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Manchi MR, Venkatachalam AM, Atem FD, Stone S, Mathews AA, Abraham AM, Chavez AA, Welch BG, Ifejika NL. Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients. J Stroke Cerebrovasc Dis 2023; 32:107109. [PMID: 37031503 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 04/11/2023] Open
Abstract
OBJECTIVE To determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients. MATERIALS AND METHODS This prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days. RESULTS Among 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05). CONCLUSIONS In ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.
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Affiliation(s)
- Maunica R Manchi
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | | | - Folefac D Atem
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States
| | - Suzanne Stone
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Amy A Mathews
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | - Annie M Abraham
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | - Audrie A Chavez
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States
| | - Babu G Welch
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Stop 9055, Dallas, TX 75390, United States; Department of Neurology, University of Texas Southwestern Medical Center, DALLAS, TX, United States.
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van der Vet PCR, Kusen JQ, Rohner-Spengler M, Link BC, Verleisdonk EJMM, Knobe M, Henzen C, Schmid L, Babst R, Beeres FJP. The Quality of Life, Patient Satisfaction and Rehabilitation in Patients With a Low Energy Fracture-Part III of an Observational Study. Geriatr Orthop Surg Rehabil 2021; 12:21514593211046407. [PMID: 34868722 PMCID: PMC8642119 DOI: 10.1177/21514593211046407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 07/29/2021] [Accepted: 08/17/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Due to the aging population the incidence of Low Energy Fractures (LEF) increases. LEF have high mortality and morbidity rates and often cause elderly to lose independence. Patient-reported outcomes, such as Quality of Life (QoL) and patient satisfaction (PS) are needed to evaluate treatment, estimate cost-benefit analyses, and to improve clinical decision-making and patient-centered care. Objective The primary goal was to evaluate QoL and PS in patients with LEF, and to compare QoL scores to the community dwelling population. Second, we observed the amount and type of physiotherapy (PT) sessions the patients conducted. Methods A single-center cohort study was conducted in Switzerland. Patients between 50 and 85 years, who were treated in the hospital for LEF, were followed 1 year after initial fracture. Data on QoL were obtained through the Euroqol-5-Dimension questionnaire-3-Level (EQ-5D-3L) and the EQ VAS (visual analog scale). PS was measured by a VAS on satisfaction with treatment outcome. Data on PT sessions, mobility and use of analgesics were collected by telephone interviews and written surveys. Results were compared between the different fracture locations and subgroup analyses were performed for age categories. Results 411 patients were included for analysis. The median scores of the EQ-5D-3L index-VAS and PS were 0.90 (0.75-1.0), 90 (71.3-95) and 100 (90-100). Significant differences in all scores were found between fracture location (P < .05), with hip fracture patients and patients with a malleolar fracture scoring lowest in all measures. QoL index in hip fracture patients was 0.76 (0.70-1.00), QoL VAS 80 (70-90), and PS 95 (80-100). Median amount of PT sessions in all patients was 18 (9-27) and a significant difference was found between fracture locations. Patients with a fracture of the humerus received the highest amount of PT sessions 27 (18-36), hip fracture patients had a median of 18 (9-27) sessions. Conclusion At follow-up, QoL throughout all patients with a LEF was comparable to a normal population. Remarkably, though hip fracture patients seem to suffer from a clinically relevant loss of QoL, they received fewer PT sessions and performed fewer long-lasting home training than patients with a humerus fracture. Intensive, progressive rehabilitation with a high frequency of supervised training is recommended after hip fracture. The low frequency of PT sessions found in this study is unsatisfying. In hip fracture patients and in patients with a malleolar fracture, especially when aged over 75 years, more efforts are required to improve rehabilitation and subsequently QoL.
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Affiliation(s)
- Puck C R van der Vet
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Jip Q Kusen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Bjoern-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Egbert-Jan M M Verleisdonk
- Department of Orthopaedic and Trauma Surgery, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, The Netherlands
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Christoph Henzen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Lukas Schmid
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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3
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Stein J, Rodstein BM, Levine SR, Cheung K, Sicklick A, Silver B, Hedeman R, Egan A, Borg-Jensen P, Magdon-Ismail Z. Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study. Stroke 2021; 53:947-955. [PMID: 34706561 DOI: 10.1161/strokeaha.121.034815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients. METHODS We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies. RESULTS In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%). CONCLUSIONS This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.
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Affiliation(s)
- Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, NY (J.S.).,Department of Rehabilitation Medicine, Weill Cornell Medical College, NY (J.S.).,NewYork-Presbyterian Hospital, NY (J.S.)
| | - Barry M Rodstein
- University of Massachusetts Medical School-Baystate Health, Springfield (B.M.R.)
| | - Steven R Levine
- Departments of Neurology and Emergency Medicine, and Stroke Center, SUNY Downstate Health Sciences University, Brooklyn, NY (S.R.L.).,Department of Neurology, Kings County Hospital Center, Brooklyn, NY (S.R.L.).,Jaffe Stroke Center and Department of Neurology, Maimonides Medical Center, Brooklyn, NY (S.R.L.)
| | - Ken Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, NY (K.C.)
| | | | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester (B.S.)
| | | | - Abigail Egan
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.)
| | - Pamela Borg-Jensen
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.)
| | - Zainab Magdon-Ismail
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.).,Capital District Physician's Health Plan, Albany NY (Z.M.-I.)
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Jordan N, Deutsch A. Why and How to Demonstrate the Value of Rehabilitation Services. Arch Phys Med Rehabil 2021; 103:S172-S177. [PMID: 34407445 DOI: 10.1016/j.apmr.2021.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/29/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
Abstract
The health care delivery landscape in the United States is changing as payment models consider both costs and health outcomes, which are key components of value in health care. Without evidence about the effectiveness and costs of rehabilitation interventions, it is difficult to judge the value of rehabilitation interventions. Understanding the short- and long-term costs associated with implementing a rehabilitation intervention and the intervention's cost-effectiveness compared with other alternatives is critical to supporting decision-making by policymakers, health care administrators, and other decision makers. This article describes the policy context for considering the costs and outcomes of postacute care and rehabilitation interventions, introduces methods for assessing the value of rehabilitation interventions, and summarizes the challenges and opportunities associated with applying value measurement to rehabilitation services. Assessing the value of rehabilitation interventions is critical as we continue to identify, implement, and sustain evidence-based interventions that promote the health and function of people with disabilities.
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Affiliation(s)
- Neil Jordan
- Northwestern University Feinberg School of Medicine, Chicago, IL; Edward J Hines Jr Hospital VA, Hines, IL.
| | - Anne Deutsch
- Northwestern University Feinberg School of Medicine, Chicago, IL; Shirley Ryan AbilityLab, Chicago, IL; RTI International, Chicago, IL
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5
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Ifejika NL, Vahidy FS, Reeves M, Xian Y, Liang L, Matsouaka R, Fonarow GC, Grotta JC. Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage. J Am Heart Assoc 2021; 10:e020528. [PMID: 34387132 PMCID: PMC8475024 DOI: 10.1161/jaha.120.020528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals. Conclusions The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.
