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Dervaux B, Van Berleere M, Lenne X, Wyckaert M, Dubos F. Impact of RSV test positivity, patient characteristics, and treatment characteristics on the cost of hospitalization for acute bronchiolitis in a French university medical center (2010-2015). Front Pediatr 2023; 11:1126229. [PMID: 37528879 PMCID: PMC10390249 DOI: 10.3389/fped.2023.1126229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 06/27/2023] [Indexed: 08/03/2023] Open
Abstract
Background In young children, respiratory syncytial virus (RSV)-related bronchiolitis is typically more severe than other respiratory tract infections, with a greater need for oxygen therapy and respiratory support. Few studies have compared the cost of hospitalization with regard to virological status. The objective of this study was to compare the costs of hospitalization for RSV-positive vs. RSV-negative bronchiolitis in a French university medical center between 2010 and 2015. Methods The cost models were compared using conventional goodness-of-fit criteria. Covariates included the characteristics of the patients, pre-existing respiratory and non-respiratory comorbidities, superinfections, medical care provided, and the length of stay. Results RSV was detected in 679 (58.3%) of the 1,164 hospital stays by children under 2 years with virological data. Oxygen therapy and respiratory support were twice as frequent for the RSV-positive cases. The median hospitalization cost was estimated at €3,248.4 (interquartile range: €2,572.1). The cost distribution was positively skewed with a variation coefficient (CV = standard deviation/mean) greater than one (mean = €4,212.9, standard deviation = €5,047, CV = 1.2). In univariate analyses, there was no significant cost difference between the RSV-positive and RSV-negative cases. In the best multivariate model, the significant positive effect of RSV positivity on cost waned after the introduction of medical care variables and the length of stay. The results were sensitive to the specification of the model. Conclusions It was impossible to firmly conclude that hospitalization costs were higher for the RSV-positive cases.
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Affiliation(s)
- Benoit Dervaux
- CHU Lille, Direction de la Recherche et de l’Innovation, Lille, France
| | | | - Xavier Lenne
- CHU Lille, Département d’Information Médicale, Lille, France
| | - Marine Wyckaert
- CHU Lille, Urgences pédiatriques & maladies infectieuses, Lille, France
| | - François Dubos
- CHU Lille, Urgences pédiatriques & maladies infectieuses, Lille, France
- Univ Lille, ULR 2694 - Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
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Bouchibti S, Maul T, Rivera-Sepulveda A. Comparison Between Physicians' and Nurse Practitioners' Resource Utilization in the Diagnosis and Management of Bronchiolitis in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1564-e1568. [PMID: 36040473 PMCID: PMC11061880 DOI: 10.1097/pec.0000000000002608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to describe the resource utilization of nurse practitioners (NPs) in the pediatric emergency department (ED) and compare among physicians. METHODS A retrospective cross-sectional study of secondary data analysis in a level 1 academic pediatric trauma center was conducted. Patients were aged 1 to 24 months, evaluated in the ED between January 1, 2014, and November 30, 2018, with a diagnosis of bronchiolitis or wheezing. Data included age group, length of stay, disposition, diagnostic tests (chest radiography [CXR], viral testing, respiratory syncytial virus test), treatment (bronchodilator, corticosteroid, antibiotic), and medical provider (physician, NP, combination of both). Resources were evaluated before (early era) and after (late era) the implementation of an institutional clinical practice guideline.Comparisons between groups were done through χ2, Fisher exact, or Kruskal-Wallis test, as appropriate. RESULTS A total of 5311 cases were treated by a physician (65.3%), an NP (30.3%), or a combination of both (4.3%). The was a difference in the use of CXR, respiratory syncytial virus testing, bronchodilators, and corticosteroids among providers (P = 0.001). In the late era, NPs were less likely to order a bronchodilator (odds ratio [OR], 0.390 [95% confidence interval, 0.318-0.478; P < 0.001]), whereas physicians were less likely to order a CXR (OR, 0.772 [0.667-0.894, P = 0.001]), bronchodilator (OR, 0.518 [0.449-0.596, P < 0.001]), or a corticosteroid (OR, 0.630 [0.531-0.749, P < 0.001]). CONCLUSIONS Nurse practitioners made fewer diagnostic and therapeutic orders. A clinical practice guideline on the diagnosis and management of children with bronchiolitis successfully decreased the use of nonrecommended tests and therapies among NP and physicians.
