Modeling case mix adjustment of stroke rehabilitation outcomes

Mobile Game-based Virtual Reality Program for Upper Extremity Stroke Rehabilitation

Stroke rehabilitation requires repetitive, intensive, goal-oriented therapy. Virtual reality (VR) has the potential to satisfy these requirements. Game-based therapy can promote patients' engagement in rehabilitation therapy as a more interesting and a motivating tool. Mobile devices such as smartphones and tablet PCs can provide personalized home-based therapy with interactive communication between patients and clinicians. In this study, a mobile VR upper extremity rehabilitation program using game applications was developed. The findings from the study show that the mobile game-based VR program effectively promotes upper extremity recovery in patients with stroke. In addition, patients completed two weeks of treatment using the program without adverse effects and were generally satisfied with the program. This mobile game-based VR upper extremity rehabilitation program can substitute for some parts of the conventional therapy that are delivered one-on-one by an occupational therapist. This time-efficient, easy to implement, and clinically effective program would be a good candidate tool for tele-rehabilitation for upper extremity recovery in patients with stroke. Patients and therapists can collaborate remotely through these e-health rehabilitation programs while reducing economic and social costs.

A systematic review of case-mix adjustment models for stroke

Objective:

To identify any externally validated prognostic model for predicting outcome in unselected populations following acute stroke comprising variables feasible for collection in routine care.

Data sources:

Searches were run in MEDLINE, EMBASE, CINAHL, PsycInfo, AMED and ISI Web of Science with no limits on publication date or language.

Review methods:

Any study describing the development or external validation of a discernible prognostic model to predict any valid outcome following acute stroke was included. Papers were retained if they met pre-specified inclusion criteria identified from previous reviews and pertinent discussion papers. Data extraction focused on methodological quality of model development, generalizability and feasibility of variable collection. Model performance was examined through consideration of external validation studies.

Results:

Seventeen externally validated models were identified from 43 papers fulfilling inclusion criteria. Quality of studies describing model development was variable and model performance in external validation studies was generally poor. Models were generally constructed through secondary use of randomized trial or stroke database data. Prognostic variables broadly encompassed markers of stroke severity, pre-stroke function and comorbidities. One model that fulfilled the review criteria and had extensive external validation in a range of post-stroke populations was identified (the Six Simple Variables model).

Conclusion:

The Six Simple Variables model performed well in six external validation studies, although prediction of outcome in patients with milder strokes was less reliable. Other models identified in this review have been developed using robust methodology but comprise more complex clinical variables which may limit their utility in routine stroke care.

The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities

OBJECTIVE

To examine the relation between therapy intensity, including physical therapy (PT), occupational therapy (OT), and speech and language therapy (SLT), provided in a skilled nursing facility (SNF) setting and patients' outcomes as measured by length of stay (LOS) and stage of functional independence as measured by the FIM instrument.

DESIGN

A retrospective analysis of secondary data from an administrative dataset compiled and owned by SeniorMetrix Inc.

SETTING

Seventy SNFs under contract with SeniorMetrix health plan clients.

PARTICIPANTS

Patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions (N=4988) covered by Medicare+Choice plans, and admitted to an SNF in 2002.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

LOS and improvement in stage of independence in the mobility, activities of daily living (ADLs), and executive control domains of function as determined by the FIM instrument.

RESULTS

Higher therapy intensity was associated with shorter LOS ( P <.05). Higher PT and OT intensities were associated with greater odds of improving by at least 1 stage in mobility and ADL functional independence across each condition ( P <.05). The OT intensity was associated with an improved executive control stage for patients with stroke, and PT and OT intensities were associated with improved executive control stage for patients with cardiovascular and pulmonary conditions ( P <.05). The SLT intensity was associated with improved motor and executive control functional stages for patients with stroke ( P <.05). Therapy intensities accounted for small proportions of model variances in all outcomes.

CONCLUSIONS

Higher therapy intensity was associated with better outcomes as they relate to LOS and functional improvement for patients who have stroke, orthopedic conditions, and cardiovascular and pulmonary conditions and are receiving rehabilitation in the SNF setting.

Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario

OBJECTIVE

To examine the effect of payment incentives on the provision of rehabilitation therapy to non elderly nursing home residents.

DESIGN

Retrospective cross-sectional study.

SETTING

Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999.

PARTICIPANTS

Non elderly nursing home residents (N=5189) admitted to nursing homes.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type.

RESULTS

A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT.

CONCLUSIONS

Little information exists to describe the characteristics and treatment of non elderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.

Predicting the cost of hospital stay for stroke patients: the use of diagnosis related groups

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.

Predicting follow-up living setting in patients with stroke

OBJECTIVE

To examine living setting at 3- to 6-month follow-up for inpatients with functional impairments discharged from medical rehabilitation.

DESIGN

Retrospective performed by using information from the Uniform Data System for Medical Rehabilitation (UDSMR) representing medical rehabilitation patients across the United States.

SETTING

National survey data.