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Affiliation(s)
- Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation UT Southwestern Medical Center Dallas TX.,Department of Neurology UT Southwestern Medical Center Dallas TX.,Department of Population and Data Sciences UT Southwestern Medical Center Dallas TX
| | - Farhaan S Vahidy
- Centers for Outcomes Research Houston Methodist Research Institute Houston TX
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics College of Human Medicine Michigan State University Lansing MI
| | - Ying Xian
- Department of Neurology Duke University Hospital Durham NC.,Duke Clinical Research Institute Durham NC
| | - Li Liang
- Duke Clinical Research Institute Durham NC
| | | | - Gregg C Fonarow
- Division of Cardiology Ahmanson-UCLA Cardiomyopathy CenterUniversity of CaliforniaLos Angeles, Medical Center Los Angeles CA
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit Memorial Hermann Hospital-Texas Medical Center Houston TX
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Ifejika NL, Bhadane M, Cai CC, Watkins JN, Grotta JC. Characteristics of Acute Stroke Patients Readmitted to Inpatient Rehabilitation Facilities: A Cohort Study. PM R 2020; 13:479-487. [PMID: 32737961 DOI: 10.1002/pmrj.12462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Reducing acute care readmissions from inpatient rehabilitation facilities (IRFs) is a healthcare reform goal. Stroke patients have higher acute readmission rates and persistent impairments, warranting second IRF hospitalization consideration. OBJECTIVE To provide evidence-based information to justify IRF readmission for patients with post-stroke impairments. MAIN OUTCOME MEASURE Variables that increase the likelihood of a second IRF hospitalization. DESIGN Retrospective cohort study. SETTING Seven-center rehabilitation network. PARTICIPANTS Stroke patients, readmitted to acute care, who returned or did not return to an in-network IRF between 1 October 2014-31 December 2017(n = 380). INTERVENTIONS Univariable analyses (Returned/Did Not Return to IRF) described demographics, stroke type and risk factors. Between group differences in readmission causes, motor impairments and functional independence measure (FIM) scores were examined. Return to IRF logistic regression model included variables with P < .1. Odds ratio and 95% CI were calculated; Relative risk was calculated for categorical variables. P < .05 equaled statistical significance. RESULTS One hundred ninety-two stroke patients returned to IRF, 188 did not. Returned to IRF patients were younger (60.6 vs. 66 years; P < .001), sustained hemorrhagic strokes (22.4 vs. 14.2%; P = .01), had lower cardiac disease prevalence (41.7 vs. 55.3%; P = .008) or non-Medicare insurance (59.9 vs. 39.4%; P < .001). Did Not Return to IRF patients had higher admission and discharge motor and total FIM scores. Per point decrease in discharge FIM, second IRF hospitalization odds increased 4% (OR 1.04; 95% CI 1.01-1.07; P = .02). Hemorrhagic stroke patients had 33% increased odds or a 15% higher relative risk of second IRF hospitalization than patients with ischemic stroke [OR 1.33; 95% CI 1.21-1.47; RR 1.15; 95% CI 1.1-1.2; P < .001]. Non-Medicare insurance was associated with 39% increased odds or a 20% higher relative risk of second IRF hospitalization than Medicare [OR 1.39; 95% CI 1.01-1.92; RR 1.2, 95% CI 1.006-1.404; P = .04). CONCLUSIONS Hemorrhagic stroke, non-Medicare insurance or lower discharge FIM score during the first IRF hospitalization predict a second IRF stay. Further work is needed to establish the validity of within IRF stay readmission measures.
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Affiliation(s)
- Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, TX.,Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas, TX.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, Texas, TX
| | - Minal Bhadane
- Department of Optometry, University of Houston, Houston, Texas, TX
| | - Chunyan C Cai
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, Texas, TX
| | | | - James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas, TX
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Reyes BJ, Mendelson DA, Mujahid N, Mears SC, Gleason L, Mangione KK, Nana A, Mijares M, Ouslander JG. Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society. Geriatr Orthop Surg Rehabil 2020; 11:2151459320935100. [PMID: 32728485 PMCID: PMC7366407 DOI: 10.1177/2151459320935100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. METHODOLOGY A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. RESULTS/CONCLUSION A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.
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Affiliation(s)
- Bernardo J. Reyes
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | | | - Nadia Mujahid
- Warren Alpert School of Brown University, Rhode Island, USA
| | | | - Lauren Gleason
- The University of Chicago Medical and Biological Science, IL,
USA
| | | | - Arvind Nana
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | - Maria Mijares
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
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8
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van der Burg DA, Diepstraten M, Wouterse B. Long-term care use after a stroke or femoral fracture and the role of family caregivers. BMC Geriatr 2020; 20:150. [PMID: 32321439 PMCID: PMC7178980 DOI: 10.1186/s12877-020-01526-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/20/2020] [Indexed: 11/10/2022] Open
Abstract
Background There has been a shift from institutional care towards home care, and from formal to informal care to contain long-term care (LTC) costs in many countries. However, substitution to home care or informal care might be harder to achieve for some conditions than for others. Therefore, insight is needed in differences in LTC use, and the role of potential informal care givers, across specific conditions. We analyze differences in LTC use of previously independent older patients after a fracture of femur and stroke, and in particular examine to what extent having a partner and children affects LTC use for these conditions. Methods Using administrative data on Dutch previously independent older people (55+) with a fracture of femur or stroke in 2013, we investigate their LTC use in the year after the condition takes place. We use administrative treatment data to select individuals who were treated by a medical specialist for a stroke or femoral fracture in 2013. Subsequent LTC use is measured as using no formal care, home care, institutional care or being deceased at 13 consecutive four-weekly periods after initial treatment. We relate long-term care use to having a partner, having children, other personal characteristics and the living environment. Results The probability to use no formal care 1 year after the initial treatment is equally high for both conditions, but patients with a fracture are more likely to use home care, while patients with a stroke are more likely to use institutional care or have died. Having a spouse has a negative effect on home care and institutional care use, but the timing of the effect, especially for institutional care, differs strongly between the two conditions. Having children also has a negative effect on formal care use, and this effect is consistently larger for patients with a fracture than patients with a stroke. Conclusion As the condition and the effect of potential informal care givers matter for subsequent long-term care use, policy makers should take the expected prevalence of specific conditions within the older people population into account when designing long-term care policies.
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Affiliation(s)
| | - Maaike Diepstraten
- The Netherlands Bureau for Economic Policy Analysis (CPB), The Hague, The Netherlands
| | - Bram Wouterse
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000, DR, Rotterdam, The Netherlands.
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9
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Stein J, Borg-Jensen P, Sicklick A, Rodstein BM, Hedeman R, Bettger JP, Hemmitt R, Silver BM, Thode HC, Magdon-Ismail Z. Are Stroke Survivors Discharged to the Recommended Postacute Setting? Arch Phys Med Rehabil 2020; 101:1190-1198. [PMID: 32272107 DOI: 10.1016/j.apmr.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine the processes and barriers involved in providing postdischarge stroke care. DESIGN Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination. SETTING Twenty-three hospitals in the northeastern United States. PARTICIPANTS After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. INTERVENTIONS None. MAIN OUTCOME MEASURES Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. RESULTS In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). CONCLUSIONS Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.
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Affiliation(s)
- Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, New York, New York.
| | - Pamela Borg-Jensen
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
| | | | | | | | - Janet Prvu Bettger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Roseanne Hemmitt
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
| | - Brian M Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Henry C Thode
- Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Zainab Magdon-Ismail
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
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Abstract
In the United States, we are blessed with many options for postacute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports.
