A study of the factors which influence the length of hospital stay of stroke patients

Clinical Characteristics of Ischemic Stroke Patients <50 Years Old at a University Hospital: A Retrospective Descriptive Study

Background Stroke is a leading cause of mortality and disability around the world. It is responsible for 10% of all fatalities and about 5% of all disabilities. Risk factors include age, hypertension (HTN), dyslipidemia, and atrial fibrillation. The incidence of acute ischemic stroke (AIS) is increasing among young adults compared to older ones. It has a direct impact on their quality of life and working activities while also burdening the healthcare system. Aim The aim of this study is to investigate the possible risk factors for ischemic stroke in patients who are under 50 years old. Methods This is a single-center retrospective record review of patients with ischemic stroke from 2010 to 2022. Eighty patients who had an ischemic stroke at an age below 50 were included in the analysis. Patients above or equal to 50 years old who had ischemic stroke and all patients with hemorrhagic stroke were excluded. Baseline characteristics, length of hospitalization, and in-hospital mortality were compared with different comorbidities. Results The mean age was 36.65 among males and females who had an ischemic stroke. 56.8% of them were non-Saudi, while 43.2% were Saudis. Diabetes, hypertension, and dyslipidemia were among the most frequent comorbidities among patients who had ischemic stroke, with a percentage of 82.7%. Other comorbidities, such as autoimmune disease, thrombophilia, and heart failure, were present. Conclusion There are different comorbidities found in patients who have had an ischemic stroke and are under 50 years old. However, diabetes and hypertension remain the most common risk factors.

Prism Adaptation Treatment Predicts Improved Rehabilitation Responses in Stroke Patients with Spatial Neglect

Spatial neglect (SN) impedes functional recovery after stroke, leading to reduced rehabilitation gains and slowed recovery. The objective of the present study was to investigate whether integrating prism adaptation treatment (PAT) into a highly intensive rehabilitation program eliminates the negative impact of spatial neglect on functional and motor recovery. We examined clinical data of the 355 consecutive first-time stroke patients admitted to a sub-acute inpatient neurorehabilitation program that integrated PAT. The 7-item Motor Functional Independence Measure, Berg Balance Scale, and Motor Activity Log were used as main outcome measures. We found that 84 patients (23.7%) had SN, as defined by a positive score on the Catherine Bergego Scale via the Kessler Foundation Neglect Assessment Process (KF-NAP^®). Although 71 patients (85%) received PAT, the presence of SN at baseline, regardless of PAT completion, was associated with lower functional independence, higher risk of falls, and a lower functional level of the affected upper limb both at admission and at discharge. The severity of SN was associated with inferior rehabilitation outcomes. Nonetheless, patients with SN who received PAT had similar rehabilitation gains compared to patients without SN. Thus, the present study suggests that integrating PAT in an intensive rehabilitation program will result in improved responses to regular therapies in patients with SN.

Factors Associated to Returning Home in the First Year after Stroke

The objective of this study was to investigate factors affecting the return home one year after a stroke. The subjects of this study consisted of patients who participated in a large-scale multi-objective cohort study of initial stage stroke patients who were admitted to 9 representative hospitals in Korea. We analyzed the distribution of the subjects who had experienced stroke a year earlier by distinguishing the group who returned home and the other group that was hospitalized in rehabilitation hospitals. Based on this distribution, we evaluated the demographic, environmental, clinical, and psychological factors that can affect the return home. Overall, there were 464 subjects in the 'Return home' group and 99 subjects in the 'Rehabilitation hospitalization' group. job status, inconvenient housing structures, residential types, diagnosis, Functional Ambulation Categories, modified Rankin Scale, Korea-Modified Barthel Index, Function Independence Measure, Fugl-Meyer Assessment, Korean version of Mini-Mental State Examination, Korean version of Frenchay Aphasia Screening Test, Psychosocial Well-being Index-Short Form, Geriatric Depression Scale-Short Form, EuroQol-five Dimensional showed a significant difference between the 2 groups one year after the stroke. The factors affecting the return home one year after a stroke include functional status, activities of daily living, cognition, depression, stress, quality of life, job status. It is expected that factors affecting the rehabilitation of patients with stroke can be considered as basic data for establishing rehabilitation goals and treatment plans.

Attitudes, perceptions, and behaviours associated with hospital admission avoidance: a qualitative study of high-risk patients in primary care

BACKGROUND

There is little evidence documenting the attitudes, experiences, and behavioural factors of high-risk patients who are associated with avoiding hospital.

AIM

To explore the health, healthcare management, and behavioural factors that contribute to enabling high-risk patients to avoid unplanned hospital admissions.

DESIGN AND SETTING

This was an in-depth qualitative, primary care, interview study with patients who were registered on the Northumberland High Risk Patient Programme (NHRPP) in Northumberland, UK.

METHOD

There were 30 participants in this study, of who 21 were high-risk patients and nine were carers, spouses, or relatives. A grounded-theory approach was used to explore themes that emerged from the semi-structured interviews.

