Discharge Patterns for Ischemic and Hemorrhagic Stroke Patients Going From Acute Care Hospitals to Inpatient and Skilled Nursing Rehabilitation

Navigating the acute to post-acute transition with patients: a first characterization of medical student knowledge gaps in rehabilitation and post-acute care

PURPOSE

Clinical rehabilitation and post-acute care (PAC) learning experiences are not uniformly required within medical school core curricula in the United States or internationally. This study aims to characterize what medical students might know/need to know to support patients in the transition from acute hospitalization to post-acute rehabilitation settings.

MATERIALS/METHODS

The medical student cohort completing required clinical rotations in a United States quaternary care hospital system was provided a voluntary survey prompting reflection on experiences discharging patients to rehabilitation/PAC and related learning needs. Data were analyzed using descriptive statistics and qualitative grounded theory.

RESULTS

Response rate was 72% (39/54). All respondents reported at least one gap in rehabilitation/PAC knowledge, falling into 8 themes: daily experience of rehabilitation/PAC; determination of eligibility/screening processes; distinctions among levels of rehabilitation/PAC; insurance coverage/equity; rehabilitation/PAC clinical practice environment; post-rehabilitation/PAC discharge support; medical capabilities within PAC settings; developing rehabilitation goals.

CONCLUSIONS

Despite caring for patients discharged to post-acute rehabilitation settings, medical students lack essential knowledge about the process of rehabilitation and recovery, including patient eligibility for and service availability across PAC settings. Explicit rehabilitation/PAC education for medical students could enhance their ability to counsel and advocate for patients with disability and rehabilitation needs through care transitions.Implications for rehabilitationMedical students lack knowledge about rehabilitation and post-acute care that is important for helping patients navigate the acute to post-acute transition.Dedicated rehabilitation/post-acute care education could prepare trainees for counseling and advocating for patients during care transitions.Knowledge gaps identified in this study could inform development of curricular interventions to address medical student learning needs.

Racial and Ethnic Disparities in the Medical Management of Poststroke Complications Among Patients With Acute Stroke

BACKGROUND

To inform clinical practice, we sought to identify racial and ethnic differences in the medical management of common poststroke complications.

METHODS AND RESULTS

A cohort of acutely hospitalized, first-time non-Hispanic White (NHW), non-Hispanic Black, and Hispanic patients with stroke was identified from electronic medical records of 51 large health care organizations (January 1, 2003 to December 5, 2022). Matched propensity scores were used to account for baseline differences. Primary outcomes included receipt of medication(s) associated with the management of the following poststroke complications: arousal/fatigue, spasticity, mood, sleep, neurogenic bladder, neurogenic bowel, and seizure. Differences were measured at 14, 90, and 365 days. Subgroup analyses included differences restricted to patients with ischemic stroke, younger age (<65 years), and stratified by decade (2003-2012 and 2013-2022). Before matching, the final cohort consisted of 348 286 patients with first-time stroke. Matching resulted in 63 722 non-Hispanic Black-NHW pairs and 24 009 Hispanic-NHW pairs. Non-Hispanic Black (versus NHW) patients were significantly less likely to be treated for all poststroke complications, with differences largest for arousal/fatigue (relative risk (RR), 0.58 [95% CI, 0.54-0.62]), spasticity (RR, 0.64 [95% CI, 0.0.62-0.67]), and mood disorders (RR, 0.72 [95% CI, 0.70-0.74]) at 14 days. Hispanic-NHW differences were similar, albeit with smaller magnitudes, with the largest differences present for spasticity (RR, 0.67 [95% CI, 0.63-0.72]), arousal/fatigue (RR, 0.77 [95% CI, 0.70-0.85]), and mood disorders (RR, 0.79 [95% CI, 0.77-0.82]). Subgroup analyses revealed similar patterns for ischemic stroke and patients aged <65 years. Disparities for the current decade remained significant but with smaller magnitudes compared with the prior decade.

CONCLUSIONS

There are significant racial and ethnic disparities in the treatment of poststroke complications. The differences were greatest at 14 days, outlining the importance of early identification and management.

Occupational Therapy for Poststroke Anxiety and Depressive Symptoms in Inpatient Rehabilitation

Poststroke anxiety and depressive symptoms (P-SADS) affect one in three people and are associated with decreased participation in activities of daily living. This study sought to characterize occupational therapy (OT) P-SADS care practices and identify factors influencing P-SADS care provision in one U.S. inpatient rehabilitation (IRF) facility. An explanatory sequential mixed-methods study design was used by gathering data from electronic health records (from January 1, 2019 to December 31, 2019) as well as semi-structured interviews with OT practitioners in the IRF. No objective P-SADS screens were documented nor were any P-SADS-focused goals written. Minimal evidence-based P-SADS interventions were identified. Practitioners reported multi-level barriers to OT P-SADS care including limited time, pressure to prioritize physical recovery, and inadequate resources to guide practice. OT practitioner P-SADS care was inconsistent with established evidence-based practice. This research identifies gaps in comprehensive stroke recovery and informs implementation efforts to support evidence-based P-SADS care in IRFs.