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Affiliation(s)
- Robert Samuel Mayer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA.
| | - Amira Noles
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA
| | - Dominique Vinh
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA
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11
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Changes in Use of Postacute Care Associated With Accountable Care Organizations in Hip Fracture, Stroke, and Pneumonia Hospitalized Cohorts. Med Care 2019; 57:444-452. [PMID: 31008898 DOI: 10.1097/mlr.0000000000001121] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine changes in more and less discretionary condition-specific postacute care use (skilled nursing, inpatient rehabilitation, home health) associated with Medicare accountable care organization (ACO) implementation. DATA SOURCES 2009-2014 Medicare fee-for-service claims. STUDY DESIGN Difference-in-difference methodology comparing postacute outcomes after hospitalization for hip fracture and stroke (where rehabilitation is fundamental to the episode of care) to pneumonia, (where it is more discretionary) for beneficiaries attributed to ACO and non-ACO providers. PRINCIPAL FINDINGS Across all 3 cohorts, in the baseline period ACO patients were more likely to receive Medicare-paid postacute care and had higher episode spending. In hip fracture patients where rehabilitation is standard of care, ACO implementation was associated with 6%-8% increases in probability of admission to a skilled nursing facility or inpatient rehabilitation (compared with home without care), and a slight reduction in readmissions. In a clinical condition where rehabilitation is more discretionary, pneumonia, ACO implementation was not associated with changes in postacute location, but episodic spending decreased 2%-3%. Spending decreases were concentrated in the least complex patients. Across all cohorts, the length of stay in skilled nursing facilities decreased with ACO implementation. CONCLUSIONS ACOs decreased spending on postacute care by decreasing use of discretionary services. ACO implementation was associated with reduced length of stay in skilled nursing facilities, while hip fracture patients used institutional postacute settings at higher rates. Among pneumonia patients, we observed decreases in spending, readmission days, and mortality associated with ACO implementation.
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Thompson LR, Ifejika NL. The Transition from the Hospital to an Inpatient Rehabilitation Setting for Neurologic Patients. Nurs Clin North Am 2019; 54:357-366. [PMID: 31331623 DOI: 10.1016/j.cnur.2019.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Transitions of care from acute hospitalization to postacute rehabilitation settings evolved as a function of cost-saving changes to the Medicare Prospective Payment System. Restricted criteria for inpatient rehabilitation facility admission limited access for patients with severe physical and cognitive deficits. Once used as a resource-intense supplement to hospital care, skilled nursing facilities have metamorphosed into rehabilitation settings with limited nursing staff, lower intensity of therapies, and decreased community discharge rates. A collaborative approach to care transitions, using acute and postacute health care providers, provides the opportunity to improve this process. Early physiatry consultation is a strategy for patients with neurologic disease.
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Affiliation(s)
| | - Nneka L Ifejika
- Physical Medicine and Rehabilitation, Neurology and Neurotherapeutics, Population and Data Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9055, USA.
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Seamon BA, Simpson KN. The Effect of Frailty on Discharge Location for Medicare Beneficiaries After Acute Stroke. Arch Phys Med Rehabil 2019; 100:1317-1323. [PMID: 30922879 DOI: 10.1016/j.apmr.2019.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To examine the effect of frailty on poststroke discharge location with respect to stroke severity and create a risk-adjusted model for understanding the effects of frailty on discharge to an inpatient rehabilitation facility. DESIGN Retrospective cohort. SETTING A 2014 5% Medicare sample. PARTICIPANTS Patients hospitalized for a first-time acute ischemic stroke (N=7258). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A prehospitalization 6-month baseline was used to calculate a frailty score. Logistic regression to predict odds of discharge to inpatient rehabilitation was used to calculate for 3 levels of baseline frailty, controlling for patient demographics, stroke severity, and comorbidities. RESULTS About 1603 patients were discharged to inpatient rehabilitation. Patients who were nonfrail (odds ratio [OR] 1.716; 95% confidence interval [95% CI], 1.463-2.013) or prefrail (OR 1.519; 95% CI, 1.296-1.779) were more likely to be discharged to inpatient rehabilitation. The final logistic regression model had a C-statistic of 0.63. Most of the patients discharged to inpatient rehabilitation were nonfrail (44.2%) and had moderate strokes (38.9%). Individuals who were frail and suffered a moderate (OR 0.78; 95% CI, 0.558-1.091) or severe stroke (OR 0.509; 95% CI, 0.358-0.721) were less likely to be discharged to an inpatient rehabilitation facility. CONCLUSIONS A lack of a claims-based measure for prestroke functional ability makes it difficult to understand discharge decision-making patterns for individuals' poststroke. Prestroke frailty was found to have a significant effect on predicating inpatient rehabilitation discharge after an acute stroke when controlling for stroke severity, comorbidities, and age. Further investigation is warranted to examine differences in rehabilitation utilization based on frailty and to quantify the effect of rehabilitation on frailty status in individuals poststroke.
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Affiliation(s)
- Bryant A Seamon
- Ralph H. Johnson VA Medical Center, Charleston, SC, the United States; Department of Health and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, the United States.
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, SC, the United States
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So C, Lage DE, Slocum CS, Zafonte RD, Schneider JC. Utility of Functional Metrics Assessed During Acute Care on Hospital Outcomes: A Systematic Review. PM R 2019; 11:522-532. [PMID: 30758920 PMCID: PMC10108704 DOI: 10.1002/pmrj.12013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/10/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Traditionally, illness severity, social factors, and comorbid conditions have been examined as predictors of hospital outcomes. However, recent research in the rehabilitation setting demonstrated that physical function outperformed comorbidity indices as a predictor of 30-day readmission. The purpose of this study was to review the literature examining the association between acute hospital physical function and various hospital outcomes and health care utilization. TYPE: Systematic review. LITERATURE SURVEY A review of the MEDLINE database was performed. Search terms included acute functional outcomes and frailty outcomes. Studies up to September 2017 were included if they were in English and examined how functional metrics collected at acute care hospitalization affected hospital outcomes. METHODOLOGY Cohort characteristics and measures of associations were extracted from the studies. Outcomes include hospital readmission, length of stay, mortality, discharge location, and physical function post acute care. The studies were assessed for potential confounders as well as selection, attrition, and detection bias. SYNTHESIS A total of 30 studies were identified (hospital readmissions: 6; discharge location: 11; length of stay: 4; mortality: 15; function: 6). Thirteen different metrics assessed function during acute care. Lower function during acute care was associated with statistically significant higher odds of hospital readmission, lower likelihood of discharge to home, longer hospital length of stay, increased mortality, and worse functional recovery when compared to patients with higher function during acute care, when adjusted for age and gender. The Barthel Index may be a useful marker for mortality in the elderly whereas the Functional Independence Measure instrument may be valuable for examining discharge location. CONCLUSIONS There is increasing evidence that function measured during acute care predicts a broad array of meaningful clinical outcomes. Further research would help direct the use of practical, yet parsimonious functional metrics that effectively screen high-need, high-cost patients to deliver optimal care. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Conan So
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,University of Maryland School of Medicine, Baltimore, MD
| | - Daniel E Lage
- Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Chloe S Slocum
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Magdon-Ismail Z, Ledneva T, Sun M, Schwamm LH, Sherman B, Qian F, Bettger JP, Xian Y, Stein J. Factors associated with 1-year mortality after discharge for acute stroke: what matters? Top Stroke Rehabil 2018; 25:576-583. [PMID: 30281414 DOI: 10.1080/10749357.2018.1499303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate factors associated with 1-year mortality after discharge for acute stroke. METHODS In this retrospective cohort study, we studied 305 patients with ischemic stroke or intracerebral hemorrhage discharged in 2010/2011. We linked Get With The Guidelines®-Stroke clinical data with New York State administrative data and used multivariate regression models to examine variables related to 1-year all-cause mortality poststroke. RESULTS The mean age was 68.6 ± 14.8 years and 51.1% were women. A total of 146 (47.9%) were discharged directly home, 96 (31.5%) to inpatient rehabilitation facilities (IRFs), and 63 (20.7%) to skilled nursing facilities (SNFs). Overall, 24 (7.9%) patients died within 1-year post-discharge. Older age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), higher National Institutes of Health Stroke Scale (NIHSS) on admission (OR 1.10, 95% CI 1.03-1.17), and discharge destination (IRF vs. home, OR 0.10, 95% CI 0.01-0.94; and SNF vs. home, OR 2.22, 95% CI 0.71-6.95) were factors associated with 1-year all-cause mortality. When ambulation status at discharge was added to the model, ambulation with assistance and non-ambulation were significantly associated with mortality (ambulatory with assistance vs. ambulatory, OR 9.42, 95% CI 1.87-47.61; nonambulatory vs. ambulatory, OR 12.65, 95% CI 1.89-84.89). CONCLUSIONS While age and NIHSS on admission are important predictors of long-term outcomes, factors at discharge - ambulation status at discharge and discharge destination - are associated with 1-year mortality post-discharge for acute stroke and therefore could represent therapeutic targets to improve long-term survival in future studies.
