Determinants of length of stay in stroke patients: a geriatric rehabilitation unit experience

Is communication key in stroke rehabilitation and recovery? National linked stroke data study

BACKGROUND

Information on the characteristics or long-term outcomes of people with communication support needs post-stroke is limited. We investigated associations between communication gains in rehabilitation and long-term outcomes (quality-of-life [EuroQOL-ED-3 L], mortality) by post-stroke communication support need status.

METHODS

Retrospective cohort study using person-level linked data from the Australian Stroke Clinical Registry and the Australasian Rehabilitation Outcomes Centre (2014-2017). Communication support needs were assessed using the Functional Independence Measure™ comprehension and expression items recorded on admission indicated by scores one (total assistance) to five (standby prompting). Multivariable multilevel and Cox regression models were used to determine associations with long-term outcomes.

RESULTS

Of 8,394 patients who received in-patient rehabilitation after stroke (42% female, median age 75.6 years), two-thirds had post-stroke communication support needs. Having aphasia (odds ratio [OR] 4.34, 95% CI 3.67-5.14), being aged ≥65 years (OR 1.21, 95% CI 1.08-1.36), greater stroke severity (unable to walk on admission; OR 1.48, 95% CI 1.32-1.68) and previous stroke (OR 1.25, 95% CI 1.11-1.41) were associated with increased likelihoods of having communication support needs. One-point improvement in FIM™ expression was associated with reduced likelihood of self-reporting problems related to mobility (OR 0.85, 95% CI: 0.80-0.90), self-care (OR 0.79, 95% CI: 0.74-0.86) or usual activities (OR 0.84, 95% CI: 0.75-0.94) at 90-180 days. Patients with communication support needs had greater mortality rates within one-year post-stroke (adjusted hazard ratio 1.99, 95% CI: 1.65-2.39).

CONCLUSIONS

Two-thirds of patients with stroke require communication support to participate in healthcare activities. Establishing communication-accessible stroke care environments is a priority.

Effects of functional performance and national health insurance cost on length of hospitalization for postacute care in stroke: a retrospective observational study

BACKGROUND

The postacute care for cerebrovascular disease (PAC-CVD) program was launched in Taiwan nearly a decade ago. However, no clear regulations regarding length of stay (LOS) in the program and extension standards exist. Thus, the allocation of limited medical resources such as hospital beds is a major issue.

METHODS

This novel study retrospectively investigated the effects of functional performance and national health insurance (NHI) costs on PAC-CVD LOS. Data for 263 patients with stroke who participated in the PAC-CVD program were analysed. Hierarchical multiple regression was used to estimate the effects of functional performance and NHI costs on LOS at three time points: weeks 3, 6, and 9.

RESULTS

At week 3, age, NHI costs, modified Rankin scale score, and Barthel index significantly affected LOS, whereas at week 6, age and NHI costs were significant factors. However, functional performance and NHI costs were not significant factors at week 9.

CONCLUSIONS

The study provides crucial insights into the factors affecting LOS in the PAC-CVD program, and the results can enable medical decision-makers and health care teams to develop inpatient rehabilitation plans or provide transfer arrangements tailored to patients. Specifically, this study highlights the importance of early functional recovery and consideration of NHI costs when managing LOS in the PAC-CVD program.

A randomized sham-controlled trial on the effects of dual-tDCS "during" physical therapy on lower limb performance in sub-acute stroke and a comparison to the previous study using a "before" stimulation protocol

Background

Dual-transcranial direct current stimulation (tDCS) has been used to rebalance the cortical excitability of both hemispheres following unilateral-stroke. Our previous study showed a positive effect from a single-session of dual-tDCS applied before physical therapy (PT) on lower limb performance. However, it is still undetermined if other timings of brain stimulation (i.e., during motor practice) induce better effects. The objective of this study was to examine the effect of a single-session of dual-tDCS “during” PT on lower limb performance in sub-acute stroke and then compare the results with our previous data using a “before” stimulation paradigm.