The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

A Comparison of Acute Ischemic Stroke Patients Discharged to Inpatient Rehabilitation vs a Skilled Nursing Facility: The Paul Coverdell National Acute Stroke Program

OBJECTIVE

To compare the sociodemographic, clinical, and hospital related factors associated with discharge of acute ischemic stroke (AIS) survivors to inpatient rehabilitation (IRF) and skilled nursing facility (SNF) rehabilitation services.

DESIGN

Retrospective descriptive study from the Paul Coverdell National Acute Stroke Program (PCNASP) participating hospitals during 2016 to 2019.

SETTING

9 Participating states from PCNASP in United States.

PARTICIPANTS

130,988 patients with AIS from 569 hospitals (N=337,857).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Discharge to IRF and SNF.

RESULTS

Patients discharged to a SNF had longer length of hospital stay, more comorbidities, and higher modified Rankin scores compared with patients discharged to an IRF. Nine characteristics were associated with being less likely to be discharged to an IRF than an SNF: older age (85+ years old, adjusted odds ratio [AOR]=0.20 [confidence interval [CI]=0.18-0.21]), identifying as non-Hispanic Black (AOR=0.85 [CI=0.81-0.89]), identifying as Hispanic (AOR=0.80 [CI=0.74-0.87]), having Medicaid or Medicare (AOR=0.73 [CI=0.70-0.77]), being able to ambulate with assistance from another person (AOR=0.93 [CI=0.89-0.97]), being unable to ambulate (AOR=0.73 [CI=0.62-0.87]) and having comorbidities, prior stroke (AOR=0.69 [CI=0.66-0.73]), diabetes (AOR=0.85 [CI=0.82-0.88]), and myocardial infraction or coronary artery disease (AOR=0.94 [CI=0.90-0.97]). Four characteristics were associated with being more likely to be discharged to an IRF than an SNF: being a man (AOR=1.20 [CI=1.16-1.24]), and having a slight disability (Rankin Score 2) (AOR=1.41 [CI=1.29-1.54]), being at larger hospitals (200-399 beds: AOR=1.31 [CI=1.23-1.40]; 400+ beds: AOR=1.29 [CI=1.20-1.38]), and being at a hospital with stroke unit (AOR=1.12 [CI=1.07-1.17]).

CONCLUSION

This study found differences in demographic, clinical, and hospital characteristics of AIS patients discharged for rehabilitation to an IRF vs SNF. The characteristics of patients receiving rehabilitation services may be helpful for researchers and hospitals making policies related to stroke discharge and practices that optimize patient outcomes. Populations experiencing inequities in access to rehabilitation services should be identified, and those who qualify for rehabilitation in IRF should receive this care in preference to rehabilitation in SNF.

Is the Activity Measure for Postacute Care "6-Clicks" Tool Associated With Discharge Destination Postacute Stroke?

Objective

To investigate the association of poststroke physical function, measured within 24 hours prior to discharge from the acute care hospital using Activity Measure for Postacute Care (AM-PAC) Inpatient "6-Clicks" scores and discharge destination (home vs facility and inpatient rehabilitation facility [IRF] vs skilled nursing facility [SNF]).

Design

Retrospective cross-sectional cohort study.

Setting

Acute care, University Hospital.

Participants

Individuals post acute ischemic stroke, N=721, 51.3% male, mean age 63.6±16.4 years.

Interventions

Not applicable.

Main Outcome Measures

AM-PAC "6-Clicks" 3 domains: basic mobility, daily activity, and applied cognition.

Results

AM-PAC basic mobility and daily activity were significant predictors of discharge. Those in the home discharge group had AM-PAC basic mobility mean t scale score of 48.5 compared with a score of 34.8 for individuals sent to a facility and daily activity score of 47.2 compared with 32.7 for individuals sent to a facility. The AM-PAC variables accounted for an additional 24% of the variance in the discharge destination, with basic mobility and daily activity accounting for most of the variance.The AM-PAC scores were not statistically different and were not able to discriminate between placement in an IRF vs SNF. The mean basic mobility t scale score for individuals going to an IRF was 34.9 compared with 34.6 for those going to an SNF. The daily activity score for IRF was 32.8 compared with 32.6 for SNF. The AM-PAC accounted for no additional variance in discharge destination to an IRF or SNF.

