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Yu M, Harrison M, Bansback N. Can prediction models for hospital readmission be improved by incorporating patient-reported outcome measures? A systematic review and narrative synthesis. Qual Life Res 2024; 33:1767-1779. [PMID: 38689165 DOI: 10.1007/s11136-024-03638-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE To investigate the roles, challenges, and implications of using patient-reported outcome measures (PROMs) in predicting the risk of hospital readmissions. METHODS We systematically searched four bibliometric databases for peer-reviewed studies published in English between 1 January 2000 and 15 June 2023 and used validated PROMs to predict readmission risks for adult populations. Reported studies were analysed and narratively synthesised in accordance with the CHARMS and PRISMA guidelines. RESULTS Of the 2858 abstracts reviewed, 23 studies met predefined eligibility criteria, representing diverse geographic regions and medical specialties. Among those, 19 identified the positive contributions of PROMs in predicting readmission risks. Seven studies utilised generic PROMs exclusively, eleven used generic and condition-specific PROMs, while 5 focussed solely on condition-specific PROMs. Logistic regression was the most used modelling approach, with 13 studies aiming at predicting 30-day all-cause readmission risks. The c-statistic, ranging from 0.54 to 0.84, was reported in 22/23 studies as a measure of model discrimination. Nine studies reported model calibration in addition to c-statistic. Thirteen studies detailed their approaches to dealing with missing data. CONCLUSION Our study highlights the potential of PROMs to enhance predictive accuracy in readmission models, while acknowledging the diversity in data collection methods, readmission definitions, and model evaluation approaches. Recognizing that PROMs serve various purposes beyond readmission reduction, our study supports routine data collection and strategic integration of PROMs in healthcare practices to improve patient outcomes. To facilitate comparative analysis and broaden the use of PROMs in the prediction framework, it is imperative to consider the methodological aspects involved.
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Affiliation(s)
- Maggie Yu
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Advancing Health Outcomes, University of British Columbia, Vancouver, BC, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
- Centre for Advancing Health Outcomes, University of British Columbia, Vancouver, BC, Canada
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
- Centre for Advancing Health Outcomes, University of British Columbia, Vancouver, BC, Canada.
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Zhang S, Lin D, Wright ME, Swallow N. Acute inpatient rehabilitation improves function independent of comorbidities in medically complex patients. Arch Rehabil Res Clin Transl 2022; 4:100178. [PMID: 35756989 PMCID: PMC9214302 DOI: 10.1016/j.arrct.2022.100178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives (1) To evaluate the benefits of acute inpatient rehabilitation for a medically complex patient population and (2) to assess the effect of comorbid conditions on rehabilitation outcomes. Design Retrospective cohort study. Setting Freestanding inpatient rehabilitation facility. Participants A total of 270 medically complex adult patients including those with cardiac, pulmonary, and orthopedic conditions, with mean age of 73.6 years; 52.6% were female and 47.4% were male (N=270). Interventions Not applicable. Main Outcome Measures Functional Independence Measure (FIM) gain, FIM efficiency, rehabilitation length of stay (RLOS), home discharge rate, and readmission to acute care (RTAC). Results Among 270 medically complex patients, mean total FIM gain, mean RLOS, and mean FIM efficiency with SD were 26.0±13.6 points, 12.6±5.9 days, and 2.3±1.6, respectively. A total of 71.9% of patients were discharged to home, 12.2% for RTAC, and 15.9% to a skilled nursing facility (SNF). Hypertension (HTN) was the only comorbidity significantly associated with FIM gain (53.7% [total FIM gain ≥27] vs 67.2% [total FIM gain <27]; P=.024) and FIM efficiency (53.3% [FIM efficiency ≥2.12] vs 67.4% [FIM efficiency <2.12]; P=.025), independent of age, body mass index, sex, race, ethnicity, insurance type, and Charlson Comorbidity Index. The 5 most common reasons for RTAC were cardiac, pulmonary, acute blood loss anemia, infection, and neurologic conditions. Conclusions Among 270 medically complex patients, 71.9% were discharged to home, 15.9% to an SNF, and 12.2% for RTAC with a mean RLOS 12.6 days, mean total FIM gain of 26 points, and mean FIM efficiency of 2.3, which were all better than those of all admissions at our facility in 2018. Furthermore, RLOS, total FIM gain and FIM efficiency in this study were all better than their corresponding eRehabData weighted national benchmarks (RLOS, 15.82 days; FIM gain, 25.57; FIM efficiency, 2.13) for a total of 202,520 discharges in 2018. These findings support acute inpatient rehabilitation for this patient population. With the exception of HTN, no medical comorbidities or demographic variables were associated with rehabilitation outcomes.