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Affiliation(s)
- Zainab Magdon-Ismail
- a American Heart Association/American Stroke Association, Founders Affiliate , Albany , NY.,b School of Public Health , University at Albany, State University of New York , Rensselaer , NY
| | | | - Mingzeng Sun
- c The New York State Department of Health , Albany , NY
| | - Lee H Schwamm
- d Department of Neurology , Massachusetts General Hospital , Boston , MA.,e Harvard Medical School , Boston , MA
| | - Barry Sherman
- b School of Public Health , University at Albany, State University of New York , Rensselaer , NY
| | - Feng Qian
- b School of Public Health , University at Albany, State University of New York , Rensselaer , NY
| | | | - Ying Xian
- f Duke Clinical Research Institute , Durham , NC
| | - Joel Stein
- g Department of Rehabilitation and Regenerative Medicine , Columbia University College of Physicians and Surgeons , New York , NY.,h Department of Rehabilitation Medicine , Weill Cornell Medical College , New York , NY.,i New York-Presbyterian Hospital , New York , NY
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Soley-Bori M, Soria-Saucedo R, Youn B, Haynes AB, Macht R, Ryan CM, Schneider JC, Kazis LE. Region and Insurance Plan Type Influence Discharge Disposition After Hip and Knee Arthroplasty: Evidence From the Privately Insured US Population. J Arthroplasty 2017; 32:3286-3291.e4. [PMID: 28712798 DOI: 10.1016/j.arth.2017.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/21/2017] [Accepted: 06/03/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Little is known about regional variation in the use of postacute care services after elective procedures, such as total hip or knee arthroplasty (THA/TKA), and how insurance type may influence it. The goal of this study is to assess the influence of region and insurance arrangements on discharge disposition. METHODS A representative sample of the privately insured US population with THA or TKA in 2009 or 2010 was obtained from the MarketScan database applying individual-level weights from the Medical Expenditure Panel Survey. Multivariate logistic regression was used to predict the odds of being discharged to an extended care facility (ECF) compared with being discharged home. The model adjusted for region, insurance plan type, sociodemographic characteristics, comorbidities, and length of stay. RESULTS Large variability was observed in ECF use across the US. Patients in the Northeast were 2.5 times more likely to receive care at an ECF compared with patients in the South (odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.97-3.19). Enrollees in noncapitated plans such as fee-for-service plans or exclusive provider organizations were less likely to be discharged to an ECF compared with health maintenance organizations/preferred provider organizations with capitation enrollees (OR = 0.74, 95% CI: 0.57-0.94; OR = 0.49, 95% CI: 0.34-0.74, respectively). CONCLUSION Region and private insurance plan arrangements are related to extended care use among THA and TKA patients. Understanding regional variation in discharge disposition provides policy makers with important information as to where to focus new tests of hip and knee procedures such as same day arthroplasty.
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Affiliation(s)
- Marina Soley-Bori
- Department of Health Policy and Management, Center for the Assessment of Pharmaceutical Practices (CAPP), Boston University School of Public Health, Boston, Massachusetts; Department of Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts; RTI International, Health Care Financing and Payment Program (HCFP), Waltham, Massachusetts
| | - Rene Soria-Saucedo
- Department of Health Policy and Management, Center for the Assessment of Pharmaceutical Practices (CAPP), Boston University School of Public Health, Boston, Massachusetts; Department of Pharmaceutical Outcomes and Policy, University of Florida, College of Pharmacy, Gainesville, Florida
| | - Bora Youn
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Alex B Haynes
- Ariadne Labs, Harvard School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan Macht
- Department of Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children - Boston, Boston, Massachusetts
| | - Jeffrey C Schneider
- Harvard Medical School, Boston, Massachusetts; Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Lewis E Kazis
- Department of Health Policy and Management, Center for the Assessment of Pharmaceutical Practices (CAPP), Boston University School of Public Health, Boston, Massachusetts
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Community Use of Physical and Occupational Therapy After Stroke and Risk of Hospital Readmission. Arch Phys Med Rehabil 2017; 99:26-34.e5. [PMID: 28807692 DOI: 10.1016/j.apmr.2017.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/29/2017] [Accepted: 07/18/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether receipt of therapy and number and timing of therapy visits decreased hospital readmission risk in stroke survivors discharged home. DESIGN Retrospective cohort analysis of Medicare claims (2010-2013). SETTING Acute care hospital and community. PARTICIPANTS Patients hospitalized for stroke who were discharged home and survived the first 30 days (N=23,413; mean age ± SD, 77.6±7.5y). INTERVENTIONS Physical and occupational therapist use in the home and/or outpatient setting in the first 30 days after discharge (any use, number of visits, and days to first visit). MAIN OUTCOME MEASURES Hospital readmission 30 to 60 days after discharge. Covariates included demographic characteristics, proxy variables for functional status, hospitalization characteristics, comorbidities, and prior health care use. Multivariate logistic regression analyses were conducted to examine the relation between therapist use and readmission. RESULTS During the first 30 days after discharge, 31% of patients saw a therapist in the home, 11% saw a therapist in an outpatient setting, and 59% did not see a therapist. Relative to patients who had no therapist contact, those who saw an outpatient therapist were less likely to be readmitted to the hospital (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Although the point estimates did not reach statistical significance, there was some suggestion that the greater the number of therapist visits in the home and the sooner the visits started, the lower the risk of hospital readmission. CONCLUSIONS After controlling for observable demographic-, clinical-, and health-related differences, we found that individuals who received outpatient therapy in the first 30 days after discharge home after stroke were less likely to be readmitted to the hospital in the subsequent 30 days, relative to those who received no therapy.
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Burke RE, Lawrence E, Ladebue A, Ayele R, Lippmann B, Cumbler E, Allyn R, Jones J. How Hospital Clinicians Select Patients for Skilled Nursing Facilities. J Am Geriatr Soc 2017; 65:2466-2472. [PMID: 28682456 DOI: 10.1111/jgs.14954] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a skilled nursing facility (SNF) for postacute care. DESIGN Semistructured interviews paired with a qualitative analytical approach informed by Social Constructivist theory. SETTING Inpatient care units in three hospitals. Purposive sampling was used to maximize variability in hospitals, units within hospitals, and staff on those units. PARTICIPANTS Clinicians (hospitalists, nurses, therapists, social workers, case managers) involved in evaluation and decision-making regarding postacute care (N = 25). MEASUREMENTS Central themes related to clinician evaluation and discharge decision-making. RESULTS Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNFs as a "safety net" for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in lack of a standardized evaluation process or a clear primary decision-maker. CONCLUSION Hospital clinician evaluation and decision-making about postacute care in SNFs may be characterized as rushed, without a clear system or framework for making decisions and uninformed by knowledge of SNF or patient outcomes in those discharged to SNFs. This leads to SNFs being used as a "safety net" for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of individuals transitioning between hospitals and SNFs, novel solutions for improving evaluation and decision-making are urgently needed.