Method

For the current “during” protocol, 19 participants were participated in a randomized sham-controlled crossover trial. Dual-tDCS over the M1 of both cortices (2 mA) was applied during the first 20 min of PT. The Timed Up and Go and Five-Times-Sit-To-Stand tests were assessed at pre- and post-intervention and 1-week follow-up. Then, data from the current study were compared with those of the previous “before” study performed in a different group of 19 subjects. Both studies were compared by the difference of mean changes from the baseline.

Results

Dual-tDCS “during” PT and the sham group did not significantly improve lower limb performance. By comparing with the previous data, performance in the “before” group was significantly greater than in the “during” and sham groups at post-intervention, while at follow-up the “before” group had better improvement than sham, but not greater than the “during” group.

Conclusion

A single-session of dual-tDCS during PT induced no additional advantage on lower limb performance. The “before” group seemed to induce better acute effects; however, the benefits of the after-effects on motor learning for both stimulation protocols were probably not different.

Trial registration Current randomized controlled trials was prospectively registered at the clinicaltrials.gov, registration number: NCT04051671. The date of registration was 09/08/2019.

Long-Term Rehabilitation Utilization Pattern Among Stroke Patients Under the National Health Insurance Program

OBJECTIVE

The aim of this study was to understand the frequency of patients receiving rehabilitation services at various periods after stroke and the possible medical barriers to receiving rehabilitation.

DESIGN

A retrospective cohort study was conducted using a nationally representative sample in Taiwan. A total of 14,600 stroke patients between 2005 and 2011 were included. Utilization of physical therapy or occupational therapy at different periods after stroke onset was the outcome variable. Individual and geographic characteristics were investigated to determine their effect on patients' probability of receiving rehabilitation.

RESULTS

More severe stroke or more comorbid diseases increased the odds of receiving physical therapy and occupational therapy; older age was associated with decreased odds. Notably, sex and stroke type influenced the odds of rehabilitation only in the early period. Copayment exemption lowered the odds of rehabilitation in the first 6 mos but increased the odds in later periods. Rural and suburban patients had significantly lower odds of receiving physical therapy and occupational therapy, as did patients living in areas with fewer rehabilitation therapists.

CONCLUSIONS

Besides personal factors, geographic factors such as urban-rural gaps and number of therapists were significantly associated with the utilization of post-stroke rehabilitation care. Furthermore, the influence of certain factors, such as sex, stroke type, and copayment exemption type, changed over time.

Hospitalization Costs and Length of Stay in Chinese Naval Hospitals Between 2008 and 2016 Based on Influencing Factors: A Longitudinal Comparison

INTRODUCTION

A retrospective review conducted in three hospitals of Guangdong and Hainan, China. To analyze the variation tendency of mean hospitalization costs and length of stay (LOS) in naval hospitals over nine years, paying special attention to the factors affecting hospitalization costs and LOS to provide a reference base for health resource allocation in naval hospitals.

MATERIALS AND METHODS

A total of 21,375 cases of military patients who were hospitalized and treated in three naval hospitals between January 2008 to December 2016 were extracted from the military health system. There were 16,278 complete and effective cases during those nine years. The situation, trends, and factors influencing hospitalization costs and LOS were analyzed using descriptive statistics, Mann-Whitney U test, Kruskal-Wallis H test, and multiple linear regressions.

RESULTS

The following factors showed statistically significant differences in hospitalization costs: special care, primary care, year, military rank, critical illness, allergies, and condition (p < 0.0001); and number of hospitalizations, gender, and age (p < 0.01). The following factors showed statistically significant differences in hospital LOS: year, number of hospitalizations, outcomes, military rank, special care, severity of illness, and condition (p < 0.0001); allergy (p < 0.01); and service and gender (p < 0.05). LOS between 2008-2016 showed a decreasing tendency, while hospitalization costs showed an increasing trend. There were 6 factors that affected Abstract (or Structured Summary) both the cost of hospitalization and LOS: special care, year, military rank, condition, allergy, and gender.

CONCLUSIONS

The results suggest that improving efficiency of military hospital require strengthening hierarchical referrals and controlling hospital LOS. Shortening LOS, optimizing clinical pathways, and reasonably controlling the costs associated with medicines and surgery can help reduce hospitalization costs for military patients. Controlling the growth of hospitalization costs can help avoid the physical and psychological burden of medical over-treatment on patients and may also optimize the allocation of military health resources.

