respectively. The admission mobility status accounted for 40% and 50% of the variability in rehabilitation LOS for the stroke and TBI groups, respectively. Either the admission mobility status or the physical therapist's prediction of the discharge status could be used to determine the actual discharge mobility status, although the physical therapist's predictions were more accurate than using a statistical model. CONCLUSIONS The TBI group showed a higher mobility status at admission and discharge from inpatient rehabilitation than the stroke group; however, the rate of improvement (improvement in mobility status per day) did not differ between groups. Admission mobility status using the COVS was an excellent predictor of discharge mobility status and rehabilitation LOS in stroke and TBI patients.
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Affiliation(s)
- Janice J Eng
- School of Rehabilitation Sciences, University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada.
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Tu F, Tokunaga S, Deng Z, Nobutomo K. Analysis of hospital charges for cerebral infarction stroke inpatients in Beijing, People's Republic of China. Health Policy 2002; 59:243-56. [PMID: 11823027 DOI: 10.1016/s0168-8510(01)00182-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Stroke is a heavy economic burden on the individuals, society and health services in China, where health expenditure is rising rapidly. The purpose of the present study is to examine health services and demographic factors associated with inpatient charges for cerebral infarction in China, focusing on hospital charges of insured and uninsured patients. METHODS The study subjects were 545 patients with a principal diagnosis of cerebral infarction stroke who were discharged from the China-Japan Friendship Hospital from January 1, 1997 through December 31, 1998. Demographic, clinical and administrative data were retrospectively collected from the medical record and financial database. The influence of social and medical factors on total charges was analyzed with stepwise multiple regression model. RESULTS Of 545 subjects, 429 (79%) were the insured patients and 116 (21%) were the uninsured patients. Length of hospital stay (LOHS) for the insured patients (median, 32 days) was significantly longer (P<0.001) than that for the uninsured (median, 23 days). The hospital charges per discharge for the insured was significantly higher (geometric mean, 10407 yuan) (P<0.0001) than that for the uninsured patients (geometric mean, 5857 yuan). With stepwise multiple regression, factors associated independently with the hospital charge were: longer hospital stay, insurance status, increased number of head magnetic resonance imaging (MRI) and computerized tomography (CT), infection in hospital stay, and more severe condition of stroke. CONCLUSIONS Inpatient charge for cerebral infarction stroke was positively associated with being the insured. The findings suggest an overuse of health care resources in insured patients and limited use of resources by those who are not.
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Affiliation(s)
- Feng Tu
- Department of Health Services Management and Policy, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
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Maddox JM, MacWalter RS, McMahon AD. Relationship of volume of lesion to length of hospital stay and outcome at one year in stroke patients. Scott Med J 2001; 46:178-83. [PMID: 11852633 DOI: 10.1177/003693300104600609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to investigate the relationship between the volume of lesion (VOL) in patients with stroke and the associated length of hospital stay (LOS), as well as longer-term functional outcome. Computerised tomography (CT) scans were used to measure the volume, region and type of lesion, volume being measured by planimetry. LOS and other patient details were obtained from the Dundee Stroke Database. The total LOS was associated with the VOL on univariate analysis (p = 0.004) and after adjustment for the other variables (p = 0.006) due to a larger lesion being associated with longer stay in hospital. Patient follow-up confirmed that the VOL was also highly significant when related to functional outcome measures of impairment, disability and handicap at one year, as determined by Orgogozo (p = 0.03), Barthel (p < 0.01) and Rankin scores (p < 0.01) respectively. The VOL is related to the length of stay in hospital and outcome at one year. This is of particular interest with the increasing use of thrombolysis and development of neuroprotectant agents designed to limit VOL.
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Affiliation(s)
- J M Maddox
- Departments of Medicine & Clinical Pharmacology, Ninewells Hospital & Medical School, Dundee
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Roth EJ, Lovell L, Harvey RL, Heinemann AW, Semik P, Diaz S. Incidence of and risk factors for medical complications during stroke rehabilitation. Stroke 2001; 32:523-9. [PMID: 11157192 DOI: 10.1161/01.str.32.2.523] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aims of this study were to examine the frequency, types, and clinical factors associated with medical complications that occur during inpatient rehabilitation and to identify risk factors for complications that require a transfer to an acute care facility. METHODS A cohort of 1029 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke information, impairment, preexisting medical conditions, and admission laboratory abnormalities were recorded. Medical complications, defined as new or exacerbated medical problems, were documented for each patient. Complications that required transfer off rehabilitation were noted. Univariate and multiple logistic regression analyses were used to determine factors that were associated with risk of medical complications and risk of transfer off rehabilitation. RESULTS Seventy-five percent of patients experienced >/=1 medical complication during rehabilitation. Significant factors for the development of any medical complication included greater neurological deficit (odds ratio [OR], 4.10; confidence interval [CI], 1.88 to 8.91), hypoalbuminemia (OR, 1.71; 95% CI, 1.15 to 2.52), and history of hypertension (OR, 1.81; 95% CI, 1.27 to 2.59). Nineteen percent of patients had a medical complication that required transfer to an acute care facility. Significant factors for transfers were elevated admission white blood cell counts (OR, 1.92; 95% CI, 1.32 to 2.79), low admission hemoglobin levels (OR, 1.89; 95% CI, 1.32 to 2.68), greater neurological deficit (OR, 2.46; 95% CI, 1.37 to 4.39), and a history of cardiac arrhythmia (OR, 1.79; 95% CI, 1.18 to 2.67). CONCLUSIONS Medical complications are common among patients undergoing stroke rehabilitation. A significant number of these medical complications may require a transfer to an acute facility.
