Stroke rehabilitation outcome variation in Veterans Affairs rehabilitation units: accounting for case-mix

Postacute Care Setting, Facility Characteristics, and Poststroke Outcomes: A Systematic Review

OBJECTIVES

To synthesize research comparing poststroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and those in inpatient rehabilitation facilities (IRFs) as well as to evaluate relations between facility characteristics and outcomes.

DATA SOURCES

PubMed and CINAHL searches spanned January 1, 1998, to October 6, 2016, and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Searches were restricted to peer-reviewed research in humans published in English.

STUDY SELECTION

Observational and experimental studies examining outcomes of adult patients with stroke rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report ≥1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by 1 author, and when uncertain, discussion with study coauthors achieved consensus. Fourteen titles (0.3%) were included.

DATA EXTRACTION

The types of data, time period, size, design, and primary outcomes were extracted. We also extracted 2 secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by 1 author, and the accuracy was verified by a second reviewer.

DATA SYNTHESIS

Two studies evaluating community discharge, 1 study evaluating the predicted probability of readmission, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation.

CONCLUSIONS

The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.

Association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation

BACKGROUND

Limited evidence exists regarding the association of pre-existing mental health conditions in patients with stroke and stroke outcomes such as rehospitalization, mortality, and function. We examined the association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation.

METHODS

Our observational study used the 2001 VA Integrated Stroke Outcomes database of 2162 patients with stroke who underwent rehabilitation at a Veterans Affairs Medical Center. Separate models were fit to our outcome measures that included 6-month rehospitalization or death, 6-month mortality post-discharge, and functional outcomes post inpatient rehabilitation as a function of number and type of mental health conditions. The models controlled for patient socio-demographics, length of stay, functional status, and rehabilitation setting.

RESULTS

Patients had an average age of 68 years. Patients with stroke and two or more mental health conditions were more likely to be readmitted or die compared to patients with no conditions (OR: 1.44, p = 0.04). Depression and anxiety were associated with a greater likelihood of rehospitalization or death (OR: 1.33, p = 0.04; OR:1.47, p = 0.03). Patients with anxiety were more likely to die at six months (OR: 2.49, p = 0.001).

CONCLUSIONS

Patients with stroke with pre-existing mental health conditions may need additional psychotherapy interventions, which may potentially improve stroke outcomes post-hospitalization.

Dependence in Prestroke Mobility Predicts Adverse Outcomes Among Patients With Acute Ischemic Stroke

Background and Purpose— Stroke survivors are commonly dependent in activities of daily living; however, the relation between prestroke mobility impairment and poststroke outcomes is poorly understood. The primary objective of this study was to evaluate the association between prestroke mobility impairment and 4 poststroke outcomes. The secondary objective was to evaluate the association between prestroke mobility impairment and a plan for physical therapy.

Methods— This was a secondary analysis of the National Stroke Project data, a retrospective cohort of Medicare beneficiaries who were hospitalized with an acute ischemic stroke (1998 to 2001). Logistic-regression modeling was used to examine the adjusted association between prestroke mobility impairment with patient outcomes and a plan for physical therapy.

Results— Among the 67 445 patients hospitalized with an ischemic stroke, 6% were dependent in prestroke mobility. Prestroke mobility dependence was independently associated with an increased odds of poststroke mobility impairment (odds ratio [OR]=9.9; 95% CI, 9.0 to 10.8); in-hospital mortality (OR=2.4; 95% CI, 2.2 to 2.7); discharge to a skilled nursing facility (OR=3.5; 95% CI, 3.2 to 3.8); and the combination of in-hospital death or discharge to a skilled nursing facility (OR=3.5; 95% CI, 3.3 to 3.8). Prestroke mobility dependence was independently associated with a decreased odds of having a plan for physical therapy (OR=0.79; 95% CI, 0.73 to 0.85).

Conclusions— These data, obtained from a large, geographically diverse cohort from the United States, demonstrate a strong association between dependence in prestroke mobility and adverse outcomes among elderly stroke patients. Clinicians should screen patients for prestroke mobility impairment to identify patients at greatest risk for adverse events.