PARTICIPANTS

Information submitted in 1997 and 1998 to the UDSMR by 167 facilities from 40 states was examined. A total of 9587 patient records were included in the final sample. The mean age +/- standard deviation was 70.2+/-12.4 years. The sample included 51.6% women and was comprised of 77.5% non-Hispanic white patients, with an average length of stay of 22.3+/-4.6 days.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Living setting (home vs not at home) at 3- to 6-month follow-up.

RESULTS

A discriminant function training model including 8 statistically significant variables correctly classified 85.1% of the patients (n=8149). The total FIM instrument score, patient age, function-related group, and marital status were found to be useful classification variables. Wilks lambda for the model was.924 (chi(2)=1031.49, P<.000). The area under the receiver operating characteristics curve was.85.

CONCLUSION

The association among functional abilities, demographic characteristics, and follow-up living setting in patients with stroke is complex. Functional variables can be used to help predict follow-up living setting. These variables change based on patient severity level.

Systematic review of prognostic models in patients with acute stroke

Prognostic models in stroke may be useful in clinical practice and research. We systematically reviewed the methodology and results of studies that have identified independent predictors of survival, independence in activities of daily living, and getting home in patients with acute stroke. Eligible studies (published in full in English) included at least 100 patients in whom at least 3 predictor variables were assessed within 30 days of stroke onset and who were followed up for at least 30 days. We recorded 25 indicators of the validity and practicality of each model and identified variables that were consistent independent predictors of each outcome. Eighty-three separate prognostic models were found but most had potentially serious deficiencies in internal and statistical validity, many had limited generalisability, and none had been adequately validated. Only 4 studies met 8 simple quality criteria. Over 150 different predictor variables have been analysed but most were assessed in only 1 or 2 models. None of the existing prognostic models have been sufficiently well developed and validated to be useful in either clinical practice or research. Better quality models must be produced to enable, for example, adequate case-mix correction when comparing outcome among different groups of stroke patients.

The tools of disability outcomes research functional status measures

OBJECTIVE

To review the major functional status measures currently used in rehabilitation research, including the domains and scope of functional status measures, as well as the psychometric properties of selected functional status measures and their use in adult rehabilitation populations.

DATA SOURCES

Measures of physical functioning widely used in rehabilitation research.

STUDY SELECTION

Major generic measures included the following activities of daily living and instrumental activities of daily living: the FIM instrument, the Katz Activities of Daily Living Scale, the Level of Rehabilitation Scale, the Barthel index, and the Patient Evaluation and Conference System. Measures were evaluated based on published evidence of validity, reliability, and sensitivity.

DATA EXTRACTION

Measures were chosen on the basis of the amount and quality of published research on the functional measures widely used in rehabilitation medicine. Independent research of computer databases and reviews of functional measures were conducted to determine suitability for inclusion. The quality and validity of the measures were assessed using standard psychometric guidelines.

DATA SYNTHESIS

Measures were evaluated based on published evidence of validity, reliability, sensitivity response and administrative burdens and instrument bias. Each criterion was graded on a 3-point scale reflecting the level of evidence.

CONCLUSION

Researchers in the field of disabilities research need to consider carefully study objectives when measuring physical functioning in people with disabilities.

Stroke rehabilitation. 4. Stroke outcome and psychosocial consequences

This self-directed learning module highlights recent research in assessment of stroke outcomes and management of the psychosocial consequences of stroke. It is a part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses predictive factors for mortality and functional recovery; proposed case mix adjustment and prospective payment systems for stroke rehabilitation; continuum of care and utilization of acute, nursing home, outpatient and home health rehabilitation programs; reintegration and socialization after stroke; vocational rehabilitation of stroke patients; and management of the psychosocial effects of stroke on patients and families.

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

OBJECTIVE

To assess variation in stroke outcomes and create a case-mix adjustment model for stroke rehabilitation in Veterans Affairs Medical Centers.

DESIGN

Observational

SETTING AND PATIENTS

Within Veteran's Health Administration hospitals, there are 63 acute rehabilitation bedservice units that care for approximately 2,000 stroke patients annually.

MAIN OUTCOME MEASURES

Functional gain in FIM points, length of stay (LOS), LOS efficiency (FIM gain/LOS).

RESULTS

Significant variation in average patient functional gain, LOS, and LOS efficiency was observed among the 37 highest-volume rehabilitation units. Using analysis of covariance, a model was developed that adjusted functional gain and LOS (logged LOS) unit means using 10 potential covariates identified in a literature review and in pilot studies. Four and six covariates, respectively, were retained in the final models for FIM gain and LOS. The R2 for FIM gain and LOS accounted for by rehabilitation unit alone increased from .07 to .31 (FIM gain) and from .13 to .34 (logLOS) with the addition of the significant covariates to each model.

CONCLUSIONS

As much as 24% of the variation in two important stroke rehabilitation outcomes is attributable to largely immutable patient and system characteristics (eg, patient function on admission, age, days since stroke onset, year of discharge, marital status, and referral source). Hence, controlling for case-mix is critical for accurate comparison of unit outcomes. Further, the variation in LOS efficiency between VA rehabilitation units suggests a large potential for cost and resource utilization savings system-wide.