Conclusions

The AM-PAC Inpatient "6-Clicks" 3 domains are able to distinguish individuals with stroke being discharged to home from postacute care (PAC) but not for differentiating between PAC facilities (IRF vs SNF) in this cohort of individuals post stroke.

Emulating Three Clinical Trials that Compare Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities

OBJECTIVE

To inform the design of a potential future randomized controlled trial, we emulated three trials where patient-level outcomes were compared following stroke rehabilitation at Inpatient Rehabilitation Facilities (IRFs) to Skilled Nursing Facilities (SNFs).

DESIGN

Trials were emulated using a 1:1 matched propensity score analysis. The three trials differed as facilities from rehabilitation networks with different case-volumes were compared. Rehabilitation network case-volumes were based on the number of stroke patients that each hospital discharged to each specific IRF or SNF. Trial 1 included 60,529 patients from all networks, trial 2 included 34,444 patients from networks with medium- and large case-volumes (i.e., ≥5 patients), trial 3 included 19,161 patients from networks with large case-volumes (i.e., ≥10 patients). E-values were calculated to estimate the minimum strength that an unmeasured confounder would need to be to nullify the results.

SETTING

A national sample of IRFs and SNFs from across the United States.

PARTICIPANTS

Acute Fee-for-service Medicare stroke patients who received IRF or SNF based rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

1-year successful community discharge (home for >30 consecutive days) and all-cause mortality.

RESULTS

Overall, 29,500, 15,156, and 7,450 patients were matched for trials 1, 2 and 3. For 1-year successful community discharge, absolute risk differences for IRF patients were 0.21 (95% CI: 0.20, 0.22), 0.17 (95% CI: 0.16, 0.19), and 0.12 (95% CI: 0.10, 0.14) in trials 1, 2 and 3, respectively. For 1-year all-cause mortality, corresponding risk differences were -0.11 (95% CI: -0.12, -0.11), -0.11 (95% CI: -0.12, -0.09), and -0.08 (95% CI: -0.10, -0.06). E-values indicated that a moderately sized unmeasured confounder, with a relative risk of 1.6 to 2.0 would nullify differences in successful community discharge.

CONCLUSION(S)

IRF patients had superior outcomes, but differences were attenuated when IRFs and SNFs from larger rehabilitation networks were compared. The vulnerability of the findings to unmeasured confounding supports the need for an RCT.

Effects of Systemic Rehabilitation Nursing Combined with WeChat Publicity and Education on the Early Cognitive Function and Living Quality of the Patients with Cerebral Arterial Thrombosis

Objective

To investigate the effects of systemic rehabilitation nursing combined with WeChat publicity and education on the early cognitive function and living quality of the patients with cerebral arterial thrombosis.

Methods

Ninety-two patients with cerebral arterial thrombosis treated in our hospital (January 2019–January 2021) were selected as the research objects and equably divided into control group and study group according to their nursing model, with 46 patients in each group. The control group received routine nursing, while the study group received systemic rehabilitation nursing combined with WeChat publicity and education based on the routine nursing. The early cognitive functions, living quality, and other observation indexes of the two groups after nursing were compared, and the intervention effects were evaluated.

Results

No statistical difference in the general data was observed between the two groups (P > 0.05). The NIHSS (National Institutes of Health Stroke Scale) scores, Fugl-Meyer scores, and MoCA (Montreal Cognitive Assessment) scores of the two groups after nursing were all better than those before nursing, and the NIHSS score, Fugl-Meyer score, and MoCA score of the study group after nursing were better than those of the control group (P < 0.05). Compared with the control group, the study group had a remarkably higher excellent and good rate of daily living ability after nursing (P < 0.05) and prominently higher SIS (Sensory Index Score) after nursing (P < 0.05). The SIS included the scores of emotion, strength, ADL (activities of daily living), memory and thinking, hand function, communication and participation as well as the total score.

Conclusion

The systemic rehabilitation nursing combined with WeChat publicity and education can effectively reduce the degree of neurological deficit of the patients with cerebral arterial thrombosis, improve their early cognitive function and motor function, and increase their daily living ability and prognostic living quality.

Intervention Effect of Rapid Rehabilitation Nursing Combined with Continuous Nursing after Discharge on Patients with Cerebral Infarction in Recovery Period and the Changes in Motor Function, Mental State, and Quality of Life

OBJECTIVE

To explore the effect of rapid rehabilitation nursing combined with continuous nursing after discharge on patients with cerebral infarction (CI) in recovery period and its influence on motor function, mental state, and quality of life.