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Abstract
OBJECTIVES To derive and internally validate a bronchiolitis-specific illness severity score (the Critical Bronchiolitis Score) that out-performs mortality-based illness severity scores (e.g., Pediatric Risk of Mortality) in measuring expected duration of respiratory support and PICU length of stay for critically ill children with bronchiolitis. DESIGN Retrospective database study using the Virtual Pediatric Systems (VPS, LLC; Los Angeles, CA) database. SETTING One-hundred twenty-eight North-American PICUs. PATIENTS Fourteen-thousand four-hundred seven children less than 2 years old admitted to a contributing PICU with primary diagnosis of bronchiolitis and use of ICU-level respiratory support (defined as high-flow nasal cannula, noninvasive ventilation, invasive mechanical ventilation, or negative pressure ventilation) at 12 hours after PICU admission. INTERVENTIONS Patient-level variables available at 12 hours from PICU admission, duration of ICU-level respiratory support, and PICU length of stay data were extracted for analysis. After randomly dividing the cohort into derivation and validation groups, patient-level variables that were significantly associated with the study outcomes were selected in a stepwise backward fashion for inclusion in the final score. Score performance in the validation cohort was assessed using root mean squared error and mean absolute error, and performance was compared with that of existing PICU illness severity scores. MEASUREMENTS AND MAIN RESULTS Twelve commonly available patient-level variables were included in the Critical Bronchiolitis Score. Outcomes calculated with the score were similar to actual outcomes in the validation cohort. The Critical Bronchiolitis Score demonstrated a statistically significantly stronger association with duration of ICU-level respiratory support and PICU length of stay than mortality-based scores as measured by root mean squared error and mean absolute error. CONCLUSIONS The Critical Bronchiolitis Score performed better than PICU mortality-based scores in measuring expected duration of ICU-level respiratory support and ICU length of stay. This score may have utility to enrich interventional trials and adjust for illness severity in observational studies in this very common PICU condition.
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Effect of Preexisting and Co-Occurring Comorbid Conditions on Recovery in the 5 Years After Rehabilitation for Traumatic Brain Injury. J Head Trauma Rehabil 2020; 35:E288-E298. [DOI: 10.1097/htr.0000000000000521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Richard-Denis A, Beauséjour M, Thompson C, Nguyen BH, Mac-Thiong JM. Early Predictors of Global Functional Outcome after Traumatic Spinal Cord Injury: A Systematic Review. J Neurotrauma 2018; 35:1705-1725. [PMID: 29455634 DOI: 10.1089/neu.2017.5403] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Accurately predicting functional recovery is an asset for all clinicians and decision makers involved in the care of patients with acute traumatic spinal cord injury (TSCI). Unfortunately, there is a lack of information on the relative importance of significant predictors of global functional outcome. There is also a need for identifying functional predictors that can be timely optimized by the medical and rehabilitation teams throughout the hospitalizations phases. The main objective of this work was to systematically review and rate early factors that are consistently and independently associated with global functional outcome in individuals with TSCI. A literature search using MEDLINE, EMBASE, and Cochrane databases from January 1, 1970 to April 1, 2017 was performed. Two authors independently reviewed the titles and abstracts yielded by this literature search and subsequently selected studies to be included based on predetermined eligibility criteria. Disagreements were resolved by a consensus-based discussion, and if not, by an external reviewer. Data were extracted by three independent reviewers using a standardized table. The quality of evidence of the individual studies was assessed based on the Oxford Center for Evidence-Based Medicine modified by Wright and colleagues (2000) as well as the National Institutes of Health (2014). Fifteen articles identifying early clinical predictors of functional outcome using multiple regression analyses were included in this systematic review. Based on the compiled data, this review proposes a rating of early factors associated to global functional outcome according to their importance and their potential to be modified by the medical/rehabilitation team throughout the early phases of hospitalization. It also proposes a new conceptual framework that illustrates the impact of specific categories of factors and their interaction with each other. Ultimately, this review aims to guide clinicians and researchers in improving the continuum of care throughout early phases post-SCI.
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Affiliation(s)
- Andréane Richard-Denis
- 1 Hôpital du Sacré-Cœur de Montréal , Montréal, Quebec, Canada .,2 Department of Medicine, Faculty of Medicine, University of Montréal , Montréal, Quebec, Canada
| | - Marie Beauséjour
- 4 Sainte-Justine University Hospital Research Center , Montréal, Quebec, Canada
| | | | - Bich-Han Nguyen
- 2 Department of Medicine, Faculty of Medicine, University of Montréal , Montréal, Quebec, Canada .,5 Institut de réadaptation Gingras-Lindsay de Montréal , Montréal, Quebec, Canada
| | - Jean-Marc Mac-Thiong
- 1 Hôpital du Sacré-Cœur de Montréal , Montréal, Quebec, Canada .,3 Department of Surgery, Faculty of Medicine, University of Montréal , Montréal, Quebec, Canada .,4 Sainte-Justine University Hospital Research Center , Montréal, Quebec, Canada
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Rodríguez-Martínez CE, Sossa-Briceño MP, Nino G. Systematic review of instruments aimed at evaluating the severity of bronchiolitis. Paediatr Respir Rev 2018; 25:43-57. [PMID: 28258885 PMCID: PMC5557708 DOI: 10.1016/j.prrv.2016.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/27/2016] [Accepted: 12/13/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE No recent studies have performed a systematic review of all available instruments aimed at evaluating the severity of bronchiolitis. The objective of the present study was to perform a systematic review of instruments aimed at evaluating the severity of bronchiolitis and to evaluate their measurement properties. METHODS A systematic search of the literature was performed in order to identify studies in which an instrument for evaluating the severity of bronchiolitis was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, and lack of ambiguity. RESULTS A total of 77 articles, describing a total of 32 different instruments were included in the review. The number of items included in the instruments ranged from 2 to 26. Upon analyzing their content, respiratory rate turned out to be the most frequently used item (in 26/32, 81.3% of the instruments), followed by wheezing (in 25/32, 78.1% of the instruments). In 18 (56.3%) instruments, there was a report of at least one of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, one was considered to be the best one available. CONCLUSIONS Among the 32 instruments aimed at evaluating the severity of bronchiolitis that were identified and systematically examined, one was considered to be the best one available. However, there is an urgent need to develop better instruments and to validate them in a more comprehensive and proper way.
