A study protocol of a randomised controlled trial incorporating a health economic analysis to investigate if additional allied health services for rehabilitation reduce length of stay without compromising patient outcomes

Mapping the Functional Independence Measure to a multi-attribute utility instrument for economic evaluations in rehabilitation: a secondary analysis of randomized controlled trial data

Purpose: To test whether the Functional Independence Measure (FIM) could be mapped to the EQ-5D-3L to give researchers a viable but "second-best" option for calculating quality-adjusted life-years (QALYs) and conducting a cost-utility analysis when only clinical outcomes have been collected.Materials and methods: Secondary analysis of repeated measures data collected during a randomized controlled trial (n = 3506 observations) at two inpatient rehabilitation centres. Participants had a mean age of 74 (SD 13) years, 63% were women and 58% were admitted with an orthopaedic diagnosis. Ordinary least-squares regression and adjusted limited dependent variable mixture models were used to estimate regression-based mappings. Performance was evaluated based on mean absolute error and the proportion of errors in excess of the minimally important difference.Results: In orthopaedic and neurological patients, high mean absolute errors (0.2 on the quality-adjusted life years scale) and a high proportion of errors (60%) in excess of the minimally important difference suggest that predicted EQ-5D-3L values provided a poor substitute for observed EQ-5D-3L values.Conclusions: Regression-based mappings from the FIM to the EQ-5D-3L are error-prone and unsuitable for calculating QALYs in rehabilitation patients. Researchers and rehabilitation professionals should therefore include a multi-attribute utility instrument such as the EQ-5D as well as the FIM to evaluate the effect of rehabilitation interventions and in rehabilitation registries. This will provide additional information on health-related quality of life and support cost-utility analyses.Implications for rehabilitationThe Functional Independence Measure (FIM) cannot be used to calculate quality-adjusted life-years (QALYs) for cost-utility analyses.Predicting QALYs from FIM data is a poor substitute for direct measurement of QALYs in orthopaedic or neurological rehabilitation populations.Multi-attribute utility instruments (MAUIs) allow direct measurement of QALYs, as well as providing a patient-reported measure of clinical quality and outcomes in rehabilitation.A MAUI should be included routinely in clinical practice by rehabilitation professionals as well as in rehabilitation trials and registries to track patient outcomes and improve clinical practice.

Satisfaction levels with physical therapy in hospitalized patients

BACKGROUND

Patient's satisfaction level is considered an indicator that interferes with interventions effectiveness. There is evidence from other health professionals that patients with higher satisfaction level recover faster. However, benefits toward physical therapy intervention is poorly known.

OBJECTIVE

To measure the inpatient satisfaction level receiving physical therapy care and to evaluate which aspects of these treatments are flawed.

METHODS

Patients admitted to hospital were evaluated using MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) that scores from 1 to 5 (higher values indicate higher satisfaction) for each item. Patients clinical and demographic characteristics and the Global Perceived Effect (GPE) were also collected. Exploratory factor analysis was conducted.

RESULTS

200 patients were evaluated (50.9±18.81 years, 58% male). Most of MRPS items were above 4. The highest scoring item (4.75) was physical therapist's respect to the patient. The lowest scoring item (1.82) was in relation to physical therapy guidelines at hospital discharge. Mean MRPS total score and GPE were 46.09±4.93 and 2.18±1.18, respectively.

CONCLUSION

The majority of patients are satisfied and showed improvement after physical therapy treatment. There is the need for advances and intervention in relation to physical therapy guidelines at hospital discharge. MRPS instrument proved to be appropriate to measure inpatient's satisfaction level with physical therapy care.

Standardization of medical service indicators: A useful technique for hospital administration

Background

Many comparability problems appear in the process of the performance assessment of medical service. When comparing medical evaluation indicators across hospitals, or even within the same hospital, over time, the differences in the population composition such as types of diseases, comorbidities, demographic characteristics should be taken into account. This study aims to introduce a standardization technique for medical service indicators and provide a new insight on the comparability of medical data.

Methods

The medical records of 142592 inpatient from three hospitals in 2017 were included in this study. Chi-square and Kruskal-Wallis tests were used to explore the compositions of confounding factors among populations. The procedure of stratified standardization technique was applied to compare the differences of the average length of stay and the average hospitalization expense among three hospitals.