The Accuracy of Artificial Neural Networks in Predicting Long-term Outcome After Traumatic Brain Injury

OBJECTIVE

This study compared the accuracy of artificial neural networks to multiple regression and classification and regression trees in predicting outcomes of 1,644 patients in the Traumatic Brain Injury Model Systems database 1 year after injury.

METHODS

Data from rehabilitation admission were used to predict discharge scores on the Functional Independence Measure, the Disability Rating Scale, and the Community Integration Questionnaire.

RESULTS

Artificial neural networks did not demonstrate greater accuracy in predicting outcomes than did the more widely used method of multiple regression. Both of these methods outperformed classification and regression trees.

CONCLUSION

Because of the sophisticated form of multiple regression with splines that was used, firm conclusions are limited about the relative accuracy of artificial neural networks compared to more widely used forms of multiple regression.

Team functioning and patient outcomes in stroke rehabilitation

OBJECTIVE

To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes.

DESIGN

Prospective observational study.

SETTING

Veterans Administration (VA) inpatient and subacute rehabilitation units.

PARTICIPANTS

Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS).

RESULTS

Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness.

CONCLUSIONS

Characteristics of team functioning predict selected rehabilitation outcomes.

Length of stay in the rehabilitation center, the admission functional independence measure and the functional independence measure gain

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.

Functional and self-efficacy changes of patients admitted to a Geriatric Rehabilitation Unit

BACKGROUND

Geriatric Rehabilitation Units (GRUs) have been established to restore functional abilities of older hospitalized patients. Although considerable health care resources have been allocated to these units, few outcome-based research studies have been reported on Canadian GRUs.

AIM

The aim of this paper is to report a study examining the effect of admission to a GRU on changes in patients' functional ability and self-efficacy in performing everyday activities at home.

METHODS

Following Institutional Review Board approval, data were collected from 40 patients age 65-101 years (mean 83.8, sd 6.57) admitted to a 21-bed interdisciplinary GRUs over a 7-month period. All were living independently prior to hospital admission. Data were collected on admission to the unit and on discharge using two instruments: the Functional Independence Measure and Falls Efficacy Scale.

RESULTS

Statistically significant improvements were found in functional ability and self-efficacy following admission to the GRUs.

CONCLUSIONS

Although functional level and feelings of self-efficacy on admission to the unit were at levels which may have prevented participants from returning home, the majority were discharged to the community. Results suggest that admission to a GRU helps prepare patients to return to community living.

Risk Adjusting Rehabilitation Outcomes

The complexity and mix of rehabilitation patients varies across clinicians and institutions. Comparisons of outcomes across providers must therefore adjust for differences in risk factors across patient populations. Research on risk adjustment has generally focused on acute care hospital outcomes, although techniques for risk adjusting financial outcomes are fairly well developed in rehabilitation, primarily to support Medicare and other prospective payment systems. This article reviews important methodologic issues in risk adjusting rehabilitation outcomes in observational studies of routine clinical practice or for management, such as assessing quality or costs of care. Risk adjusting rehabilitation outcomes is more difficult than risk adjusting other clinical results, such as outcomes of many acute care services. At the outset, characterizing rehabilitation interventions is frequently difficult. Furthermore, outcomes are diverse and depend on myriad factors, including patients' physical and cognitive abilities, underlying medical diseases, sensory and emotional factors, willingness to participate in care, and supportive environments. No risk-adjustment approach can control for every factor affecting outcomes of care. Knowing which risk factors are missing helps guide interpretation of the results and determines how well risk-adjusted outcomes fairly compare providers or treatments.

Urinary incontinence in subacute care--a retrospective analysis of clinical outcomes and costs

OBJECTIVE

To investigate the effect of incontinence on clinical outcomes and costs for patients in subacute care.

DESIGN

Retrospective analysis of data collected over a 3-month period in 1996.

SETTING

54 medical facilities in Australia and New Zealand providing subacute care in an inpatient setting.