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Affiliation(s)
- Carlos E. Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia,Research Unit, Military Hospital of Colombia, Bogota, Colombia
| | - Monica P. Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Gustavo Nino
- Division of Pediatric Pulmonary, Sleep Medicine and Integrative Systems Biology. Center for Genetic Research, Children’s National Medical Center, George Washington University, Washington, D.C
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Horn SD, Corrigan JD, Bogner J, Hammond FM, Seel RT, Smout RJ, Barrett RS, Dijkers MP, Whiteneck GG. Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes. Arch Phys Med Rehabil 2015; 96:S178-96.e15. [PMID: 26212396 PMCID: PMC4516907 DOI: 10.1016/j.apmr.2014.09.042] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 08/26/2014] [Accepted: 09/09/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population. DESIGN Prospective, longitudinal, observational study. SETTING Ten inpatient rehabilitation centers. PARTICIPANTS Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being. RESULTS The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations. CONCLUSIONS This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT.
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Flora M Hammond
- Carolinas Rehabilitation, Charlotte, NC; Indiana University School of Medicine, Indianapolis, IN
| | - Ronald T Seel
- Crawford Research Institute, Shepherd Center, Atlanta, GA
| | - Randall J Smout
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT
| | - Marcel P Dijkers
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Conroy BE, Hatfield B, Nichols D. Opening the Black Box of Stroke Rehabilitation with Clinical Practice Improvement Methodology. Top Stroke Rehabil 2015; 12:36-48. [PMID: 15940583 DOI: 10.1310/l3x7-9y2r-aabf-nf5m] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although stroke survivors are the largest consumer group for postacute rehabilitation services, there has been little quantification of the details of poststroke rehabilitation (PSR), with the major exception of the AHCPR Clinical Practice Guidelines #16 of 1995. The gold standard research methodology of a randomized controlled trial cannot practically encompass PSR. Using clinical practice improvement (CPI), a statistically based, validated research methodology, a mathematical representation of the inpatient stroke rehabilitation experience has been constructed. This article examines the principle aspects of CPI methodology and how it was adapted to a multicenter study of inpatient PSR.
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Affiliation(s)
- Brendan E Conroy
- Stroke Recovery Program, National Rehabilitation Hospital, Washington, DC, USA
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Factors Associated with Pressure Ulcer Risk in Spinal Cord Injury Rehabilitation. Am J Phys Med Rehabil 2014; 93:971-86. [DOI: 10.1097/phm.0000000000000117] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Miert C, Abbott J, Verheoff F, Lane S, Carter B, McNamara P. Development and validation of the Liverpool infant bronchiolitis severity score: a research protocol. J Adv Nurs 2014; 70:2353-62. [PMID: 24673581 DOI: 10.1111/jan.12387] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2014] [Indexed: 11/30/2022]
Abstract
AIM To develop and validate a bronchiolitis severity scoring instrument for use by nurses and other healthcare professions. BACKGROUND Bronchiolitis is a viral lower respiratory tract infection of infancy. In industrialized countries, admission rates have increased over the last decade with up to 3% of all infants born being admitted to hospital. A small number of these hospitalized infants will require admission to critical care for either invasive or non-invasive ventilation. During the seasonal epidemic, the number of unplanned admissions to critical care with bronchiolitis substantially increases. DESIGN We will use a mixed methods study design. METHODS We will use scale development and psychometric methods to develop a scoring instrument and to test the instrument for content, construct and criterion validity and reliability in several different clinical locations. This study protocol has been reviewed and approved by the NHS National Research Ethics Service, January 2011. DISCUSSION There is an urgent need to develop a valid and reliable severity scoring instrument sensitive to clinical changes in the infant, to facilitate clinical decision-making and help standardize patient care. Furthermore, a valid and reliable scoring instrument could also be used as a proxy patient-reported outcome measure to evaluate the efficacy of clinical interventions in randomized controlled trials.
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Affiliation(s)
- Clare van Miert
- R&D, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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DeJong G, Tian W, Hsieh CH, Junn C, Karam C, Ballard PH, Smout RJ, Horn SD, Zanca JM, Heinemann AW, Hammond FM, Backus D. Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation. Arch Phys Med Rehabil 2013; 94:S87-97. [PMID: 23527776 DOI: 10.1016/j.apmr.2012.10.037] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/27/2012] [Accepted: 10/30/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization. DESIGN Prospective observational cohort study. SETTING Six geographically dispersed rehabilitation centers in the U.S. PARTICIPANTS Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations. RESULTS More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered. CONCLUSIONS Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.
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Affiliation(s)
- Gerben DeJong
- Center for Post-acute Innovation & Research, MedStar National Rehabilitation Hospital, Washington, DC 20010, USA.