Results

Age, gender, comorbidity, and principal diagnoses category were considered as confounding factors. After correcting all factors, the average length of stay of hospital A and C were increased by 0.21 and 1.20 days, respectively, while that of hospital B was reduced by 1.54 days. The average hospitalization expenses of hospital A and C were increased by 1494 and 660 Yuan, whilst that of hospital B was decreased by 810 Yuan.

Conclusions

Standardization method will be helpful to improve the comparability of medical service indicators in hospital administration. It could be a practical technique and worthy of promotion.

Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data

QUESTIONS

Among people receiving inpatient rehabilitation after stroke, does additional weekend physiotherapy and/or occupational therapy reduce the length of rehabilitation hospital stay compared to those who receive a weekday-only service, and does this change after controlling for individual factors? Does additional weekend therapy improve the ability to walk and perform activities of daily living, measured at discharge? Does additional weekend therapy improve health-related quality of life, measured 6 months after discharge from rehabilitation? Which individual, clinical and hospital characteristics are associated with shorter length of rehabilitation hospital stay?

DESIGN

This study pooled individual data from two randomised, controlled trials (n=350) using an individual patient data meta-analysis and multivariate regression.

PARTICIPANTS

People with stroke admitted to inpatient rehabilitation facilities.

INTERVENTION

Additional weekend therapy (physiotherapy and/or occupational therapy) compared to usual care (5 days/week therapy).

OUTCOME MEASURES

Length of rehabilitation hospital stay, independence in activities of daily living measured with the Functional Independence Measure, walking speed and health-related quality of life.

RESULTS

Participants who received weekend therapy had a shorter length of rehabilitation hospital stay. In the un-adjusted analysis, this was not statistically significant (MD -5.7 days, 95% CI -13.0 to 1.5). Controlling for hospital site, age, walking speed and Functional Independence Measure score on admission, receiving weekend therapy was significantly associated with a shorter length of rehabilitation hospital stay (β=7.5, 95% CI 1.7 to 13.4, p=0.001). There were no significant between-group differences in Functional Independence Measure scores (MD 1.9 points, 95% CI -2.8 to 6.6), walking speed (MD 0.06 m/second, 95% CI -0.15 to 0.04) or health-related quality of life (SMD -0.04, 95% CI -0.26 to 0.19) at discharge.

DISCUSSION

Modest evidence indicates that additional weekend therapy might reduce rehabilitation hospital length of stay.

CLINICAL TRIAL REGISTRATION

ACTRN12610000096055, ACTRN12609000973213. [English C, Shields N, Brusco NK, Taylor NF, Watts JJ, Peiris C, et al. (2016) Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data.Journal of Physiotherapy62: 124-129].

Exergames for Patients in Acute Care Settings: Systematic Review of the Reporting of Methodological Quality, FITT Components, and Program Intervention Details

OBJECTIVE

This study was designed to summarize (1) the evidence from studies investigating the use of exergames in acute care settings, (2) the methodological quality of these studies, (3) the reporting of frequency, intensity, time, and type (FITT) of exergaming components and adherence, and (4) reporting of intervention details enabling study replication.

MATERIALS AND METHODS

Medline-Ovid, EMBASE, CINAHL, PsychInfo, and the Cochrane Library were consulted. Two authors independently selected and systematically reviewed the included reports. Study quality was scored for each study.

RESULTS

Of the nine reports representing five randomized clinical trials, one controlled clinical trial, and three single-group studies, the methodological quality was rather low, and the majority of the reports appeared to have a high risk of bias. Altogether, 365 patients were included in the selected articles. Energy expenditure, 6-Minute Walking Test, Timed Up and Go Test, Modified Berg Balance Scale, level of enjoyment, Transitional Dyspnea Index, upper limb activity, cognitive performance, and length of hospital stay favored exergaming. Three studies considered 70 percent or more of methodological quality items. Two studies reported all four FITT components. No studies reported adherence. Three studies each included descriptions of six intervention details.

CONCLUSIONS

The included studies suggest that patients in acute care settings may benefit from exergaming. The relationship between exergaming and patient outcomes requires, however, further exploration. Future adequately powered studies with low risk of bias and with acute care populations that are followed over extended time periods should be performed to substantiate or refute the advantageous effect of exergaming in acute care settings. Future studies should pay attention to the description of FITT components and adherence to the intervention. Attention to include details of the used exergaming intervention is important for replication purposes.