Sex Differences in Stroke Rehabilitation Care in Alberta

Background:

Female stroke patients may experience poorer functional outcomes than males following inpatient rehabilitation.

Methods:

Data from Alberta inpatient stroke rehabilitation units were examined to determine: (1) the impact of sex on time to inpatient rehabilitation, functional gains (using the Functional Independence Measure (FIM)), length of stay (LOS), and discharge destination; (2) if sex was related to age at the time of stroke, stroke severity, and living arrangement at discharge from rehabilitation; and (3) whether patients’ age and preadmission living arrangement had an influence on LOS in rehabilitation or discharge destination.

Results:

Two thousand two hundred sixty-six adult stroke patients (1283 males and 983 females) were subcategorized as mild (FIM >80; n = 1155), moderate (FIM 40–80; n = 994), or severe (FIM <40; n = 117). Fifty-five percent of males (45.7% females) had mild stroke; 39.5% of males (49.5% females) had moderate stroke; and 5.5% of males (4.8% females) had severe stroke. Females were significantly older than males (p = 2.4 × 10−4). No sex difference existed in time from acute care to rehabilitation admission (p = 0.73) or in mean FIM change (p = 0.294). Mean LOS was longer for females than males (p=0.018). Males were more likely than females to be discharged home (p = 1.8 × 10−13). Further, male patients (p = 6.4 × 10−7) and those < 65 years (p = 1.4 × 10−23) were more likely to be discharged home without homecare.

Conclusion:

There are significant sex and age differences in LOS in rehabilitation and discharge destination of stroke patients. These differences may suggest that sex and age of the patient need to be considered in care planning.

The Impact of Comorbidity on Rehabilitation Outcome after Ischemic Stroke

SUMMARY – Comorbidity decreases survival but it still remains unknown to what extent functional recovery after ischemic stroke is affected. The aim of this research was to determine the prevalence of the most common comorbidities in patients with ischemic stroke and to examine their predictive value on the functional status and recovery. In order to obtain relevant information for this research, we conducted a prospective study over a two-year period. It included patients with acute/subacute ischemic stroke who had inhospital rehabilitation treatment in our institution. Functional status of the patients was evaluated by the following three aspects at the beginning and at the end of rehabilitation treatment: Rivermead Mobility Index was used for mobility, Barthel Index for independence in activities of daily living, and modified Rankin Scale for total disability. Modified Charlston Comorbidity Index was used to assess comorbidity. Multivariate analysis was applied to evaluate the impact of recorded comorbidities on the patient functional outcome. Independent predictors of rehabilitation success in our study were the value of modified Charlston Comorbidity Index, atrial fibrillation and myocardial infarction. Our study demonstrated that patients with more comorbidities had worse functional outcome after stroke, so it is important to consider the comorbidity status when planning the rehabilitation treatment.

Predicting the length of hospital stay of post-acute care patients in Taiwan using the Chinese version of the continuity assessment record and evaluation item set

Background

The Chinese version of the Continuity Assessment Record and Evaluation (CARE-C) item set was developed to facilitate the assessment of post-acute care (PAC) patients in Taiwan. Considering that the length of hospital stay (LOS) has a significant effect on the total healthcare cost, determining whether the CARE-C scores could predict the LOS of PAC patients is of great interest to the PAC providers.

Methods

This prospective trial included PAC patients with stroke or central nervous system injuries. The demographic data and CARE-C scores were collected after admission and before discharge. A multivariable stepwise linear regression model was used to identify the predictors of the LOS using age, sex, tube placement status, CARE-C component scores at admission, and score differences between admission and discharge as independent variables.

Results

This study included 178 patients (66 women and 112 men), with a mean age of 61.9 ± 15.6 years. Indwelling urinary catheter placement status at admission (β = 0.241, p = 0.002) was a positive predictor of the LOS, whereas age (β = −0.189, p = 0.010), core transfer subscale score at admission (β = −0.176, p = 0.020), and difference in continence subscale score (β = −0.203, p = 0.008) were negative predictors of the LOS. The model explained 14% of the total variance.