PATIENTS

6773 episodes of care provided to 6455 rehabilitation and geriatric evaluation and management patients.

MAIN OUTCOME MEASURES

Urinary continence status, treatment outcomes, length of stay, discharge destination, and nursing and allied healthcare costs.

RESULTS

Discharge destination differed between incontinent and continent patients (57% compared with 82%, respectively, discharged home, and 29% compared with 12%, respectively, discharged to a nursing home or to further care). There was a difference in cost between patients who were continent and those who were incontinent throughout their episode of care (rehabilitation: $185.60 [95% CI, $181-$190] per day for incontinent and $156.82 [95% CI, $153-$160] for continent patients; and geriatric evaluation and management: $164.62 [95% CI, $157-$172] for incontinent and $121.40 [95% CI, $114-$129] for continent patients). However, multilevel analyses showed that, after allowing for age and level of functional independence, the contribution of continence status to the cost of care depended on the functional independence of the patient (cognitive function for orthopaedic patients [P < 0.01] and motor function for stroke patients [P = 0.04]).

CONCLUSION

The relationship between continence status and cost of care is complex. However, the cost differences found in our study need to be considered in payment systems, allocation of staff levels on wards and in development of casemix classifications.

National guidelines for rehabilitation staffing levels: a literature review

Canadian rehabilitation staffing guidelines do not exist; consequently, significant service-level differences are found. This article reviews methods of determining rehabilitation staffing and presents factors to consider in developing staffing guidelines. Skill mix, service intensity, patient diagnosis and cost of care should drive staffing benchmarks.

Structure, process, and outcomes in stroke rehabilitation

BACKGROUND

The health services research framework of structure, process, and outcome is used commonly to examine quality of care, and it indicates that structure influences process, which in turn influences outcomes. However, little empirical work has been done to test this hypothesis, particularly for medical rehabilitation.

OBJECTIVES

To determine if, among stroke patients, (1) structure of care was associated with process of care, and (2) structure of care was associated with outcomes after adjusting for process.

RESEARCH DESIGN

Two-year, prospective study of 288 acute stroke patients in 11 VA medical centers, of whom 128 were included in the current analysis.

MEASURES

Structure of care: systemic organization, staffing expertise, and technological sophistication. Process of care: compliance with the AHCPR poststroke rehabilitation guidelines.

PATIENT CHARACTERISTICS

baseline prior walking ability and Functional Independence Measure (FIM) motor subscale.

OUTCOMES

the FIM motor subscale 6-months poststroke.

RESULTS

The combination of systemic organization and staffing expertise, along with technological sophistication, were independent predictors of process of care (beta coefficients 0.21, P<0.05 and 0.37, P<0.001, respectively). When controlling simultaneously for patient characteristics, structure and process of care, structure of care did not have and process of care did have a statistically significant association (beta coefficient 0.18, P<0.01) with functional outcomes.

CONCLUSIONS

Better process of care was associated with better 6-month functional outcomes, therefore improving process of care probably would improve stroke outcomes. However, our results indicate that improving key structure of care elements might facilitate improving process of care for stroke patients.

Predicting discharge outcomes for stroke patients in Australia

OBJECTIVE

This study aimed to describe discharge outcomes and explore their correlates for patients rehabilitated after stroke at an Australian hospital from 1993 to 1998.

DESIGN

Data on length of stay, discharge functional status, and discharge destination were retrospectively obtained from medical records. Patients' actual rehabilitation length of stay was compared with the Australian National Sub-Acute and Non-Acute Patient predicted length of stay. The change in length of stay over the 5-yr period from 1993 to 1998 was documented.

RESULTS

Patients' mean converted motor FIM scores improved from 53.1 at admission to 74.1 at discharge. Lower admission-converted motor FIM scores were related to longer length of stay, lower discharge-converted motor FIM scores, and the need for a change in living situation on discharge.

CONCLUSION

The results of this study provide Australian data on discharge outcomes after stroke to assist in the planning and delivery of appropriate interventions to individual patients during rehabilitation.