Empirical evidence of recall bias for primary health care visits

Background

While it is common for an economic evaluation of health care to rely on trial participants for self-reported health service utilisation, there is variability in the accuracy of this data due to potential recall bias. The aim of this study was to quantify the level of recall bias in self-reported primary health care general practitioner (GP) visits following inpatient rehabilitation over a 12 month period.

Methods

This report is a secondary analysis from a larger randomised control trial of an economic evaluation of additional Saturday inpatient rehabilitation. Participants were adults who had been discharged into the community following admission to an acute general rehabilitation hospital. Participants were asked to recall primary health care visits, including community GP visits, via a telephone questionnaire which was administered at 6 and 12 months following discharge from inpatient rehabilitation. Participants were asked to recall health service utilisation over each preceding 6 month period. The self-reported data were compared to equivalent claims data from the national insurer, over the same period.

Results

751 participants (75 % of the full trial) with a mean age of 74 years (SD 13) were included in this analysis. Over the 12 month period following discharge from rehabilitation there was an under-reporting of 14 % in self-reported health service utilisation for GP visits compared to national insurer claims data over the same period. From 0 to 6 months following discharge from rehabilitation, there was an over-reporting of self-reported GP visits of 35 % and from 7 to 12 months there was an under-reporting of self-reported GP visits of 36 %, compared to national insurer claims data over the same period. 46 % of patients reported the same or one number difference in self-reported GP visits between the 0 to 6 and the 7 to 12 month periods.

Conclusion

Based on these findings we recommend that an economic evaluation alongside a clinical trial for an elderly adult rehabilitation population include a sensitivity analysis that inflates self-reported GP visits by 16 % over 12 months. However caution is required when utilising self-reported GP visits as the data may contain periods of both over and under reporting. Where general practitioner visits are expected to vary significantly between intervention and control groups we recommend that administrative data be included in the trial to accurately capture resources for an economic evaluation.

Responsiveness, construct and criterion validity of the Personal Care-Participation Assessment and Resource Tool (PC-PART)

BACKGROUND

The Personal Care-Participation Assessment and Resource Tool (PC-PART) was designed to measure participation restrictions in activities of daily living required for community life. Rasch analysis has confirmed that the PC-PART contains two unidimensional scales providing interval-level measurement: the Self Care and Domestic Life scales. This study investigated validity and responsiveness of these PC-PART scales using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) approach.

METHODS

Thirteen hypotheses about Self Care and Domestic Life scale scores were established prior to conducting the analyses. Data from a prospective randomized controlled trial of additional (weekend) inpatient rehabilitation in Melbourne, Australia, were used. The 996 participants had a mean (SD) age of 74 (13) years and were admitted with orthopaedic (n = 581), neurological (n = 203) or other disabling impairments (n = 212). Self Care and Domestic Life scores were compared to functional independence (FIM), comorbidity (Charlson Comorbidity Index), whether activities of daily living goals were met, and discharge destination.

RESULTS

Low to moderate correlations between FIM and PC-PART scales' scores supported hypotheses that the PC-PART measures a different construct from functional independence: Self Care r s -0.52(95 % CI -.46 to -.57) and Domestic Life r s -0.32(95 % CI -.25 to -.38). The scales had low to moderate discriminative ability for discharge destination, with the area under the curve for Self Care, 0.70 (95 % CI 0.62-0.78), and Domestic Life, 0.72 (95 % CI 0.64-0.80). The discharge to community living cut-off scores for Self Care: 5.50 (sensitivity .83, specificity .53) and Domestic Life: 7.50 (sensitivity .75, specificity .60), represented patients having no participation restrictions. Change scores from admission to discharge demonstrated larger effect sizes for the Self Care (1.67) and Domestic Life (1.50) scales than for the FIM (1.10), supporting hypotheses about responsiveness. Ten of the 13 hypotheses were supported.

CONCLUSIONS

This study provided evidence supporting construct validity, criterion validity and responsiveness of the PC-PART Self Care and Domestic Life scales for inpatient rehabilitation. Clinicians, managers and researchers who wish to measure the patterns and extent of people's participation restrictions in activities of daily living and the associated burden of care, before and/or after intervention, can be somewhat confident about the PC-PART's validity and responsiveness for this purpose.