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Horn SD, Smout RJ, DeJong G, Dijkers MP, Hsieh CH, Lammertse D, Whiteneck GG. Association of various comorbidity measures with spinal cord injury rehabilitation outcomes. Arch Phys Med Rehabil 2013; 94:S75-86. [PMID: 23527775 DOI: 10.1016/j.apmr.2012.10.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 10/07/2012] [Accepted: 10/09/2012] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status. DESIGN Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury. SETTING Inpatient rehabilitation and community follow-up at 6 SCI treatment centers. PARTICIPANTS Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI). RESULTS Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school. CONCLUSIONS Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA.
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Comparing Rehabilitation Services and Outcomes Between Older and Younger People With Spinal Cord Injury. Arch Phys Med Rehabil 2013; 94:S175-86. [DOI: 10.1016/j.apmr.2012.10.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 10/08/2012] [Accepted: 10/09/2012] [Indexed: 11/22/2022]
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Whiteneck G, Gassaway J, Dijkers MP, Heinemann AW, Kreider SED. Relationship of patient characteristics and rehabilitation services to outcomes following spinal cord injury: the SCIRehab project. J Spinal Cord Med 2012; 35:484-502. [PMID: 23318033 PMCID: PMC3522893 DOI: 10.1179/2045772312y.0000000057] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND/OBJECTIVE To examine associations of patient characteristics along with treatment quantity delivered by seven clinical disciplines during inpatient spinal cord injury (SCI) rehabilitation with outcomes at rehabilitation discharge and 1-year post-injury. METHODS Six inpatient SCI rehabilitation centers enrolled 1376 patients during the 5-year SCIRehab study. Clinicians delivering standard care documented details of treatment. Outcome data were derived from SCI Model Systems Form I and II and a project-specific interview conducted at approximately 1-year post-injury. Regression modeling was used to predict outcomes; models were cross-validated by examining relative shrinkage of the original model R(2) using 75% of the dataset to the R(2) for the same outcome using a validation subsample. RESULTS Patient characteristics are strong predictors of outcome; treatment duration adds slightly more predictive power. More time in physical therapy was associated positively with motor Functional Independence Measure at discharge and the 1-year anniversary, CHART Physical Independence, Social Integration, and Mobility dimensions, and smaller likelihood of rehospitalization after discharge and reporting of pressure ulcer at the interview. More time in therapeutic recreation also had multiple similar positive associations. Time spent in other disciplines had fewer and mixed relationships. Seven models validated well, two validated moderately well, and four validated poorly. CONCLUSION Patient characteristics explain a large proportion of variation in multiple outcomes after inpatient rehabilitation. The total amount of treatment received during rehabilitation from each of seven disciplines explains little additional variance. Reasons for this and the phenomenon that sometimes more hours of service predict poorer outcome, need additional study. Note: This is the first of nine articles in the SCIRehab series.
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Affiliation(s)
- Gale Whiteneck
- Department of Research, Craig Hospital, Englewood, CO, USA.
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Practice-Based Evidence Research in Rehabilitation: An Alternative to Randomized Controlled Trials and Traditional Observational Studies. Arch Phys Med Rehabil 2012; 93:S127-37. [DOI: 10.1016/j.apmr.2011.10.031] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 10/19/2011] [Accepted: 10/19/2011] [Indexed: 11/19/2022]
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Physical therapy activities in stroke, knee arthroplasty, and traumatic brain injury rehabilitation: their variation, similarities, and association with functional outcomes. Phys Ther 2011; 91:1826-37. [PMID: 22003165 PMCID: PMC3229046 DOI: 10.2522/ptj.20100424] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown. OBJECTIVE The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups. DESIGN This was a prospective observational cohort study. METHODS The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patient's medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities. RESULTS All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average=31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average=65.3 minutes per day), whereas the TBI group received the least physical therapy (average=38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome. LIMITATIONS The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities. CONCLUSIONS All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes.
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Whiteneck G, Gassaway J, Dijkers M, Backus D, Charlifue S, Chen D, Hammond F, Hsieh CH, Smout RJ. The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation. J Spinal Cord Med 2011; 34:133-48. [PMID: 21675353 PMCID: PMC3066504 DOI: 10.1179/107902611x12971826988011] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/30/2010] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND/OBJECTIVE Length of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs. METHODS Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline. RESULTS Average LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics. CONCLUSIONS Variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.