Medical comorbidity and rehabilitation efficiency in geriatric inpatients

OBJECTIVES

To measure and describe medical comorbidity in geriatric rehabilitation patients and investigate its relationship to rehabilitation efficiency.

DESIGN

Prospective, multivariate, within-subject design.

SETTING

The Geriatric Rehabilitation inpatient unit of the SCO Health Service in Ottawa, Canada.

PARTICIPANTS

One hundred ten patients, with a mean age of 82 years.

MEASUREMENTS

The rehabilitation efficiency ratio, based on gains in functional status achieved with rehabilitation treatment, and the length of stay were computed for all patients. Values were regressed on the scores of the Cumulative Illness Rating Scale (CIRS), the Mini-Mental State Examination, and the Geriatric Depression Scale to establish predictive power.

RESULTS

The findings suggest that geriatric rehabilitation patients experience considerable medical comorbidity. Sixty percent of patients had impairments across six of the 13 dimensions of the CIRS, whereas 36% of patients had impairments across 11 of the 13 dimensions. In addition, medical comorbidity was negatively related to rehabilitation efficiency. This relationship was significant even after controlling for age, cognitive status, depressive symptoms, and functional independence status at admission.

CONCLUSION

Medical comorbidity was a significant predictor of rehabilitation efficiency in geriatric patients. Comorbidity scores >5 were prognostic of poorer rehabilitation outcomes and can serve as an empirical guide in estimating a patient's suitability for rehabilitation. Medical comorbidity predicted both the overall functional change achieved with retabilitation (Functional Independence Measure gains) and the rate at with which those gains were reached (rehabilitation efficiency ratio).

Quality Enhancement Research Initiative in stroke: prevention, treatment, and rehabilitation

Stroke is the third leading cause of death and a leading cause of adult disability in the United States. Both within and outside of the Veterans Health Administration (VHA), the lack of a systematic approach to stroke prevention and treatment may have contributed to reduced rates of compliance with recommended practices and increased rates of stroke. Gaps in the knowledge base inhibit a systematic approach to high-quality care within the veteran population. Initial recommendations for closing those gaps are proposed. In some cases (eg, systematic anticoagulation management), the VHA is perceived as a leader in applied research; therefore, a systematic national policy for implementing these clinics may significantly reduce stroke rates. In other areas (eg, carotid endarterectomy), databases exist that would help advance quality and outcomes, but short-term studies are necessary to establish their utility. To promote strategic improvement in prevention, treatment, and rehabilitation for veterans who may be at risk or have had a stroke, specific objectives are proposed to (1) identify best practices for the effective delivery of long-term anticoagulation and enhance veterans' access to these services, (2) develop risk-adjusted models for the surgical preventive procedure carotid endarterectomy to understand facility variation in outcomes so practices can be improved, (3) define a systematic acute stroke management system so that high-quality stroke-related care can be generalizable to a variety of VHA settings, and (4) assess the impact of poststroke rehabilitation on risk adjustment and the location of outcomes so as to facilitate the implementation of best rehabilitation practices.

A multinational comparison of aphasia management practices

The effect of restructuring of healthcare on the quality, quantity, and nature of aphasia management is largely unknown. The current study is the first to examine access, diagnostic, treatment, and discharge patterns of patients with aphasia in Australia, Canada, the UK, the US private sector (US-Private), and the US Veterans Health Administration in the Department of Veterans Affairs (US-VA). The authors developed a 37-item survey to be completed by clinicians working with aphasic patients. The survey focused on eight areas: access to care, evaluation procedures, group treatment, number and duration of treatment sessions, limitations of the number of sessions, termination of treatment, follow-up practices, and resumption of treatment. 394 surveys were distributed and 175 were returned completed (44% return rate). Respondents represented a range of ages, work experiences, and work settings. There was considerable consistency among respondents from our five healthcare systems. Results suggest that patients may be routinely denied treatment in direct contradiction to the research literature. Just as we carefully monitor the progress of patients receiving our treatment, we are obliged to monitor the effects of managed care on our patients, fellow clinicians, and our profession.