TRIAL REGISTRATION

Data used in this research were gathered during a registered randomized controlled trial: Australian and New Zealand Clinical Trials Registry ACTRN12609000973213.

Is cost effectiveness sustained after weekend inpatient rehabilitation? 12 month follow up from a randomized controlled trial

Background

Our previous work showed that providing additional rehabilitation on a Saturday was cost effective in the short term from the perspective of the health service provider. This study aimed to evaluate if providing additional rehabilitation on a Saturday was cost effective at 12 months, from a health system perspective inclusive of private costs.

Methods

Cost effectiveness analyses alongside a single-blinded randomized controlled trial with 12 months follow up inclusive of informal care. Participants were adults admitted to two publicly funded inpatient rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus additional Saturday rehabilitation. Incremental cost effectiveness ratios were reported as cost per quality adjusted life year (QALY) gained and for a minimal clinical important difference (MCID) in functional independence.

Results

A total of 996 patients [mean age 74 years (SD 13)] were randomly assigned to the intervention (n = 496) or control group (n = 500). The intervention was associated with improvements in QALY and MCID in function, as well as a non-significant reduction in cost from admission to 12 months (mean difference (MD) AUD$6,325; 95% CI −4,081 to 16,730; t test p = 0.23 and MWU p = 0.06), and a significant reduction in cost from admission to 6 months (MD AUD$6,445; 95% CI 3,368 to 9,522; t test p = 0.04 and MWU p = 0.01). There is a high degree of certainty that providing additional rehabilitation services on Saturday is cost effective. Sensitivity analyses varying the cost of informal carers and self-reported health service utilization, favored the intervention.

Conclusions

From a health system perspective inclusive of private costs the provision of additional Saturday rehabilitation for inpatients is likely to have sustained cost savings per QALY gained and for a MCID in functional independence, for the inpatient stay and 12 months following discharge, without a cost shift into the community.

Trial registration

Australian and New Zealand Clinical Trials Registry November 2009 ACTRN12609000973213.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0822-3) contains supplementary material, which is available to authorized users.

Evaluation of the internal construct validity of the Personal Care Participation Assessment and Resource Tool (PC-PART) using Rasch analysis

Background

The Personal Care Participation Assessment and Resource Tool (PC-PART) is a 43-item, clinician-administered assessment, designed to identify patients’ unmet needs (participation restrictions) in activities of daily living (ADL) required for community life. This information is important for identifying problems that need addressing to enable, for example, discharge from inpatient settings to community living. The objective of this study was to evaluate internal construct validity of the PC-PART using Rasch methods.

Methods

Fit to the Rasch model was evaluated for 41 PC-PART items, assessing threshold ordering, overall model fit, individual item fit, person fit, internal consistency, Differential Item Functioning (DIF), targeting of items and dimensionality. Data used in this research were taken from admission data from a randomised controlled trial conducted at two publically funded inpatient rehabilitation units in Melbourne, Australia, with 996 participants (63% women; mean age 74 years) and with various impairment types.

Results

PC-PART items assessed as one scale, and original PC-PART domains evaluated as separate scales, demonstrated poor fit to the Rasch model. Adequate fit to the Rasch model was achieved in two newly formed PC-PART scales: Self-Care (16 items) and Domestic Life (14 items). Both scales were unidimensional, had acceptable internal consistency (PSI =0.85, 0.76, respectively) and well-targeted items.

Conclusions

Rasch analysis did not support conventional summation of all PC-PART item scores to create a total score. However, internal construct validity of the newly formed PC-PART scales, Self-Care and Domestic Life, was supported. Their Rasch-derived scores provided interval-level measurement enabling summation of scores to form a total score on each scale. These scales may assist clinicians, managers and researchers in rehabilitation settings to assess and measure changes in ADL participation restrictions relevant to community living.

Trial registration

Data used in this research were gathered during a registered randomised controlled trial: Australian and New Zealand Clinical Trials Registry ACTRN12609000973213. Ethics committee approval was gained for secondary analysis of data for this study.