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Affiliation(s)
- Gale Whiteneck
- Rocky Mountain Regional Spinal Injury System, Craig Hospital, Englewood, CO, USA
| | - Julie Gassaway
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
| | - Marcel Dijkers
- Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Deborah Backus
- Shepherd Center, Atlanta, GA, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Susan Charlifue
- Rocky Mountain Regional Spinal Injury System, Craig Hospital, Englewood, CO, USA
| | - David Chen
- Rehabilitation Institute of Chicago, Chicago, IL, USA
| | - Flora Hammond
- Carolinas Rehabilitation, Charlotte, NC, USA
- Indiana University, Indianapolis, IN, USA
| | - Ching-Hui Hsieh
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington, DC, USA
| | - Randall J. Smout
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
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Analysis of rehabilitation activities within skilled nursing and inpatient rehabilitation facilities after hip replacement for acute hip fracture. Am J Phys Med Rehabil 2010; 89:530-40. [PMID: 20567135 DOI: 10.1097/phm.0b013e3181e29f54] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize rehabilitation services in two types of postacute facilities in patients who underwent hip replacement following a hip fracture. DESIGN Multisite prospective observational cohort from 6 freestanding skilled nursing facilities and 11 inpatient rehabilitation facilities. Patients (n = 218) with hip fracture who had either hemiarthroplasty or total hip arthroplasty followed by rehabilitation at skilled nursing facilities or inpatient rehabilitation facilities were enrolled. Using a point-of-care methodology, we recorded data from actual physical therapy and occupational therapy sessions completed including functional outcomes during the postacute admission. RESULTS Onset time from surgical repair to rehabilitation admission was not significantly different between sites. Average skilled nursing facilities length of stay was 24.7 +/- 13.6 days, whereas inpatient rehabilitation facilities was 13.0 +/- 5.7 days (P < 0.01). Total hours of physical therapy and occupational therapy services per patient day were 1.2 in skilled nursing facilities and 2.0 in inpatient rehabilitation facilities. For weekdays only, these data changed to 1.6 in skilled nursing facilities and 2.6 hrs per patient in inpatient rehabilitation facilities (P < 0.01). Patients in inpatient rehabilitation facilities accrued more time for gait training and exercise in physical therapy, which was found to be 48% and 40% greater, respectively, through day 8. In occupational therapy, patients of inpatient rehabilitation facilities had more time allocated to lower body dressing and transfers. CONCLUSIONS Significant differences in rehabilitation activities were observed, and intensity was notably different within the first 8 therapy days even though baseline demographics and medical complexity were comparable across facility types. Our data suggest that after more complex hip replacement surgery, hip fracture patients can tolerate more intensive therapy earlier within the rehabilitation program.
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Practice based evidence: incorporating clinical heterogeneity and patient-reported outcomes for comparative effectiveness research. Med Care 2010; 48:S17-22. [PMID: 20421825 DOI: 10.1097/mlr.0b013e3181d57473] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Comparative effectiveness research analyzes groups of patients and looks for associations between medical treatments and patient outcomes. To make meaningful comparisons of medical interventions, one must consider clinical heterogeneity of patient populations, intervention combinations, and outcomes. OBJECTIVES To explain how practice-based evidence (PBE) study methodology measures and controls for heterogeneity of patients, treatments, and outcomes seen in real-world clinical settings. RESEARCH DESIGN Overview of PBE methodology. CONCLUSIONS PBE study designs address comparative effectiveness by creating a comprehensive set of patient, treatment, and outcome variables, and analyzing them to identify treatments associated with better outcomes for specific types of patients. PBE studies are an alternative to randomized controlled trials, well suited to determine what works best for specific patient types, and provide clinicians with a rational basis for treatment recommendations for individual patients. They provide a holistic picture of patients, treatments, and outcomes, with no preset limits to the number of variables that can be included. Such an approach is needed for high quality comparative effectiveness research.
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DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Smith P, Gassaway J, DaVanzo JE. Use of Rehabilitation and Other Health Care Services by Patients With Joint Replacement After Discharge From Skilled Nursing and Inpatient Rehabilitation Facilities. Arch Phys Med Rehabil 2009; 90:1297-305. [DOI: 10.1016/j.apmr.2008.12.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 11/17/2008] [Accepted: 12/05/2008] [Indexed: 11/25/2022]
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DeJong G, Hsieh CH, Gassaway J, Horn SD, Smout RJ, Putman K, James R, Brown M, Newman EM, Foley MP. Characterizing Rehabilitation Services for Patients With Knee and Hip Replacement in Skilled Nursing Facilities and Inpatient Rehabilitation Facilities. Arch Phys Med Rehabil 2009; 90:1269-83. [DOI: 10.1016/j.apmr.2008.11.021] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 10/28/2008] [Accepted: 11/24/2008] [Indexed: 11/28/2022]
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Joint Replacement Rehabilitation Outcomes on Discharge From Skilled Nursing Facilities and Inpatient Rehabilitation Facilities. Arch Phys Med Rehabil 2009; 90:1284-96. [DOI: 10.1016/j.apmr.2009.02.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Revised: 01/15/2009] [Accepted: 02/15/2009] [Indexed: 11/17/2022]
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Whiteneck G, Gassaway J, Dijkers M, Jha A. New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project. J Spinal Cord Med 2009; 32:251-9. [PMID: 19810627 PMCID: PMC2718827 DOI: 10.1080/10790268.2009.11760779] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Limited research evidence is available to show the effectiveness of the many specific interventions provided in spinal cord injury (SCI) rehabilitation; what is available typically focuses on effects of the full rehabilitation package but not specific therapy interventions, medical procedures, patient education, or counseling. Given the problems of conducting randomized controlled trials (RCTs) in rehabilitation, practice-based evidence (PBE) research has been suggested as an alternative methodology for identifying which rehabilitation interventions are associated most strongly with positive outcomes, after controlling for patient differences. Using the PBE research methodology, the SCIRehab project attempts to "open the black box" of acute SCI rehabilitation, provide detailed information on treatments delivered by all rehabilitation disciplines, and contribute to outcomes-based guidelines for clinical decision-making. METHODS The SCIRehab project includes 1,500 patients with acute SCI, consecutively admitted to 1 of 6 US inpatient rehabilitation facilities. Details of the rehabilitation process are captured by clinicians from multiple disciplines documenting their interventions in handheld personal digital assistants after sessions with their patients. Outcome data are abstracted from medical records (clinical outcomes data) and obtained from patient interviews at 6 and 12 months after injury. Extensive patient, injury, and other treatment characteristics are abstracted from medical records. SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team. RESULTS SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team. These findings are presented in a series of 9 articles. CONCLUSIONS To date, SCIRehab's major contribution is a system for categorizing specific contributions of each discipline and a technology for documenting that detail. After data collection is complete, future manuscripts will relate those process elements to outcomes. The SCIRehab Project is an important step toward establishing outcomes-based guidelines for SCI rehabilitation.