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Affiliation(s)
- Robert E Burke
- Denver-Seattle Center of Innovation, Denver Veterans Affairs Medical Center, Denver, Colorado.,Hospital Medicine Section, Department of Medicine, Denver Veterans Affairs Medical Center, Denver, Colorado.,Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Emily Lawrence
- Denver-Seattle Center of Innovation, Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Amy Ladebue
- Denver-Seattle Center of Innovation, Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Roman Ayele
- Denver-Seattle Center of Innovation, Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Brandi Lippmann
- Denver-Seattle Center of Innovation, Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Ethan Cumbler
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Rebecca Allyn
- Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado
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Adair WA. 48th Walter J. Zeiter Lecture, Physiatry in the Era of Population Health Management: Why We Must Change. PM R 2017; 9:513-520. [PMID: 28284965 DOI: 10.1016/j.pmrj.2017.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/03/2017] [Indexed: 11/16/2022]
Affiliation(s)
- William A Adair
- Advocate Christ Medical Center, 4440 W. 95th St., Oak Lawn, IL 60453(∗).
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Burke RE, Cumbler E, Coleman EA, Levy C. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med 2017; 12:46-51. [PMID: 28125831 DOI: 10.1002/jhm.2673] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Nearly all practicing hospitalists have firsthand experience discharging patients to post-acute care (PAC), which is provided by inpatient rehabilitation facilities, skilled nursing facilities, or home healthcare providers. Many may not know that PAC is poised to undergo transformative change, spurred by recent legislation resulting in a range of reforms. These reforms have the potential to fundamentally reshape the relationship between hospitals and PAC providers. They have important implications for hospitalists and will open up opportunities for hospitalists to improve healthcare value. In this article, the authors explore the reasons for PAC reform and the scope of the reforms. Then they describe the implications for hospitalists and hospitalists' opportunities to Choose Wisely and improve healthcare value for the rapidly growing number of vulnerable older adults transitioning to PAC after hospital discharge.
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Affiliation(s)
- Robert E Burke
- Research Section, Denver VA Medical Center, Denver, CO, USA
- Hospital Medicine Section, Denver VA Medical Center, Denver, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ethan Cumbler
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cari Levy
- Research Section, Denver VA Medical Center, Denver, CO, USA
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA
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Acute Rehabilitation after Trauma: Does it Really Matter? J Am Coll Surg 2016; 223:755-763. [DOI: 10.1016/j.jamcollsurg.2016.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/07/2016] [Accepted: 09/07/2016] [Indexed: 11/21/2022]
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Abstract
We tested the effectiveness of a nursing intervention model to improve health, function, and return-home outcomes in elders with hip fracture via a 2-year randomized clinical trial. Thirty three elders (age > 65 years) were tracked from hospital discharge to 12 months postfracture. The treatment group had a gerontologic advanced practice nurse as postacute care coordinator for 6 months who intervened with each elder regardless of the postacute care setting, making biweekly visits and/or phone calls. The coordinator assessed health and function, and informed elders, families, long-term care staff, and physicians of the patient's progress. The control group had care based on postacute facility protocols. Nonnormal distribution of data led to nonparametric analysis using Freidman's test with post hoc comparisons (Mann—Whitney U tests, Bonferroni adjustment). The treatment group had better function at 12 months on several activities and instrumental activities of daily living, and no differences in health, depression, or living situation.
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Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 47:e98-e169. [PMID: 27145936 DOI: 10.1161/str.0000000000000098] [Citation(s) in RCA: 1519] [Impact Index Per Article: 189.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. CONCLUSIONS As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).
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Kane RL. A new long-term care manifesto. THE GERONTOLOGIST 2015; 55:296-301. [PMID: 26035606 DOI: 10.1093/geront/gnv010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 01/21/2015] [Indexed: 11/13/2022] Open
Abstract
This article argues for a fresh look at how we provide long-term care (LTC) for older persons. Essentially, LTC offers a compensatory service that responds to frailty. Policy debate around LTC centers on costs, but we are paying for something we really don't want. Building societal enthusiasm (or even support) for LTC will require re-inventing and re-branding. LTC has three basic components: personal care, housing, and health care (primarily chronic disease management). They can be delivered in a variety of settings. It is rare to find all three done well simultaneously. Personal care (PC) needs to be both competent and compassionate. Housing must provide at least minimal amenities and foster autonomy; when travel time for PC raises costs dramatically, some form of clustered housing may be needed. Health care must be proactive, aimed at preventing exacerbations of chronic disease and resultant hospitalizations. Enhancing preferences means allowing taking informed risks. Payment incentives should reward both quality of care and quality of life, but positive outcomes must be defined as slowing decline. Paying for services but not for housing under Medicaid would automatically level the playing field between nursing homes (NH) and community-based services. Regulations should achieve greater parity between NH and community care and include both positive and negative feedback. Providing post-acute care should be separate from LTC. Using the tripartite LTC framework, we can create innovative flexible approaches to providing needed services for frail older persons in formats that are both desirable and affordable. Such care will be more socially desirable and hence worth paying for.
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Affiliation(s)
- Robert L Kane
- Division of Health Management and Policy, University of Minnesota School of Public Health, Minneapolis.
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Beyond the hospital doors: Improving long-term outcomes for elderly trauma patients. J Trauma Acute Care Surg 2015; 78:837-43. [PMID: 25742250 DOI: 10.1097/ta.0000000000000567] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Elderly trauma patients (TPs) are the fastest growing trauma population, increasing the need for postacute care rehabilitation. For TP, discharge to skilled nursing facilities (SNFs) has been associated with higher 1-year mortality compared with discharge to inpatient rehabilitation facilities (IRFs) or home. The availability of IRF beds has been decreasing, but the proportion occupied by non-TPs, specifically stroke patients (SPs), has increased. We wanted to better characterize trends in trauma discharges and compare them with a population that is equally dependent on postdischarge rehabilitation. We hypothesized that discharge to SNF is rapidly increasing, while discharge to IRF is declining for trauma, but not for SPs. METHODS This is retrospective cohort study of adult trauma and SPs discharged from 2003 to 2009. The National Trauma Data Bank and National Inpatient Sample were used to study TPs and SPs, respectively. RESULTS Falls became the leading cause of injury, and the proportion of older TPs increased from 23% to 30%. Older TPs discharged to SNF increased from 30.7% in 2003 to 40.8% in 2009 (p < 0.001). TPs were 34% (adjusted relative risk [RR], 1.34; 95% confidence interval [CI], 1.15-1.57) more likely to be discharged to an SNF and 36% (adjusted RR, 0.64; 95% CI, 0.48-0.85) less likely to be discharged to an IRF. From 2003 to 2009, SPs were 78% more likely to be discharged to an IRF (adjusted RR, 1.78; 95% CI, 1.74-1.82). The largest absolute increase in SP discharges to IRFs occurred the year following implementation of the stroke center certification program. CONCLUSION For TPs, there was a significant increase in SNF discharges and a decrease in IRF discharges. During the same period, after implementation of stroke center certification, SPs were more likely to be discharged to an IRF. Future research should focus on evaluating which postacute care setting is most effective in providing rehabilitation for TPs and adjusting our discharge efforts to improve long-term outcomes. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Cary MP, Baernholdt M, Anderson RA, Merwin EI. Performance-based outcomes of inpatient rehabilitation facilities treating hip fracture patients in the United States. Arch Phys Med Rehabil 2015; 96:790-8. [PMID: 25596000 PMCID: PMC4410059 DOI: 10.1016/j.apmr.2015.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 12/17/2014] [Accepted: 01/03/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the influence of facility and aggregate patient characteristics of inpatient rehabilitation facilities (IRFs) on performance-based rehabilitation outcomes in a national sample of IRFs treating Medicare beneficiaries with hip fracture. DESIGN Secondary data analysis. SETTING U.S. Medicare-certified IRFs (N=983). PARTICIPANTS Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community. RESULTS Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P<.001] and Hispanics [P<.001], higher percentage of women [P=.030], higher motor function on admission [P<.001], longer length of stay [P<.001]) and facility characteristics (freestanding [P<.001], rural [P<.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P<.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P<.001], higher motor function on admission [P<.001]). No facility characteristics were associated with the percentage discharged to the community. CONCLUSIONS Performance-based measurement offers health policymakers, administrators, clinicians, and consumers a major opportunity for securing health system improvement by benchmarking or comparing their outcomes with those of other similar facilities. These results might serve as the basis for benchmarking and quality-based reimbursement to IRFs for 1 impairment group: hip fracture.