Conclusions

Indwelling urinary catheter placement status at admission, age, core transfer subscale score at admission, and difference in the CARE-C continence subscale score were identified as predictors of the LOS. The explanatory power of these predictors might be limited due to the regulations of Taiwan’s National Health Insurance.

A narrative review of the impact of medical comorbidities on stroke rehabilitation outcomes

PURPOSE

Medical comorbidities in stroke patients influence acute mortality, but may also affect participation of survivors in rehabilitation. There is limited research investigating the impact of comorbidities on stroke rehabilitation outcomes. The review will explore the literature on the impact of comorbidities on stroke rehabilitation outcome.

MATERIALS AND METHODS

The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome.

RESULTS

Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes.

CONCLUSIONS

There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes. Implications for rehabilitation Benefit of rehabilitation after stroke in improving functional outcome is well-established. Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation. The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.

Predicting length of stay in specialist neurological rehabilitation

AIMS

A retrospective case series was performed to determine which measures of complexity, dependency and function most accurately predict inpatient neurorehabilitation length of stay for individuals with post-acute neurological disorders.

METHODS

Sociodemographic, medical and functional variables were extracted from data submitted to the UK Rehabilitation Outcomes Collaborative. Length of stay was calculated as the total number of inpatient days, functional status was measured using Barthel Index, rehabilitation complexity was measured using Extended Rehabilitation Complexity Scale, and nursing dependency was measured using the Northwick Park Dependency Scale.

RESULTS

The mean rehabilitation length of stay was 70.9 days, with length of stay being 35.1 days higher in inpatients with acquired brain injury than inpatients with spinal cord injury. Diagnostic category, Barthel Index scores, Extended Rehabilitation Complexity Scale scores and Northwick Park Dependency Scale scores at admission independently predicted length of stay. Multiple regressions including diagnostic group, Barthel Index, Extended Rehabilitation Complexity Scale and Northwick Park Dependency Scale statistically significantly predicted 37.9% of the variability in length of stay (p < 0.005). Northwick Park Dependency Scale on admission was most closely correlated with inpatient length of stay.

CONCLUSIONS

In conclusion, inpatient length of stay is predicted by diagnostic category, Extended Rehabilitation Complexity Scale, Northwick Park Dependency Scale and Barthel Index. The most influential predictor of rehabilitation length of stay was Northwick Park Dependency Scale score at admission. These results may help facilitate rehabilitation resource planning and implementation of effective commissioning plans. Implications for Rehabilitation The most accurate predicting variable for length of stay in inpatient neurological rehabilitation was nursing need as measured by the Northwick Park Dependency Scale score on admission. Service users and commissioners can be provided with more realistic predictions of length of stay derived from admission variables that can be used in planning inpatient rehabilitation. Age and gender do not seem to have an effect on the total length of stay in rehabilitation.

A comparison of stroke rehabilitation; data from two national cohorts

OBJECTIVES

Inpatient rehabilitation is a commonly used complex intervention to improve a person's independence after stroke. Evaluation and comparison of the effects of routine clinical practice could provide a contribution towards optimization of stroke care. The aim of this study is to describe results of inpatient rehabilitation as a complex intervention for persons after stroke and explore possible differences between two countries.

METHODS

Data from 1055 Latvian and 1748 Swedish adult patients after stroke receiving inpatient rehabilitation, during 2011-2013, were used for this retrospective cohort study. Qualitative description of systems, as well as information on basic medical and sociodemographic information, and organizational aspects were reported. Change in the Functional Independence Measure during rehabilitation was investigated. In six domains of the instrument, the shifts for three levels of dependence were analysed using ordinal regression analysis.

RESULTS

The components of stroke care seem to be similar in Latvia and Sweden. However, the median time since stroke onset until the start of rehabilitation was 13 weeks in Latvia and 2 weeks in Sweden. The median length of rehabilitation was 12 and 49 days, respectively. The level of dependency at start, time since stroke onset and length of the period had an impact on the results of the rehabilitation.

CONCLUSIONS

Although components of the rehabilitation are reported as being the same, characteristics and the outcome of the inpatient rehabilitation are different. Therefore, comparison of stroke rehabilitation between countries requires caution.