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Affiliation(s)
- E J Roth
- Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, Rehabilitation Institute of Chicago, Chicago, IL 60611-3015, USA.
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Caro JJ, Huybrechts KF, Kelley HE. Predicting treatment costs after acute ischemic stroke on the basis of patient characteristics at presentation and early dysfunction. Stroke 2001; 32:100-6. [PMID: 11136922 DOI: 10.1161/01.str.32.1.100] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Given the pressure on healthcare budgets, assessing the cost of managing a disease has become a major research focus; yet collection of these data are labor intensive and difficult. Understanding the predictors of cost provides an efficient means of incorporating such information in decision-making concerning new therapies. METHODS Data from two 12-week multinational trials that collected information on a variety of neurological, functional, and cost parameters for 1341 ischemic stroke patients were examined by means of multiple linear regression. Because the intent is for the model to be predictive, only patient characteristics that can be known at the time of patient presentation or shortly thereafter were evaluated for inclusion in the model. RESULTS The Barthel Index was the strongest predictor of cost in all models evaluated. Other major predictors, either directly or through their impact on survival, were stroke subtype, neurological impairment, congestive heart failure, and country. A good model fit was obtained, judging by the model statistics (model F:=84, 3 df, P:<0.0001) and the accuracy of the predictions (<3% difference between mean actual and predicted cost). CONCLUSIONS Through the use of key patient characteristics, this regression model allows for prediction of the cost of stroke care, which may be helpful in the context of therapeutic decisions and budgetary planning purposes. It also provides insight into how specific treatments, through their impact on clinical characteristics, can modify the cost of stroke treatment.
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Affiliation(s)
- J J Caro
- Caro Research, Concord, MA 01742, USA.
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Bates BE, Stineman MG. Outcome indicators for stroke: application of an algorithm treatment across the continuum of postacute rehabilitation services. Arch Phys Med Rehabil 2000; 81:1468-78. [PMID: 11083350 DOI: 10.1053/apmr.2000.17808] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the feasibility and utility of applying a case-mix adjusted algorithm for treatment across the continuum of stroke rehabilitation. DESIGN Implementation of a clinical algorithm developed through national expert panels to standardize rehabilitation assessment and treatment of veterans with stroke. Stroke patients were stratified into initial severity groups using FIM instrument-Function Related Groups (FIM-FRG) classifications and were followed up from first rehabilitation referral to completion of all active restorative functional goals. FIM-FRG assignments were used to establish case-mix adjusted outcome indicators for the continuum of rehabilitation services. SETTING Rehabilitation services in medical and surgical units, intermediate care units, inpatient rehabilitation bed units, and outpatient settings in 10 participating Veterans Affairs (VA) medical centers. PATIENTS Stroke patients (n = 421) who received rehabilitation in the 10 participating VA centers. MAIN OUTCOME MEASURES Patients' functional gains, length of treatment (LOT), functional status at discharge, LOT efficiency, costs, cost efficiency, and disposition location. RESULTS Two hundred twenty-three patients began rehabilitation while in acute medical or surgical units, 171 in inpatient rehabilitation units, 24 in intermediate care, and the remainder while in other settings. With cases compiled across all settings, average total rehabilitation costs for patients in the lowest FRG class (most severe disabilities) were more than twice those for patients assigned to the highest FRG class (least severe disabilities). FIM gains were greatest in the subset of younger stroke patients with the most severe disabilities. CONCLUSIONS Implementing a standard algorithm of rehabilitation care that includes outcome indicators adjusted to patients' disability severity is feasible. The algorithm's utility is evident because it encompasses rehabilitation care provided across the full continuum, promotes access to care by advocating assessment of all stroke patients, encourages early initiation of treatment, and promotes a smooth transition though various levels of care while encouraging cost containment.
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Affiliation(s)
- B E Bates
- Veterans Affairs, Physical Medicine and Rehabilitation Service, Albany, NY 12208, USA.
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The National Institutes of Health Stroke Scale and Its Importance in Acute Stroke Management. Phys Med Rehabil Clin N Am 1999. [DOI: 10.1016/s1047-9651(18)30162-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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