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Affiliation(s)
- Michael P. Cary
- Duke University, School of Nursing, Assistant Professor, DUMC 3322, 307 Trent Drive, Durham, NC 27710, , 919-613-6031
| | - Marianne Baernholdt
- Virginia Commonwealth University, School of Nursing, Professor of Nursing, P.O. Box 980567, Richmond, VA 23298, , 804-828-5175
| | - Ruth A. Anderson
- Duke University, School of Nursing, Virginia Stone Professor of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC 27710, , 919-668-4599
| | - Elizabeth I. Merwin
- Duke University, School of Nursing, Ann Henshaw Gardiner Professor of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC 27710, , 919-681-0886
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Chenoweth L, Gietzelt D, Jeon YH. Perceived Needs of Stroke Survivors from Non-English-Speaking Backgrounds and Their Family Carers. Top Stroke Rehabil 2015; 9:67-79. [PMID: 14523723 DOI: 10.1310/d392-nul6-2j35-5egm] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this article is to discuss current findings in the research literature on the experiences and needs of stroke survivors and their family carers and to provide suggestions for future research. Based on this critical review, knowledge gaps and issues in stroke management in the community indicate that the needs of people surviving a stroke, particularly people from non-English speaking backgrounds, are not being adequately met by community-based health services. There is a critical need for changes in practices to meet the needs of this specific population.
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Affiliation(s)
- Lynn Chenoweth
- Health & Ageing Research Unit, South Eastern Sydney Area Health Service, Sydney, Australia
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Stein J, Bettger JP, Sicklick A, Hedeman R, Magdon-Ismail Z, Schwamm LH. Use of a Standardized Assessment to Predict Rehabilitation Care After Acute Stroke. Arch Phys Med Rehabil 2015; 96:210-7. [DOI: 10.1016/j.apmr.2014.07.403] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 06/07/2014] [Accepted: 07/14/2014] [Indexed: 11/26/2022]
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Lewsey J, Ebueku O, Jhund PS, Gillies M, Chalmers JWT, Redpath A, Briggs A, Walters M, Langhorne P, Capewell S, McMurray JJV, MacIntyre K. Temporal trends and risk factors for readmission for infections, gastrointestinal and immobility complications after an incident hospitalisation for stroke in Scotland between 1997 and 2005. BMC Neurol 2015; 15:3. [PMID: 25591718 PMCID: PMC4320501 DOI: 10.1186/s12883-014-0257-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 12/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improvements in stroke management have led to increases in the numbers of stroke survivors over the last decade and there has been a corresponding increase of hospital readmissions after an initial stroke hospitalisation. The aim of this study was to examine the one year risk of having a readmission due to infective, gastrointestinal or immobility (IGI) complications and to identify temporal trends and any risk factors. METHODS Using a cohort of first hospitalised for stroke patients who were discharged alive, time to first event (readmission for IGI complications or death) within 1 year was analysed in a competing risks framework using cumulative incidence methods. Regression on the cumulative incidence function was used to model the risks of having an outcome using the covariates age, sex, socioeconomic status, comorbidity, discharge destination and length of hospital stay. RESULTS There were a total of 51,182 patients discharged alive after an incident stroke hospitalisation in Scotland between 1997-2005, and 7,747 (15.1%) were readmitted for IGI complications within a year of the discharge. Comparing incident stroke hospitalisations in 2005 with 1997, the adjusted risk of IGI readmission did not increase (HR = 1.00 95% CI (0.90, 1.11). However, there was a higher risk of IGI readmission with increasing levels of deprivation (most deprived fifth vs. least deprived fifth HR = 1.16 (1.08, 1.26). CONCLUSIONS Approximately 15 in 100 patients discharged alive after an incident hospitalisation for stroke in Scotland between 1997 and 2005 went on to have an IGI readmission within one year. The proportion of readmissions did not change over the study period but those living in deprived areas had an increased risk.
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Affiliation(s)
- James Lewsey
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Osaretin Ebueku
- Public Health, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Michelle Gillies
- Public Health, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Jim W T Chalmers
- Information Services Division, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9 EB, UK.
| | - Adam Redpath
- Information Services Division, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9 EB, UK.
| | - Andrew Briggs
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Gardiner Institute, Western Infirmary, Glasgow, G11 6NT, UK.
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Gardiner Institute, Western Infirmary, Glasgow, G11 6NT, UK.
| | - Simon Capewell
- Public Health, University of Liverpool, Whelan Building, Quadrangle, Liverpool, L69 3GB, UK.
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Kate MacIntyre
- School of Medicine, University of Tasmania, 17 Liverpool Street, Hobart, Australia.
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Maciejewski ML, Radcliff TA, Henderson WG, Cowper Ripley D, Vogel WB, Regan E, Hutt E. Determinants of postsurgical discharge setting for male hip fracture patients. ACTA ACUST UNITED AC 2014; 50:1267-76. [PMID: 24458966 DOI: 10.1682/jrrd.2013.02.0041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/24/2013] [Indexed: 11/05/2022]
Abstract
Veterans hospitalized for hip fracture repair may be discharged to one of several rehabilitation settings, but it is not known what factors influence postsurgical discharge setting. The purpose of the study was to examine the patient, facility, and market factors that influence the choice of postsurgical discharge setting. Using a retrospective cohort design, we linked 11,083 veterans who had hip fracture surgeries in a Department of Veterans Affairs (VA) hospital from 1998 to 2005 as assessed by the VA National Surgical Quality Improvement Program dataset with administrative data. The factors associated with five postdischarge settings were analyzed using multinomial logistic regression. We found that few veterans (0.8%) hospitalized for hip fracture were discharged with home health. Higher proportions of veterans were discharged to a nursing home (15.4%), to outpatient rehabilitation (18.8%), to inpatient rehabilitation (16.9%), or to home (48.2%). Patients were more likely to be discharged to nonhome settings for VA-provided rehabilitation if they had total function dependence, had American Society of Anesthesiologists class 4 or 5, had surgical complications prior to discharge, or lived in counties with lower nursing home bed occupancy rates. Future research should compare postsurgical and longer-term morbidity, mortality, and healthcare utilization across these rehabilitation settings.
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Affiliation(s)
- Matthew L Maciejewski
- Center for Health Services Research in Primary Care (152), Durham VA Medical Center, 508 Fulton St, Durham, NC 27705.