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Powers MB, Pogue JR, Curcio NE, Patel S, Wierzchowski A, Thomas EV, Warren AM, Adams M, Turner E, Carl E, Froehlich-Grobe K, Sikka S, Foreman M, Leonard K, Douglas M, Bennett M, Driver S. Prolonged exposure therapy for PTSD among spinal cord injury survivors: Study protocol for a randomized controlled trial. Contemp Clin Trials Commun 2021; 22:100763. [PMID: 34013091 PMCID: PMC8113811 DOI: 10.1016/j.conctc.2021.100763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/28/2021] [Accepted: 03/26/2021] [Indexed: 10/28/2022] Open
Abstract
The National Spinal Cord Injury Statistical Center estimates 294,000 people in the US live with a spinal cord injury (SCI), with approximately 17,810 new cases each year. Although the physical outcomes associated with SCI have been widely studied, the psychological consequences of sustaining a SCI remain largely unexplored. Scant research has focused on posttraumatic stress disorder (PTSD) in this population, despite prevalence estimates suggesting that up to 60% of individuals with SCI experience PTSD post-injury, compared to only 7% of the general US population. Fortunately, prolonged exposure therapy (PE) is a well-researched and highly effective treatment for PTSD. However, no trauma focused exposure-based therapy for PTSD (e.g. PE) has not yet been tested in a SCI population. Thus, we aim to conduct the first test of an evidence-based intervention for PTSD among patients with SCI. Adults with SCI and PTSD (N = 60) will be randomly assigned to either: (1) 12-sessions of PE (2-3 sessions per week) or (2) a treatment as usual (TAU) control group who will receive the standard inpatient rehabilitation care for SCI patients. Primary outcomes will be assessed at 0, 6, 10, and 32 weeks.
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Affiliation(s)
- Mark B Powers
- Baylor University Medical Center, Dallas, TX, United States
| | - Jamie R Pogue
- Baylor University Medical Center, Dallas, TX, United States
| | | | - Sarita Patel
- Baylor University Medical Center, Dallas, TX, United States
| | | | | | | | - Maris Adams
- Baylor University Medical Center, Dallas, TX, United States
| | - Emma Turner
- Baylor University Medical Center, Dallas, TX, United States
| | - Emily Carl
- The University of Texas at Austin, Austin, TX, United States
| | | | - Seema Sikka
- Baylor Institute of Rehabilitation, Baylor Scott & White Health, Dallas, TX, United States
| | | | - Kiara Leonard
- Baylor University Medical Center, Dallas, TX, United States
| | - Megan Douglas
- Baylor Institute of Rehabilitation, Baylor Scott & White Health, Dallas, TX, United States
| | - Monica Bennett
- Baylor University Medical Center, Dallas, TX, United States
| | - Simon Driver
- Baylor Institute of Rehabilitation, Baylor Scott & White Health, Dallas, TX, United States
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McKechnie D, Fisher MJ, Pryor J, Mckechnie R. An examination of the nature and characteristics of patients readmitted to acute care from inpatient brain injury rehabilitation. J Adv Nurs 2020; 76:2586-2596. [PMID: 32748979 DOI: 10.1111/jan.14475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 05/21/2020] [Accepted: 06/26/2020] [Indexed: 11/30/2022]
Abstract
AIM To describe the nature of readmission to acute care and identify patient characteristics associated with avoidable readmission to acute care from inpatient brain injury rehabilitation. DESIGN A retrospective cohort design. METHODS Data prospectively documented between 1 January 2012 -31 December 2018 in local clinical and administrative database were used. Patient medical records were accessed when missing data were identified. Descriptive statistics were used to describe the nature of readmission episodes and univariate and multivariable logistic regression were used to identify patient characteristics associated with readmission to acute care. RESULTS Of the 383 patients admitted for rehabilitation, 83 (22%) experienced readmission to acute care for a total of 171 episodes. Thirty-seven percent of readmission episodes were due to hospital acquired complications and therefore potentially avoidable. Infection accounted for 63% of hospital acquired complications. Patients with an avoidable readmission episode (N = 38) were more likely to have a significantly lower Functional Independence Measure score, be incontinent, have a tracheostomy, require a mobility aid, and be prescribed a dysphagia diet on rehabilitation admission. Patients with a tracheostomy on rehabilitation admission had a 56% probability for an avoidable readmission to acute care. CONCLUSION Brain injury rehabilitation patients with an avoidable readmission to acute care were more likely to have a higher burden of care on rehabilitation admission and infection was the leading cause of avoidable readmission episodes. IMPACT Research into readmission to acute care in the mixed brain injury inpatient rehabilitation population is limited. In this patient population, readmission to acute care is a contemporary issue that can occur at any time during a patient's rehabilitation admission. This study provides valuable information informing practice change for preventing avoidable readmission episodes. Locally developed policy aimed at preventing readmission episodes should include proactive prevention, early recognition of complications and discrete escalation care pathways.