RESULTS

Participants described physical enablers that helped them to avoid hospital including medication, living aids, and resting; however, the benefit of these may be challenged by patient decision making. The strategies that patients used to cope with their health conditions included acceptance, positive reinterpretation, and growth. Participants felt that support networks of family and friends helped them to avoid hospital, although the strain on the spouse should be considered. The majority of patients described having trust and confidence in their healthcare providers, and continuity of care was important to patients.

CONCLUSION

Reinforcing the importance of the physical enablers, as well as support networks to patients, carers, and healthcare providers, could help patients to avoid hospital. Highlighting the coping strategies that patients use may help patients to manage their health, while promoting continuity of care will also contribute to helping high-risk patients to avoid unplanned hospital admissions.

Older Adults' Social Relationships and Health Care Utilization: A Systematic Review

BACKGROUND

Deficiencies in older people's social relationships (including loneliness, social isolation, and low social support) have been implicated as a cause of premature mortality and increased morbidity. Whether they affect service use is unclear.

OBJECTIVES

To determine whether social relationships are associated with older adults' use of health services, independently of health-related needs.

SEARCH METHODS

We searched 8 electronic databases (MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, Scopus, the Cochrane Library, and the Centre for Reviews and Dissemination) for data published between 1983 and 2016. We also identified relevant sources from scanning the reference lists of included studies and review articles, contacting authors to identify additional studies, and searching the tables of contents of key journals.

SELECTION CRITERIA

Studies met inclusion criteria if more than 50% of participants were older than 60 years or mean age was older than 60 years; they included a measure of social networks, received social support, or perceived support; and they reported quantitative data on the association between social relationships and older adults' health service utilization.

DATA COLLECTION AND ANALYSIS

Two researchers independently screened studies for inclusion. They extracted data and appraised study quality by using standardized forms. In a narrative synthesis, we grouped the studies according to the outcome of interest (physician visits, hospital admissions, hospital readmissions, emergency department use, hospital length of stay, utilization of home- and community-based services, contact with general health services, and mental health service use) and the domain of social relationships covered (social networks, received social support, or perceived support). For each service type and social relationship domain, we assessed the strength of the evidence across studies according to the quantity and quality of studies and consistency of findings.

MAIN RESULTS

The literature search retrieved 26 077 citations, 126 of which met inclusion criteria. Data were reported across 226 678 participants from 19 countries. We identified strong evidence of an association between weaker social relationships and increased rates of readmission to hospital (75% of high-quality studies reported evidence of an association in the same direction). In evidence of moderate strength, according to 2 high-quality and 3 medium-quality studies, smaller social networks were associated with longer hospital stays. When we considered received and perceived social support separately, they were not linked to health care use. Overall, the evidence did not indicate that older patients with weaker social relationships place greater demands on ambulatory care (including physician visits and community- or home-based services) than warranted by their needs.

AUTHORS' CONCLUSIONS

Current evidence does not support the view that, independently of health status, older patients with lower levels of social support place greater demands on ambulatory care. Future research on social relationships would benefit from a consensus on clinically relevant concepts to measure. Public Health Implications. Our findings are important for public health because they challenge the notion that lonely older adults are a burden on all health and social care services. In high-income countries, interventions aimed at reducing social isolation and loneliness are promoted as a means of preventing inappropriate service use. Our review cautions against assuming that reductions in care utilization can be achieved by intervening to strengthen social relationships.

Determinants of Length of Stay Following Total Anterior Circulatory Stroke

Identification of factors that determine length of stay (LOS) in total anterior circulatory stroke (TACS) has potential for targeted intervention to reduce the associated health care burden. This study aimed to determine which factors predict LOS following either ischaemic or haemorrhagic TACS. The study sample population was drawn from the Norfolk and Norwich Stroke and Transient Ischemic Attack (TIA) Register (1996–2012), a prospective registry. 2965 patients admitted with TACS verified by a stroke specialist team were included. Primary analysis identified predictors of length of stay (LOS) in either haemorrhagic or ischaemic TACS. Secondary analyses identified predictors of LOS in patients who were discharged alive or who died during admission separately. Moderate (p = 0.014) to severe disability (p = 0.015) and history of congestive heart failure (p = 0.027) in the primary analysis and pre-stroke residence in a care facility among patients who survived to discharge (p = 0.013) were associated with a shorter length of stay. Factors associated with increased length of stay included presence of neurological lateralisation in the primary analysis (p = 0.004) and amongst patients who died (p = 0.003 and p = 0.014 for ischaemic and haemorrhagic stroke, respectively). Patients with advanced age (≥85 years) with haemorrhagic stroke had longer LOS regardless of mortality outcome. Patients with low pre-morbid disability (modified Rankin score ≤2 who died following haemorrhagic TACS also had longer LOS. Our study found predictors of LOS following TACS include neurological lateralisation, pre-stroke disability status, congestive heart failure, pre-morbid residence and age. The identification of such factors would assist in resource allocation and discharge planning.