METHODS

From January 2018 to December 2020, 136 patients with CI in recovery period were selected and randomly divided into control group (n = 68) and observation group (n = 68). The control group was given routine nursing, and the observation group was given rapid rehabilitation nursing combined with continuous nursing after discharge. The general clinical data of the two groups were recorded, and the nursing efficiency, modified Barthel index scale (MBI), stroke patients motor assessment scale (MAS), self-rating anxiety and depression scale (SAS and SDS), and quality of life assessment scale (QLI) were compared between the two groups.

RESULTS

The nursing effective rate of the observation group (94.12%, 64/68) was higher than that of the control group (82.35%, 56/68) (P < 0.05). The MBI score, MAS score, and QLI score in the observation group were higher than those in the control group, while the SAS and SDS scores in the observation group were lower than those in the control group (P < 0.05).

CONCLUSION

Rapid rehabilitation nursing combined with continuous nursing after discharge can promote the rapid recovery of patients with CI in recovery period, which can improve the patient's motor function, reduce unhealthy psychology, and improve the quality of life.

Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities

In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.

Growth of Physicians and Nurse Practitioners Practicing Full Time in Nursing Homes

OBJECTIVES

The objective was to describe the growth of physicians, nurse practitioners (NPs), and physician assistants (PAs) who practice full time in nursing homes, to assess resident and nursing home characteristics associated with receiving care from full-time providers, and describe variation among nursing homes in use of full-time providers.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A 20% national sample Medicare data on long-term care residents in 2008 to 2018 and the physicians, NPs, and PAs who submitted charges to Medicare for their care.

METHODS

We measured the percentage of provider charges for services rendered in nursing homes, in addition to resident and facility characteristics.

RESULTS

Full-time nursing home providers increased from 26.0% of all nursing home providers in 2008 to 44.6% in 2017. The largest increase was in NPs: from 1986 in 2008 to 4479 in 2017. Resident age, sex, Medicaid eligibility, and race/ethnicity had minimal association with the odds of having a full-time provider, whereas residents with an NP primary care provider were 23.0 times more likely (95% confidence interval = 21.6, 24.6) to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.6% in 2008 to 62.5% in 2018. There was large variation among facilities in the percentage of residents with full-time providers, from 5.72% of residents with full-time providers in the bottom quintile of facilities to 91.44% in the top quintile. Individual nursing homes accounted for 59% of the variation in whether a resident had a full-time provider.

CONCLUSIONS AND IMPLICATIONS

The percentage of nursing home residents with full-time providers continues to grow, with very large variation among nursing homes.

Post-acute care use patterns among Hospital Service Areas by older adults in the United States: a cross-sectional study

BACKGROUND

Despite the success of stroke rehabilitation services, differences in service utilization exist. Some patients with stroke may travel across regions to receive necessary care prescribed by their physician. It is unknown how availability and combinations of post-acute care facilities in local healthcare markets influence use patterns. We present the distribution of skilled nursing, inpatient rehabilitation, and long-term care hospital services across Hospital Service Areas among a national stroke cohort, and we describe drivers of post-acute care service use.

METHODS

We extracted data from 2013 to 2014 of a national stroke cohort using Medicare beneficiaries (174,498 total records across 3232 Hospital Service Areas). Patients' ZIP code of residence was linked to the facility ZIP code where care was received. If the patient did not live in the Hospital Service Area where they received care, they were considered a "traveler". We performed multivariable logistic regression to regress traveling status on the care combinations available where the patient lived.

RESULTS

Although 73.4% of all Hospital Service Areas were skilled nursing-only, only 23.5% of all patients received care in skilled nursing-only Hospital Service Areas; 40.8% of all patients received care in Hospital Service Areas with only inpatient rehabilitation and skilled nursing, which represented only 18.2% of all Hospital Service Areas. Thirty-five percent of patients traveled to a different Hospital Service Area from where they lived. Regarding "travelers," for those living in a skilled nursing-only Hospital Service Area, 49.9% traveled for care to Hospital Service Areas with only inpatient rehabilitation and skilled nursing. Patients living in skilled nursing-only Hospital Service Areas had more than five times higher odds of traveling compared to those living in Hospital Service Areas with all three facilities.

CONCLUSIONS

Geographically, the vast majority of Hospital Service Areas in the United States that provided rehabilitation services for stroke survivors were skilled nursing-only. However, only about one-third lived in skilled nursing-only Hospital Service Areas; over 35% traveled to receive care. Geographic variation exists in post-acute care; this study provides a foundation to better quantify its drivers. This study presents previously undescribed drivers of variation in post-acute care service utilization among Medicare beneficiaries-the "traveler effect".