Are weekend inpatient rehabilitation services value for money? An economic evaluation alongside a randomized controlled trial with a 30 day follow up

BACKGROUND

Providing additional Saturday rehabilitation can improve functional independence and health related quality of life at discharge and it may reduce patient length of stay, yet the economic implications are not known. The aim of this study was to determine from a health service perspective if the provision of rehabilitation to inpatients on a Saturday in addition to Monday to Friday was cost effective compared to Monday to Friday rehabilitation alone.

METHODS

Cost utility and cost effectiveness analyses were undertaken alongside a multi-center, single-blind randomized controlled trial with a 30-day follow up after discharge. Participants were adults admitted for inpatient rehabilitation in two publicly funded metropolitan rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus an additional rehabilitation service on Saturday. Incremental cost utility ratio was reported as cost per quality adjusted life year (QALY) gained and an incremental cost effectiveness ratio (ICER) was reported as cost for a minimal clinically important difference (MCID) in functional independence.

RESULTS

996 patients (mean age 74 (standard deviation 13) years) were randomly assigned to the intervention (n = 496) or the control group (n = 500). Mean difference in cost of AUD$1,673 (95% confidence interval (CI) -271 to 3,618) was a saving in favor of the intervention group. The incremental cost utility ratio found a saving of AUD$41,825 (95% CI -2,817 to 74,620) per QALY gained for the intervention group. The ICER found a saving of AUD$16,003 (95% CI -3,074 to 87,361) in achieving a MCID in functional independence for the intervention group. If the willingness to pay per QALY gained or for a MCID in functional independence was zero dollars the probability of the intervention being cost effective was 96% and 95%, respectively. A sensitivity analysis removing Saturday penalty rates did not significantly alter the outcome.

CONCLUSIONS

From a health service perspective, the provision of rehabilitation to inpatients on a Saturday in addition to Monday to Friday, compared to Monday to Friday rehabilitation alone, is likely to be cost saving per QALY gained and for a MCID in functional independence.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry November 2009 ACTRN12609000973213.

Does additional acute phase inpatient rehabilitation help people return to work? A subgroup analysis from a randomized controlled trial

Objective:

To investigate if a Saturday rehabilitation service in addition to usual care improved return to work outcomes 12 months post discharge and to report predictors of return to work.

Design:

Subgroup analysis of a single-blind randomized controlled trial.

Setting:

General inpatient rehabilitation service.

Subjects:

A mixed cohort of 137 adults previously engaged in work, who were admitted for inpatient rehabilitation and allocated to a control group ( n=63) or an intervention group (n=74).

Intervention:

The control group received usual care rehabilitation from Monday to Friday and the intervention group received usual care plus an additional rehabilitation service on Saturdays (physiotherapy and occupational therapy).

Main outcome:

Return to paid or unpaid work.

Results:

After 12 months, 36 participants (57%) in the control group and 38 participants (51%) in the intervention group had returned to work. There was no difference between groups (mean difference -1.06 hours per week, 95% CI -8.70 to 6.57) in return to work outcomes. Functional status on discharge (OR 1.05, 95%CI 1.00 to 1.10), an orthopaedic diagnosis (OR 4.92, 95%CI 2.01 to 12.03) and engagement in unpaid work prior to rehabilitation (OR 5.08, 95%CI 1.39 to 18.58) were predictive of return to work at 12 months.

Conclusion:

A Saturday rehabilitation service in addition to usual care showed no improvement in return to work outcomes at 12 months. Predictors of return to work may help identify those at risk of not returning to work and who require follow-up vocational rehabilitation services.

Additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomized controlled trial

BACKGROUND

Many inpatients receive little or no rehabilitation on weekends. Our aim was to determine what effect providing additional Saturday rehabilitation during inpatient rehabilitation had on functional independence, quality of life and length of stay compared to 5 days per week of rehabilitation.

METHODS

This was a multicenter, single-blind (assessors) randomized controlled trial with concealed allocation and 12-month follow-up conducted in two publically funded metropolitan inpatient rehabilitation facilities in Melbourne, Australia. Patients were eligible if they were adults (aged ≥18 years) admitted for rehabilitation for any orthopedic, neurological or other disabling conditions excluding those admitted for slow stream rehabilitation/geriatric evaluation and management. Participants were randomly allocated to usual care Monday to Friday rehabilitation (control) or to Monday to Saturday rehabilitation (intervention). The additional Saturday rehabilitation comprised physiotherapy and occupational therapy. The primary outcomes were functional independence (functional independence measure (FIM); measured on an 18 to 126 point scale), health-related quality of life (EQ-5D utility index; measured on a 0 to 1 scale, and EQ-5D visual analog scale; measured on a 0 to 100 scale), and patient length of stay. Outcome measures were assessed on admission, discharge (primary endpoint), and at 6 and 12 months post discharge.