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Affiliation(s)
| | - Murray J Fisher
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Ryde, NSW, Australia
| | - Julie Pryor
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Ryde, NSW, Australia
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5
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Daras LC, Deutsch A, Ingber MJ, Hefele JG, Perloff J. Inpatient rehabilitation facilities' hospital readmission rates for medicare beneficiaries treated following a stroke. Top Stroke Rehabil 2020; 28:61-71. [PMID: 32657256 DOI: 10.1080/10749357.2020.1771927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Stroke is the leading cause for admission to the nearly 1,200 Inpatient Rehabilitation Facilities (IRFs) nationally in the US. For many patients, post-acute care is an important component of their rehabilitation. Several quality measures have been publicly reported for post-acute care providers, including hospital readmissions. However, to date none have focused on specific medical conditions, limiting the usability for patients and quality improvement. OBJECTIVE To assess hospital readmission rates for Medicare patients receiving inpatient rehabilitation following stroke and to identify risk factors in order to evaluate the feasibility of a stroke-specific hospital readmission measure. METHODS Observational study analyzing national Medicare inpatient claims and administrative data to assess hospital readmissions. Using logistic regression, we calculated unadjusted and risk-standardized readmission rates, which adjusted for patient characteristics, including type of stroke and admission function, to capture stroke severity. RESULTS Our national study included 116,073 fee-for-service Medicare beneficiary discharged from IRFs in 2013-2014 following stroke from 1,162 IRFs nationally. The observed hospital readmission rate among IRF patients following stroke was 11.6% and varied by patients' admission motor function. Patients with greater functional dependence had higher readmission rates on average. Lower admission function, hemorrhagic and other stroke types (relative to ischemic) were significantly associated with higher odds of hospital readmission. CONCLUSION Results suggest it is feasible to assess hospital readmission rates among a stroke-cohort treated in IRFs. Stroke-focused quality measures would be useful to patients in selecting a provider and for providers in evaluating their stroke rehabilitation program outcomes. Secondary results suggest that admission function (FIM) capture stroke severity, a limitation with other claims-based stroke measures.
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Affiliation(s)
| | - Anne Deutsch
- eHealth, Quality and Analytics, RTI International , Durham, NC, USA.,Shirley Ryan AbilityLab , Chicago,IL, USA.,School of Medicine, Northwestern University Feinberg
| | - Melvin J Ingber
- eHealth, Quality and Analytics, RTI International , Durham, NC, USA
| | - Jennifer Gaudet Hefele
- Heller School for Social Policy & Management, Brandeis University , Waltham, MA, USA.,Booz Allen Hamilton , Chicago,IL, USA.,Gerontology Institute, University of Massachusetts-Boston , Chicago,IL, USA
| | - Jennifer Perloff
- Heller School for Social Policy & Management, Brandeis University , Waltham, MA, USA
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Huang D, Siddiqui S, Slocum CS, Goldstein R, Zafonte RD, Schneider JC. Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population. Arch Phys Med Rehabil 2020; 101:1731-1738. [PMID: 32473110 DOI: 10.1016/j.apmr.2020.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/15/2020] [Accepted: 04/19/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population. DESIGN Retrospective cross-sectional study. PARTICIPANTS Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities. MAIN OUTCOME MEASURES International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated. RESULTS Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes. CONCLUSION Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.