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Affiliation(s)
- Gale Whiteneck
- 1Craig Hospital, Englewood, Colorado; 2Institute for Clinical Outcomes Research, Salt Lake City, Utah; 3Mt. Sinai School of Medicine, Department of Rehabilitation Medicine, New York, New York
| | - Julie Gassaway
- 1Craig Hospital, Englewood, Colorado; 2Institute for Clinical Outcomes Research, Salt Lake City, Utah; 3Mt. Sinai School of Medicine, Department of Rehabilitation Medicine, New York, New York
| | - Marcel Dijkers
- 1Craig Hospital, Englewood, Colorado; 2Institute for Clinical Outcomes Research, Salt Lake City, Utah; 3Mt. Sinai School of Medicine, Department of Rehabilitation Medicine, New York, New York
| | - Amitabh Jha
- 1Craig Hospital, Englewood, Colorado; 2Institute for Clinical Outcomes Research, Salt Lake City, Utah; 3Mt. Sinai School of Medicine, Department of Rehabilitation Medicine, New York, New York
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Abstract
OBJECTIVES To describe a new, rigorous, comprehensive practice-based evidence for clinical practice improvement (PBE-CPI) study methodology, and compare its features, advantages, and disadvantages to those of randomized controlled trials and sophisticated statistical methods for comparative effectiveness research. RESEARCH DESIGN PBE-CPI incorporates natural variation within data from routine clinical practice to determine what works, for whom, when, and at what cost. It uses the knowledge of front-line caregivers, who develop study questions and define variables as part of a transdisciplinary team. Its comprehensive measurement framework provides a basis for analyses of significant bivariate and multivariate associations between treatments and outcomes, controlling for patient differences, such as severity of illness. RESULTS PBE-CPI studies can uncover better practices more quickly than randomized controlled trials or sophisticated statistical methods, while achieving many of the same advantages. We present examples of actionable findings from PBE-CPI studies in postacute care settings related to comparative effectiveness of medications, nutritional support approaches, incontinence products, physical therapy activities, and other services. CONCLUSIONS Outcomes improved when practices associated with better outcomes in PBE-CPI analyses were adopted in practice.
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Affiliation(s)
- Susan D Horn
- International Severity Information Systems, Inc.; and Institute for Clinical Outcomes Research, Salt Lake City, Utah, USA.
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Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results. Arch Phys Med Rehabil 2006; 86:S16-S33. [PMID: 16373137 DOI: 10.1016/j.apmr.2005.08.114] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Revised: 07/24/2005] [Accepted: 08/02/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results. OBJECTIVES To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP). DESIGN Prospective observational cohort study. SETTING Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand. PARTICIPANTS Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Change in FIM score, change in severity of illness, and discharge destination. RESULTS For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4. CONCLUSIONS This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.
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Affiliation(s)
- Julie Gassaway
- Institute for Clinical Outcomes Research, International Severity Information Systems Inc, Salt Lake City, UT 84102-1282, USA
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Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another Look at Observational Studies in Rehabilitation Research: Going Beyond the Holy Grail of the Randomized Controlled Trial. Arch Phys Med Rehabil 2005; 86:S8-S15. [PMID: 16373136 DOI: 10.1016/j.apmr.2005.08.116] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Revised: 07/31/2005] [Accepted: 08/02/2005] [Indexed: 01/21/2023]
Abstract
Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the "black box" of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs.
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Affiliation(s)
- Susan D Horn
- International Severity Information Systems Inc and Institute for Clinical Outcomes Research, Salt Lake City, UT 84102-1282, USA.
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Connor SR, Horn SD, Smout RJ, Gassaway J. The National Hospice Outcomes Project: development and implementation of a multi-site hospice outcomes study. J Pain Symptom Manage 2005; 29:286-96. [PMID: 15781179 DOI: 10.1016/j.jpainsymman.2005.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2005] [Indexed: 11/23/2022]
Abstract
Hospice has become a major component of end-of-life care, but little scientific information is available to guide clinicians in knowing when the use of hospice is appropriate, in knowing how to measure the impact of its care, and in knowing which hospice interventions lead to the best outcomes. The National Hospice Outcomes Project (NHOP) arose from the need to identify patient factors and hospice interventions that are associated with better end-of-life outcomes. Clinical Practice Improvement (CPI) methodology allowed us to generate a large comprehensive database that could identify scientifically hospice interventions associated with better outcomes for specific patient populations. The complex interplay of patients, medical and complementary treatments, and families can be evaluated. This paper describes an overview of the research methods used for the NHOP, describes the project's 13 clinical sites and study population of 1,306 patients, and presents some basic findings from the study.