RESULTS

We randomly assigned 996 adults (mean (SD) age 74 (13) years) to Monday to Saturday rehabilitation (n = 496) or usual care Monday to Friday rehabilitation (n = 500). Relative to admission scores, intervention group participants had higher functional independence (mean difference (MD) 2.3, 95% confidence interval (CI) 0.5 to 4.1, P = 0.01) and health-related quality of life (MD 0.04, 95% CI 0.01 to 0.07, P = 0.009) on discharge and may have had a shorter length of stay by 2 days (95% CI 0 to 4, P = 0.1) when compared to control group participants. Intervention group participants were 17% more likely to have achieved a clinically significant change in functional independence of 22 FIM points or more (risk ratio (RR) 1.17, 95% CI 1.03 to 1.34) and 18% more likely to have achieved a clinically significant change in health-related quality of life (RR 1.18, 95% CI 1.04 to 1.34) on discharge compared to the control group. There was some maintenance of effect for functional independence and health-related quality of life at 6-month follow-up but not at 12-month follow-up. There was no difference in the number of adverse events between the groups (incidence rate ratio = 0.81, 95% CI 0.61 to 1.08).

CONCLUSIONS

Providing an additional day of rehabilitation improved functional independence and health-related quality of life at discharge and may have reduced length of stay for patients receiving inpatient rehabilitation.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12609000973213 Please see related commentary: http://www.biomedcentral.com/10.1186/1741-7015-11-199.

Exploring the effects of ecological activities during exposure to optical prisms in healthy individuals

Prism adaptation improves a wide range of manifestations of left spatial neglect in right-brain-damaged patients. The typical paradigm consists in repeated pointing movements to visual targets, while patients wear prism goggles that displace the visual scene rightwards. Recently, we demonstrated the efficacy of a novel adaptation procedure, involving a variety of every-day visuo-motor activities. This "ecological" procedure proved to be as effective as the repetitive pointing adaptation task in ameliorating symptoms of spatial neglect, and was better tolerated by patients. However, the absence of adaptation and aftereffects measures for the ecological treatment did not allow for a full comparison of the two procedures. This is important in the light of recent findings showing that the magnitude of prism-induced aftereffects may predict recovery from spatial neglect. Here, we investigated prism-induced adaptation and aftereffects after ecological and pointing adaptation procedures. Forty-eight neurologically healthy participants (young and aged groups) were exposed to rightward shifting prisms while they performed the ecological or the pointing procedures, in separate days. Before and after prism exposure, participants performed proprioceptive, visual, and visual-proprioceptive tasks to assess prism-induced aftereffects. Participants adapted to the prisms during both procedures. Importantly, the ecological procedure induced greater aftereffects in the proprioceptive task (for both the young and the aged groups) and in the visual-proprioceptive task (young group). A similar trend was found for the visual task in both groups. Finally, participants rated the ecological procedure as more pleasant, less monotonous, and more sustainable than the pointing procedure. These results qualify ecological visuo-motor activities as an effective prism-adaptation procedure, suitable for the rehabilitation of spatial neglect.

Patients value patient-therapist interactions more than the amount or content of therapy during inpatient rehabilitation: a qualitative study

QUESTION

How do patients receiving inpatient rehabilitation experience physiotherapy and does their experience differ if they receive extra Saturday physiotherapy?

DESIGN

Qualitative study using in-depth interviews and thematic analysis. Interviews were audio-taped, transcribed, member checked and coded independently by two researchers. Data were triangulated using published quantitative data.

PARTICIPANTS

Nineteen adults undergoing inpatient rehabilitation for neurological and musculoskeletal impairments who received either usual care (Monday to Friday therapy) or additional Saturday therapy.