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Affiliation(s)
- Donna Huang
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Spinal Cord Injury Service, Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, MA; Harvard Medical School, Boston, MA.
| | - Sameer Siddiqui
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Spinal Cord Injury Service, Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, MA; Harvard Medical School, Boston, MA
| | - Chloe S Slocum
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Richard Goldstein
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Harvard Medical School, Boston, MA
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McKechnie D, Fisher MJ, Pryor J, McKechnie R. Predictors of unplanned readmission to acute care from inpatient brain injury rehabilitation. J Clin Nurs 2019; 29:593-601. [PMID: 31769573 DOI: 10.1111/jocn.15118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/29/2019] [Accepted: 11/19/2019] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To identify the predictors of unplanned readmission to acute care (RTAC) from inpatient brain injury rehabilitation and to develop a risk prediction model. BACKGROUND RTAC from inpatient rehabilitation is not uncommon. Individual rehabilitation patient populations require their own body of evidence regarding predictors of RTAC. DESIGN Retrospective cohort study. METHODS Adult patients with new onset acquired brain injury admitted to a stand-alone rehabilitation facility between 1 January 2012-31 December 2018 were included in the study. The main measures were RTAC, sensitivity, specificity, the C-statistic and Youden's index. This paper is reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS Of 383 patients admitted for rehabilitation, 83 (22%) experienced a RTAC; 69 (18%) patients had at least one unplanned RTAC episode. Patients requiring unplanned RTAC were more likely to have lower Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) scores on rehabilitation admission, a higher burden of care on rehabilitation discharge and be discharged to a nonhome residence. Rehabilitation admission GCS and motor FIM were identified as the independent RTAC predictors in multivariate regression modelling. The combined C-statistic was 0.86. A GCS cut-off score of ≤14 and motor FIM cut-off score of ≤40 were identified as optimal, yielding a combined Youden's index of 0.56 (sensitivity = 0.72; specificity = 0.83). CONCLUSION Patients requiring an unplanned RTAC had a lower functional status on rehabilitation admission. A prediction model for unplanned RTAC has been developed using validated and readily available clinical measures. RELEVANCE TO CLINICAL PRACTICE The developed RTAC risk prediction model is the first step in preventing unplanned RTAC from inpatient brain injury rehabilitation. Future research should focus on discrete interventions for preventing unplanned RTAC from inpatient brain injury rehabilitation.
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Affiliation(s)
| | - Murray J Fisher
- Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Sydney, NSW, Australia
| | - Julie Pryor
- Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Sydney, NSW, Australia
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McKechnie D, Pryor J, McKechnie R, Fisher MJ. Predictors of Readmission to Acute Care from Inpatient Rehabilitation: An Integrative Review. PM R 2019; 11:1335-1345. [PMID: 31041836 DOI: 10.1002/pmrj.12179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/23/2019] [Indexed: 11/09/2022]
Abstract
Readmission to acute care (RTAC) from inpatient rehabilitation can have negative consequences for individuals and associated financial costs are increasing. Consequently, preventing avoidable RTAC represents a target for improvement in quality of care. The aim of this integrative review was to identify predictors of RTAC from inpatient rehabilitation. A systematic search of MEDLINE, EMBASE, ProQuest, and CINAHL databases was used. Thematic analysis was used to examine extracted data. Strong evidence indicating that the principal predictors of RTAC are lower functional status on admission to rehabilitation, a more severe injury and a higher number of comorbidities was identified in this review. This is despite the heterogeneous nature of impairment groups and factors/measures examined. However, the relevance of some predictors of RTAC (such as patient demographics, invasive devices and primary diagnoses) may be dependent on rehabilitation setting, impairment group or time between rehabilitation admission and RTAC (eg, below 3 vs 30 days). Consequently, findings of this integrative review highlight that RTAC is a complex, multifactorial patient issue with a complex interplay between the predictors and reasons for RTAC. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
| | - Julie Pryor
- Royal Rehab, Sydney, Australia.,Sydney Nursing School, The University of Sydney, Sydney, Australia
| | | | - Murray J Fisher
- Royal Rehab, Sydney, Australia.,Sydney Nursing School, The University of Sydney, Sydney, Australia
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