Regional variation in stroke rehabilitation outcomes

OBJECTIVE

To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation.

DESIGN

Retrospective cohort design.

SETTING

Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States.

PARTICIPANTS

Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS).

RESULTS

Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days.

CONCLUSIONS

Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.

Predicting length of stay in patients admitted to stroke rehabilitation with high levels of functional independence

PURPOSE

In Ontario, stroke patients with relatively mild functional deficits are admitted to inpatient rehabilitation programmes. Despite apparently minor impairments, many of these patients remain in rehabilitation for prolonged periods of time. The objective of the present study is to identify variables that predict length of stay (LOS) within this population of high functioning stroke patients.

METHODS

Stroke patients with Functional Independence Measure (FIM™) scores ≥100 admitted to a specialised inpatient rehabilitation programme in Ontario, Canada, from April 2005 to March 2008 were included in this study. Data from the National Rehabilitation Reporting System and chart review were used. Associations with LOS were examined among 25 potential predictor variables using bivariate correlations. Significantly correlated (p <0.002) variables were entered into a multiple linear regression.

RESULTS

Twenty-four percent (n = 134) of patients admitted during the study period were identified as presenting with mild functional deficits. These patients had a mean admission age of 63.5 (SD 14.6) years, a mean admission FIM score of 109.9 (SD 6.6) and a mean LOS of 22.3 (SD 10.5) days. FIM motor and cognitive subscale scores, Mini Mental State Exam scores and five single items assessing orientation, financial independence, and verbal, written and auditory communication ability were significantly correlated with LOS. The regression model, which included all eight variables, explained 60% of the variance associated with LOS (r = 0.80).

CONCLUSIONS

For patients admitted to stroke rehabilitation programmes with mild functional impairment, 60% of the variance in LOS can be explained by a small number of variables indicative of deficits in the areas of motor function, cognition and communication.

Geriatric rehabilitation of stroke patients in nursing homes: a study protocol

BACKGROUND

Geriatric patients are typically underrepresented in studies on the functional outcome of rehabilitation after stroke. Moreover, most geriatric stroke patients do probably not participate in intensive rehabilitation programs as offered by rehabilitation centers. As a result, very few studies have described the successfulness of geriatric stroke rehabilitation in nursing home patients, although it appears that the majority of these patients are being discharged back to the community, rather than being transferred to residential care. Nevertheless, factors associated with the successfulness of stroke rehabilitation in nursing homes or skilled nursing facilities are largely unknown. The primary goal of this study is, therefore, to assess the factors that uniquely contribute to the successfulness of rehabilitation in geriatric stroke patients that undergo rehabilitation in nursing homes. A secondary goal is to investigate whether these factors are similar to those associated with the outcome of stroke rehabilitation in the literature.

METHODS/DESIGN

This study is part of the Geriatric Rehabilitation in AMPutation and Stroke (GRAMPS) study in the Netherlands. It is a longitudinal, observational, multicenter study in 15 nursing homes in the Southern part of the Netherlands that aims to include at least 200 patients. All participating nursing homes are selected based on the existence of a specialized rehabilitation unit and the provision of dedicated multidisciplinary care. Patient characteristics, disease characteristics, functional status, cognition, behavior, and caregiver information, are collected within two weeks after admission to the nursing home. The first follow-up is at discharge from the nursing home or one year after inclusion, and focuses on functional status and behavior. Successful rehabilitation is defined as discharge from the nursing home to an independent living situation within one year after admission. The second follow-up is three months after discharge in patients who rehabilitated successfully, and assesses functional status, behavior, and quality of life. All instruments used in this study have shown to be valid and reliable in rehabilitation research or are recommended by the Netherlands Heart Foundation guidelines for stroke rehabilitation.Data will be analyzed using SPSS 16.0. Besides descriptive analyses, both univariate and multivariate analyses will be performed with the purpose of identifying associated factors as well as their unique contribution to determining successful rehabilitation.

DISCUSSION

This study will provide more information about geriatric stroke rehabilitation in Dutch nursing homes. To our knowledge, this is the first large study that focuses on the determinants of success of geriatric stroke rehabilitation in nursing home patients.