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Affiliation(s)
- Stephen R Connor
- National Hospice and Palliative Care Organization, Alexandria, Virginia 22314, USA
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Dejong G, Horn SD, Gassaway JA, Slavin MD, Dijkers MP. Toward a taxonomy of rehabilitation interventions: using an inductive approach to examine the “black box” of rehabilitation. Arch Phys Med Rehabil 2004; 85:678-86. [PMID: 15083447 DOI: 10.1016/j.apmr.2003.06.033] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A barrier in outcomes and effectiveness research is the ability to characterize the interventions under review. This has been the case especially in rehabilitation in which interventions are commonly multidisciplinary, customized to the patient, and lack standardization in definition and measurement. This commentary describes how investigators and clinicians, working together, in a major multisite stroke rehabilitation outcome study were able to define and characterize diverse stroke rehabilitation interventions in a comprehensive, yet parsimonious, fashion and thus capture what actually transpires in a hospital-based stroke rehabilitation program. We consider the implications of the study's classification system for a more comprehensive taxonomy of rehabilitation interventions and the potential utility of such a taxonomy in operationalizing practice standards, medical record keeping, and rehabilitation research.
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Affiliation(s)
- Gerben Dejong
- Brooks Center for Rehabilitation Studies and Department of Health Services Administration, College of Public Health & Health Professions, University of Florida, Gainesville, FL, USA
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Horn SD, Bender SA, Ferguson ML, Smout RJ, Bergstrom N, Taler G, Cook AS, Sharkey SS, Voss AC. The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents. J Am Geriatr Soc 2004; 52:359-67. [PMID: 14962149 DOI: 10.1111/j.1532-5415.2004.52106.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To identify resident, treatment, and facility characteristics associated with pressure ulcer (PU) development in long-term care residents. DESIGN Retrospective cohort study with convenience sampling. SETTING Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States. PARTICIPANTS A total of 1,524 residents aged 18 and older, with length of stay of 14 days or longer, who did not have an existing PU but were at risk of developing a PU, as defined by a Braden Scale for Predicting Pressure Sore Risk score of 17 or less, on study entry. MEASUREMENTS Data collected for each resident over a 12-week period included resident characteristics (e.g., demographics, medical history, severity of illness using the Comprehensive Severity Index, Braden Scale scores, nutritional factors), treatment characteristics (nutritional interventions, pressure management strategies, incontinence treatments, medications), staffing ratios and other facility characteristics, and outcome (PU development during study period). Data were obtained from medical records, Minimum Data Set, and other written records (e.g., physician orders, medication logs). RESULTS Seventy-one percent of subjects (n=1,081) did not develop a PU during the 12-week study period; the remaining 29% of residents (n=443) developed a new PU. Resident, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight loss, oral eating problems, use of catheters, and use of positioning devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new resident, nutritional intervention (e.g., use of oral medical nutritional supplements and tube feeding for >21 days), antidepressant use, use of disposable briefs for more than 14 days, registered nurse hours of 0.25 hours per resident per day or more, nurses' aide hours of 2 hours per resident per day or more, and licensed practical nurse turnover rate of less than 25%. When Stage I PUs were excluded from the analyses, the same variables were significant, with the addition of fluid orders associated with decreased likelihood of developing a PU. CONCLUSION A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long-term care residents. Research-based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, Salt Lake City, Utah, USA.
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Willson DF, Landrigan CP, Horn SD, Smout RJ. Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia. J Pediatr 2003; 143:S142-9. [PMID: 14615713 DOI: 10.1067/s0022-3476(03)00514-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize complications among infants hospitalized for bronchiolitis or respiratory syncytial virus (RSV). STUDY DESIGN Retrospective data from 684 infants with bronchiolitis or RSV pneumonia, < or =1 year old, admitted to 10 children's hospitals from April 1995 to September 1996. Outcomes included complication rates and effects on hospital and pediatric intensive care unit (PICU) length of stay (LOS) and hospital costs. RESULTS Most infants (79%) had one or more complication, with serious complications in 24%. Even minor complications were associated with significantly longer PICU and hospital LOS and higher costs (P<.001). Respiratory complications were most frequent (60%), but infectious (41%), cardiovascular (9%), electrolyte imbalance (19%), and other complications (9%) were common. Complication rates were higher in former premature infants (87%), infants with congenital heart disease (93%), and infants with other congenital abnormalities (90%) relative to infants without risk factors (76%). Infants 33 to 35 weeks gestational age (GA) had the highest complication rates (93%), longer hospital LOS, and higher costs (P<.004) than other former premature infants. CONCLUSIONS Complications were common in infants hospitalized for bronchiolitis or RSV pneumonia and were associated with longer LOS and higher costs. Former premature infants and infants with congenital abnormalities are at significantly greater risk for complications. Broader use of RSV prevention should be considered for these higher-risk infants.