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Activities of daily living in nursing home and home care settings: a retrospective 1-year cohort study. J Am Med Dir Assoc 2014; 16:114-9. [PMID: 25244958 DOI: 10.1016/j.jamda.2014.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/15/2014] [Accepted: 07/22/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Korea introduced universal long-term care insurance (LTCI) for physically dependent older adults in 2008. Older adults, their family members, and policy makers in Korea want to know patient outcomes in different care modalities because older adults who have a similar functional status and LTC needs can choose either nursing home care or home care. The aim of this study was to compare activities of daily living (ADLs) in nursing home care and home care settings for physically dependent older adults in Korea. DESIGN A retrospective 1-year cohort study using national LTCI data. SETTINGS This study used the LTCI dataset from the National Health Insurance Service in Korea. PARTICIPANTS Participants were identified from among those in the LTCI dataset who enrolled from July 2008 to June 2010. We extracted a sample consisting of 22,557 older adults who consistently received either nursing home care (n = 11,678) or home care (n = 10,879) for 1 year. MEASUREMENTS The outcome variable was change in ADLs after 1 year. Covariates were an older adult's home geographical region, LTC level, age, sex, primary caregiver, Medicaid beneficiary status, bedridden status, medical diagnosis, baseline ADLs, cognitive function, behavioral problems, nursing and special treatment, and rehabilitation needs. Multiple regression analysis of all participants unmatched and a paired t-test with a propensity-score-matched cohort were performed to explain the association of changes in ADLs with the types of LTC. RESULTS Multiple regression analysis with all participants (n = 22,557) unmatched showed that compared with older adults who received home care, those who received nursing home care had deteriorated further in terms of ADLs after 1 year (β = 0.44108, P < .0001). After propensity-score matching, paired t-test analysis also found that the ADLs of older adults had deteriorated less in the home care group compared with the nursing home group after 1 year (P < .0001). CONCLUSIONS The ADLs of older adults who received home care showed significantly less deterioration than those of the older adults in nursing home care after 1 year. The ADLs of older adults could differ according to the type of LTC they receive, and home care could result in better maintenance of ADLs than nursing home care.
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Belagaje SR, Zander K, Thackeray L, Gupta R. Disposition to home or acute rehabilitation is associated with a favorable clinical outcome in the SENTIS trial. J Neurointerv Surg 2014; 7:322-5. [DOI: 10.1136/neurintsurg-2014-011132] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 03/13/2014] [Indexed: 11/03/2022]
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Mallinson T, Deutsch A, Bateman J, Tseng HY, Manheim L, Almagor O, Heinemann AW. Comparison of Discharge Functional Status After Rehabilitation in Skilled Nursing, Home Health, and Medical Rehabilitation Settings for Patients After Hip Fracture Repair. Arch Phys Med Rehabil 2014; 95:209-17. [DOI: 10.1016/j.apmr.2013.05.031] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/24/2013] [Accepted: 05/24/2013] [Indexed: 11/29/2022]
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Katzan IL, Spertus J, Bettger JP, Bravata DM, Reeves MJ, Smith EE, Bushnell C, Higashida RT, Hinchey JA, Holloway RG, Howard G, King RB, Krumholz HM, Lutz BJ, Yeh RW. Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:918-44. [PMID: 24457296 DOI: 10.1161/01.str.0000441948.35804.77] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research. METHODS AND RESULTS This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care. CONCLUSIONS There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.
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Belagaje SR, Sun CHJ, Nogueira RG, Glenn BA, Wuermser LA, Patel V, Frankel MR, Anderson AM, Thomas TT, Horn CM, Gupta R. Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis. J Neurointerv Surg 2014; 7:99-103. [DOI: 10.1136/neurintsurg-2013-011045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Predictive factors for patients discharged after participating in a post-acute care program. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.jcgg.2011.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Hakkennes SJ, Brock K, Hill KD. Selection for Inpatient Rehabilitation After Acute Stroke: A Systematic Review of the Literature. Arch Phys Med Rehabil 2011; 92:2057-70. [DOI: 10.1016/j.apmr.2011.07.189] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 07/03/2011] [Accepted: 07/12/2011] [Indexed: 01/04/2023]
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Dossa A, Glickman ME, Berlowitz D. Association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation. BMC Health Serv Res 2011; 11:311. [PMID: 22085779 PMCID: PMC3280187 DOI: 10.1186/1472-6963-11-311] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Accepted: 11/15/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Limited evidence exists regarding the association of pre-existing mental health conditions in patients with stroke and stroke outcomes such as rehospitalization, mortality, and function. We examined the association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation. METHODS Our observational study used the 2001 VA Integrated Stroke Outcomes database of 2162 patients with stroke who underwent rehabilitation at a Veterans Affairs Medical Center. Separate models were fit to our outcome measures that included 6-month rehospitalization or death, 6-month mortality post-discharge, and functional outcomes post inpatient rehabilitation as a function of number and type of mental health conditions. The models controlled for patient socio-demographics, length of stay, functional status, and rehabilitation setting. RESULTS Patients had an average age of 68 years. Patients with stroke and two or more mental health conditions were more likely to be readmitted or die compared to patients with no conditions (OR: 1.44, p = 0.04). Depression and anxiety were associated with a greater likelihood of rehospitalization or death (OR: 1.33, p = 0.04; OR:1.47, p = 0.03). Patients with anxiety were more likely to die at six months (OR: 2.49, p = 0.001). CONCLUSIONS Patients with stroke with pre-existing mental health conditions may need additional psychotherapy interventions, which may potentially improve stroke outcomes post-hospitalization.
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Affiliation(s)
- Almas Dossa
- Center for Health Quality, Outcomes, and Economic Research, ENRM VA Hospital, Bedford, MA, USA.
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Lichtman JH, Leifheit-Limson EC, Jones SB, Watanabe E, Bernheim SM, Phipps MS, Bhat KR, Savage SV, Goldstein LB. Predictors of hospital readmission after stroke: a systematic review. Stroke 2010; 41:2525-33. [PMID: 20930150 DOI: 10.1161/strokeaha.110.599159] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Risk-standardized hospital readmission rates are used as publicly reported measures reflecting quality of care. Valid risk-standardized models adjust for differences in patient-level factors across hospitals. We conducted a systematic review of peer-reviewed literature to identify models that compare hospital-level poststroke readmission rates, evaluate patient-level risk scores predicting readmission, or describe patient and process-of-care predictors of readmission after stroke. METHODS Relevant studies in English published from January 1989 to July 2010 were identified using MEDLINE, PubMed, Scopus, PsycINFO, and all Ovid Evidence-Based Medicine Reviews. Authors of eligible publications reported readmission within 1 year after stroke hospitalization and identified ≥ 1 predictors of readmission in risk-adjusted statistical models. Publications were excluded if they lacked primary data or quantitative outcomes, reported only composite outcomes, or had < 100 patients. RESULTS Of 374 identified publications, 16 met the inclusion criteria for this review. No model was specifically designed to compare risk-adjusted readmission rates at the hospital level or calculate scores predicting a patient's risk of readmission. The studies providing multivariable models of patient-level and/or process-of-care factors associated with readmission varied in stroke definitions, data sources, outcomes (all-cause and/or stroke-related readmission), durations of follow-up, and model covariates. Few characteristics were consistently associated with readmission. CONCLUSIONS This review identified no risk-standardized models for comparing hospital readmission performance or predicting readmission risk after stroke. Patient-level and system-level factors associated with readmission were inconsistent across studies. The current literature provides little guidance for the development of risk-standardized models suitable for the public reporting of hospital-level stroke readmission performance.