RESULTS

One main theme (personal interactions), and five sub-themes (empathetic and caring physiotherapists, socialisation with other patients, alleviated boredom, changed perceptions of the weekend, and contentment with amount of therapy) emerged from the data. Patients valued interacting with physiotherapists and other patients. Patients were content with the amount of physiotherapy whether or not they had additional Saturday physiotherapy. However, having additional Saturday physiotherapy changed the patients' perceptions of Saturdays; patients who received Saturday physiotherapy viewed Saturday as a day where they would be working towards improving their function, while patients who did not receive Saturday physiotherapy expected to rest on the weekend.

CONCLUSION

The patient-therapist interaction was more important to the patient than the amount or content of their physiotherapy, but Saturday therapy changed patients' perceptions of weekends in rehabilitation.

Additional Saturday allied health services increase habitual physical activity among patients receiving inpatient rehabilitation for lower limb orthopedic conditions: a randomized controlled trial

OBJECTIVE

To determine whether adults with lower limb orthopedic conditions who received additional weekend physical therapy (PT) and occupational therapy (OT) demonstrated increased habitual physical activity.

DESIGN

Randomized controlled trial.

SETTING

Inpatient rehabilitation center.

PARTICIPANTS

Adults (N=105, 72 women; mean age ± SD, 74±12y) admitted with a lower limb orthopedic condition, cognitively alert and able to walk.

INTERVENTION

The control group received PT and OT Monday to Friday; in addition, the experimental group also received a full Saturday PT and OT service. Participants wore an activity monitor for 7 days.

MAIN OUTCOME MEASURES

Daily steps and daily upright time (hours).

RESULTS

Overall, participants took a mean of 589±640 steps per day and spent a mean of 1.2±0.9 hours upright per day. Experimental group participants took more than twice as many steps (mean difference, 428 steps; 95% confidence interval [CI], 184-673) and spent 50%±20% more time upright (mean difference, 0.5h; 95% CI, 0.1-0.9) than control group participants on Saturdays. In the days after additional therapy, experimental group participants took 63%±28% more steps (mean difference, 283 steps; 95% CI, 34-532) and spent 40%±17% more time upright (mean difference, 0.4h; 95% CI, 0.1-0.8) per day than participants in the control group.

CONCLUSIONS

Providing additional rehabilitation services on the weekend increased habitual activity, but patients with lower limb orthopedic conditions admitted to rehabilitation remained relatively inactive even with additional therapy.

Fifty ways to reduce length of stay: an inventory of how hospital staff would reduce the length of stay in their hospital

PURPOSE AND SETTING

In this study we present a bottom up approach to developing interventions to shorten lengths of stay. Between 1999 and 2009 we applied the approach in 21 Dutch clinical wards in 12 hospitals. We present the complete inventory of all interventions.

DESIGN

We organised, on the hospital ward level, structured meetings with the staff in order to first identify barriers to reduce the length of stay and then later to link them to interventions. The key components of the approach were a benchmark with the fifteenth percentile and the use of a matrix, that on one side was arranged along the main phases of the care process--the admission, stay and discharge--and on the other side to the degree to which the length of stay could be shortened by the medical specialists and nurses themselves or by involving others.

FINDINGS AND CONCLUSIONS

The matrix consists of a wide variety of interventions that mainly cover what we found in published research. As a bottom up approach is more likely to succeed, we would advise wards that have to reduce length of stay to make the inventory themselves, using appropriate benchmark data, and by using the matrix.

An evidence-based case for the value of social workers in efficient hospital discharge

A study was undertaken to make an evidence-based case for the value of social workers in efficient discharge of patients from acute care hospitals and to assist hospital managers in making informed staffing decisions. Hospital administrative databases from March 1 to November 30, 2008, were used for the analysis of inpatient discharges on days when social workers were on vacation compared with days fully staffed with social workers. Two performance measures, daily discharge rate and average length of stay, were evaluated. During the study period, 1825 patients were discharged from the General Internal Medicine inpatient service. Team discharge rates were significantly lower on social work vacation Fridays versus regular Fridays. In contrast, the average length of stay for patients discharged on social work vacation Fridays was significantly shorter than that for patients discharged on regular Fridays. It was concluded that daily discharge rate better quantified the role of social work in patient discharge. More generally, these results provide preliminary support for the need for adequate social work staffing in timely and efficient patient discharge.