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Affiliation(s)
- Douglas F Willson
- PICU and the Division of Pediatric Critical Care, University of Virginia Children's Medical Center, Charlottesville, Virginia, USA
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Abstract
OBJECTIVES To determine if gestational age (GA) is independently associated with hospital resource use and outcomes among infants hospitalized for respiratory syncytial virus (RSV). STUDY DESIGN Analysis of retrospective data from 304 infants (</=1 year) with bronchiolitis or RSV pneumonia admitted to nine children's hospitals from April 1995 to September 1996. Resource use and outcomes examined included admission to the intensive care unit (ICU), intubation, and hospital and ICU length of stay. The Comprehensive Severity Index controlled for severity of illness. RESULTS Two hundred fifteen term infants (GA > or =37 weeks) and 89 infants with GA <37 weeks, divided according to GA into 3 subgroups (< or =32, 33 to 35, and 36 weeks), were compared. Significant differences were found for rate of intubation (P=.002) and ICU and hospital length of stay (P=.021 and P<.0001, respectively), with the highest resource use in 33 to 35 weeks GA infants, which remained significant in multiple regression analyses. CONCLUSIONS Infants 33 to 35 weeks GA had hospital outcomes that were negative or worse than infants < or =32 weeks GA. Data suggest prematurity < or =35 weeks GA significantly increases the risk for severe outcomes among infants hospitalized for RSV. Infants 36 weeks GA had outcomes similar to term infants. No evidence was observed of gradation or inverse linear risk relation between GA and hospital outcomes.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, Utah 84102-1282, USA.
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Horn SD, Torres A, Willson D, Dean JM, Gassaway J, Smout R. Development of a pediatric age- and disease-specific severity measure. J Pediatr 2002; 141:496-503. [PMID: 12378188 DOI: 10.1067/mpd.2002.126925] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To adapt the adult Comprehensive Severity Index (CSI) for hospitalized pediatric patients and evaluate the ability of the CSI to predict common outcomes. STUDY DESIGN Adult CSI was modified by a panel of pediatric subspecialists from 10 children's hospitals. Predictive power was evaluated by using retrospective data collected from 16,495 randomly selected children admitted to these hospitals from April 1995 through September 1996. Outcomes were mortality, length of stay (LOS), and cost. RESULTS Admission CSI score predicted mortality well (Hosmer-Lemeshow tests: P =.41-.98) and discriminated well (area under receiver operating characteristic [ROC] curve range = 0.80-0.99) within 9 case-mix groups with > or =10 deaths (P <.0001). Maximum CSI score explained the variation in LOS (r2 = 0.13-0.67) and cost (r2 = 0.08-0.73) within 32 case-mix groups (P <.005). Significant differences existed in admission and maximum average CSI scores across sites in 26 and 29 of 32 case-mix groups, respectively (P <.05). CSI had better predictability than Pediatric Risk of Mortality. CONCLUSIONS The age- and disease-specific pediatric CSI score correlates highly with LOS, cost, and mortality in hospitalized children and can help determine the best clinical practices for specific diseases and adjust for differences in severity of illness across providers.
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Affiliation(s)
- Susan D Horn
- ISIS, Inc, the Institute for Clinical Outcomes Research, and the Department of Pediatrics, Primary Children's Medical Center, Salt Lake City, Utah 84109-1630, USA
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Willson DF, Horn SD, Hendley JO, Smout R, Gassaway J. Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness. Pediatrics 2001; 108:851-5. [PMID: 11581435 DOI: 10.1542/peds.108.4.851] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Hospital care for children with viral lower respiratory illness (VLRI) is highly variable, and its relationship to severity and impact on outcome is unclear. Using the Pediatric Comprehensive Severity Index, we analyzed the correlation of institutional practice variation with severity and resource utilization in 10 children's medical centers. METHODS Demographics, clinical information, laboratory results, interventions, and outcomes were extracted from the charts of consecutive infants with VLRI from 10 children's medical centers. Pediatric Component of the Comprehensive Severity Index scoring was performed at admission and at maximum during hospitalization. The correlation of patient variables, interventions, and resource utilization at the patient level was compared with their correlation at the aggregate institutional level. RESULTS Of 601 patients, 1 died, 6 were discharged to home health care, 4 were discharged to rehabilitative care, and 2 were discharged to chronic nursing care. Individual patient admission severity score correlated positively with patient hospital costs (r = 0.48), but institutional average patient severity was negatively correlated with average institutional costs (r = -0.26). Maximal severity score correlated well with costs (r = 0.66) and length of stay (LOS; r = 0.64) at the patient level but poorly at the institutional level (r = 0.07 costs; r = 0.40 LOS). The institutional intensity of therapy was negatively correlated with admission severity (r = -0.03) but strongly correlated with costs (r = 0.84) and LOS (r = 0.83). CONCLUSIONS Institutional differences in care practices for children with VLRI were not explained by differences in patient severity and did not affect the children's recovery but correlated significantly with hospital costs and LOS.
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Affiliation(s)
- D F Willson
- University of Virginia Children's Medical Center, Charlottesville, Virginia, USA.
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Sheridan RL. Predicting costs in the intensive care unit. Pediatr Crit Care Med 2000; 1:190-1. [PMID: 12813276 DOI: 10.1097/00130478-200010000-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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