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Abstract
BACKGROUND Elderly patients who leave an acute care hospital after a stroke or a hip fracture may be discharged home, or undergo postacute rehabilitative care in an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Because 15% of Medicare expenditures are for these types of postacute care, it is important to understand their relative costs and the health outcomes they produce. OBJECTIVE To assess Medicare payments for and outcomes of patients discharged from acute care to an IRF, a SNF, or home after an inpatient diagnosis of stroke or hip fracture between January 2002 and June 2003. RESEARCH DESIGN This is an observational study based on Medicare administrative data. We adjust for observable differences in patient severity across postacute care sites, and we use instrumental variables estimation to account for unobserved patient selection. STUDY OUTCOMES Mortality, return to community residence, and total Medicare postacute payments by 120 days after acute care discharge. RESULTS Relative to discharge home, IRFs improve health outcomes for hip fracture patients. SNFs reduce mortality for hip fracture patients, but increase rates of institutionalization for stroke patients. Both sites of care are far more expensive than discharge to home. CONCLUSIONS When there is a choice between IRF and SNF care for stroke and hip fracture patients, the marginal patient is better off going to an IRF for postacute care. However, given the marginal cost of an IRF stay compared with returning home, the gains to these patients should be considered in light of the additional costs.
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Chang NT, Chi LY, Yang NP, Chou P. The Impact of Falls and Fear of Falling on Health-Related Quality of Life in Taiwanese Elderly. J Community Health Nurs 2010; 27:84-95. [DOI: 10.1080/07370011003704958] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kind AJH, Smith MA, Liou JI, Pandhi N, Frytak JR, Finch MD. Discharge destination's effect on bounce-back risk in Black, White, and Hispanic acute ischemic stroke patients. Arch Phys Med Rehabil 2010; 91:189-95. [PMID: 20159120 DOI: 10.1016/j.apmr.2009.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 09/24/2009] [Accepted: 10/20/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30 d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. DESIGN Retrospective analysis of administrative data. SETTING Four hundred twenty-two hospitals, southern/eastern United States. PARTICIPANTS All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. RESULTS Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. CONCLUSIONS Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.
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Affiliation(s)
- Amy J H Kind
- Department of Medicine-Geriatrics Section, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA.
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Penrod JD, Goldstein NE, Deb P. When and how to use instrumental variables in palliative care research. J Palliat Med 2009; 12:471-4. [PMID: 19416044 DOI: 10.1089/jpm.2009.9631] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joan D Penrod
- Center for Research on Health Care Across Site and Systems of Care, John J. Peters VA Medical Center, Bronx, New York 10468, USA.
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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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Cecilia D, Jódar E, Fernández C, Resines C, Hawkins F. Effect of alendronate in elderly patients after low trauma hip fracture repair. Osteoporos Int 2009; 20:903-10. [PMID: 18956132 DOI: 10.1007/s00198-008-0767-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 09/22/2008] [Indexed: 10/21/2022]
Abstract
SUMMARY One year of once weekly alendronate, when given shortly after the surgical repair of a hip fracture, produces reductions in bone markers and increases proximal femoral bone density. The therapy was well tolerated. INTRODUCTION Hip fracture is the most devastating type of osteoporotic fracture and increases notably the risk of subsequent fractures. The aim of this paper was to evaluate the effects of 1 year therapy with a weekly dose of alendronate in the bone mineral density and bone markers in elderly patients after low trauma hip fracture repair. METHODS Two hundred thirty-nine patients (81 +/- 7 years; 79.8% women) were randomized to be treated either with calcium (500 mg/daily) and vitamin D(3) (400 IU/daily; Ca-Vit D group) or with alendronate (ALN, 70 mg/week) plus calcium and vitamin D(3) (500 mg/daily and 400 IU/daily, respectively; ALN + Ca-Vit D group). RESULTS One hundred forty-seven (61.5%) patients completed the trial. Alendronate increased proximal femoral bone mineral density (BMD) in the intention-to-treat analysis (mean difference (95% confidence interval); total hip 2.57% (0.67; 4.47); trochanteric 2.96% (0.71; 5.20), intertrochanteric 2.32% (0.36; 4.29)), but the differences were not significant in the BMD of the femoral neck (0.47%; (-2.03; 2.96) and the lumbar spine (0.69%; (-0.86; 2.23)). Bone turnover markers decreased during alendronate treatment. CONCLUSION The present study demonstrates for the first time the anti-resorptive efficacy of alendronate given immediately after surgical repair in an elderly population with recent hip fracture. This effect should positively affect the rate of subsequent fractures.
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Affiliation(s)
- D Cecilia
- Traumatology and Orthopedic Surgery, University Hospital 12 de Octubre, Avda de Andalucía km 5.4, Madrid 28041, Spain.
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Buntin MB, Colla CH, Escarce JJ. Effects of payment changes on trends in post-acute care. Health Serv Res 2009; 44:1188-210. [PMID: 19490159 DOI: 10.1111/j.1475-6773.2009.00968.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. DATA SOURCES Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. STUDY DESIGN We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. DATA EXTRACTION METHODS A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. PRINCIPAL FINDINGS Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. CONCLUSIONS Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.
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Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly. Arch Phys Med Rehabil 2009; 90:246-62. [PMID: 19236978 DOI: 10.1016/j.apmr.2008.06.036] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 06/02/2008] [Accepted: 06/05/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To address the need for a research synthesis on the effectiveness of the full range of hip fracture rehabilitation interventions for older adults and make evidence based conclusions. DATA SOURCES Medline, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched from 1980 to 2007 for studies published in English. The terms rehabilitation and hip fracture were exploded in order to obtain related search terms and categories. STUDY SELECTION In the initial search of the databases, a combined total of 1031 articles was identified. Studies that did not focus on hip fracture rehabilitation, did not include persons over the age of 50 years, and/or did not include measures of physical outcome were excluded. DATA EXTRACTION Only studies with an Oxford Center for Evidence-Based Medicine Levels of Evidence level of I (randomized controlled trial, RCT) or II (cohort) were reviewed. The methodologic quality of both types of studies was assessed using a modified version of the Downs and Black checklist. DATA SYNTHESIS There were 55 studies that met our selection criteria: 30 RCTs and 25 nonrandomized trials. They were distributed across 6 categories for rehabilitation intervention (care pathways, early rehabilitation, interdisciplinary care, occupational and physical therapy, exercise, intervention not specified) and 3 settings (acute care hospital, postacute care/rehabilitation, postrehabilitation). CONCLUSIONS When looking across all of the intervention types, the most frequently reported positive outcomes were associated with measures of ambulatory ability. Eleven intervention categories across 3 settings were associated with improved ambulatory outcomes. Seven intervention approaches were related to improved functional recovery, while 6 intervention approaches were related to improved strength and balance recovery. Decreased length of stay and increased falls self-efficacy were associated with 2 interventions, while 1 intervention had a positive effect on lower-extremity power generation.
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Affiliation(s)
- Anna M Chudyk
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada.
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Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D, Burant C, Covinsky KE. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc 2009; 56:2171-9. [PMID: 19093915 DOI: 10.1111/j.1532-5415.2008.02023.x] [Citation(s) in RCA: 462] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. DESIGN Observational. SETTING Tertiary care hospital, community teaching hospital. PARTICIPANTS Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998). MEASUREMENTS Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. RESULTS By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. CONCLUSION For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.
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Affiliation(s)
- Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine, School of Medicine, John Hopkins University, Baltimore, Maryland 21224, USA.
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Johanson MA, Cohen BA, Snyder KH, McKinley AJ, Scott ML. Outcomes for Aging Adults Following Total Hip Arthroplasty in an Acute Rehabilitation Facility Versus a Subacute Rehabilitation Facility: A Pilot Study. J Geriatr Phys Ther 2009. [DOI: 10.1519/00139143-200932020-00006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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