Predicting length of stay in specialist neurological rehabilitation

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Length of Hospital Stay After Stroke: A Korean Nationwide Study

Objective

To investigate the length of hospital stay (LOS) after stroke using the database of the Korean Health Insurance Review & Assessment Service.

Methods

We matched the data of patients admitted for ischemic stroke onset within 7 days in the Departments of Neurology of 12 hospitals to the data from the database of the Korean Health Insurance Review & Assessment Service. We recruited 3,839 patients who were hospitalized between January 2011 and December 2011, had a previous modified Rankin Scale of 0, and no acute hospital readmission after discharge. The patients were divided according to the initial National Institute of Health Stroke Scale score (mild, ≤5; moderate, >5 and ≤13; severe, >13); we compared the number of hospitals that admitted patients and LOS after stroke according to severity, age, and sex.

Results

The mean LOS was 115.6±219.0 days (median, 19.4 days) and the mean number of hospitals was 3.3±2.1 (median, 2.0). LOS was longer in patients with severe stroke (mild, 65.1±146.7 days; moderate, 223.1±286.0 days; and severe, 313.2±336.8 days). The number of admitting hospitals was greater for severe stroke (mild, 2.9±1.7; moderate, 4.3±2.6; and severe, 4.5±2.4). LOS was longer in women and shorter in patients less than 65 years of age.

Conclusion

LOS after stroke differed according to the stroke severity, sex, and age. These results will be useful in determining the appropriate LOS after stroke in the Korean medical system.

Functional Gains During Acute Hospitalization for Stroke

OBJECTIVES

1) Confirm clinimetric suitability of 5 Functional Independence Measure (FIM) items for characterizing functional independence. 2) Describe functional changes and relationships between selected variables and functional independence at discharge and functional change.

METHODS

For 451 patients hospitalized for acute stroke, scores were recorded at admission and discharge for 5 FIM items (transfers, eating, walking, expression, and memory). The sum of the 5 FIM items and functional change between admission and discharge were calculated.

RESULTS

The FIM scores were internally consistent (alpha = .894 and .918) and reflected 1 factor. Functional independence increased (t = 17.46, P < .001) over a mean 5.5 days. Regression analysis showed the same variables (admission function, NIHSS score, length of stay, age, and total therapy units) to best predict discharge function (R2 = .804) and function change (R2 = .184).

CONCLUSIONS

Together, 5 easily observed FIM items demonstrated that functional independence increased during hospitalization. Discharge function and functional change were predicted significantly (but weakly) by therapy units.

Should community-based services be publicly funded or contracted out?

OBJECTIVE

The introduction of Canada's Medicare in 1966 established precedence for a universally accessible and equitable healthcare system. Although Canada has been a leader in building the foundations of socialized medicine, it has stalled short of fulfilling a vision promulgated by its architects of a system that operates on a continuum of care. The aim of this review was to examine whether the expansion of publicly funded services under the Canada Health Act would be an economically and socially viable policy option.

METHOD

A literature review of the direct and indirect social and economic costs associated with contracting out community-based services in the form of outpatient rehabilitative care, palliative care, and home care was conducted.

RESULTS

This article concludes that the private financing of community-based services increases healthcare costs in the long term through increased density and frequency of acute care utilization. It is associated with increased indirect costs in the form of caregiver burden and reduced labor market participation of informal caregivers. The expansion of publicly funded community-based services minimizes these direct health and indirect societal costs.

SIGNIFICANCE OF RESULTS

The integration of publicly funded community-based services under the Canada Health Act would ensure that the principles of Medicare in the form of equity and accessibility would be enforced while maintaining an economically sustainable healthcare system.

Factors Influencing Costs of Inpatient Ischaemic Stroke Care in Singapore

Introduction:

Stroke is a major public issue in Singapore, accounting for almost 10,000 admissions annually and the burden of disease is set to increase with an ageing population. We therefore seek to examine the factors influencing the cost of acute stroke care in Singapore.

Methods:

This is a retrospective analysis of 2,087 discharges with a primary discharge diagnosis of stroke from a tertiary hospital in Singapore from 1 January 2007 to 31 December 2008. Data including age, gender, length of hospital stay, components of direct cost and discharge disposition were obtained. A generalised linear model with a log link function and gamma distribution was used to determine the predictors of total hospital cost.

Results:

Mean age was 67.8 ± 12.4 years and 54.5% were males. Mean length of stay was 12.3 ± 16 days and mean total overall cost was S$6,783. Ward costs accounted for 48% of total cost. Length of stay strongly correlated to total cost. Being discharged to step-down facilities, death, receiving inpatient rehabilitation and length of stay significantly incurred higher total cost in multivariate analysis. However, there was an inverse relationship between age and total cost, possibly as a result of higher costs incurred for radiological, laboratory investigations and expert care.

Conclusion:

Further research is needed to examine factors influencing the cost of treatment particularly for those being discharged to step-down facilities and receiving inpatient rehabilitation as they have been found to incur higher total cost. This would impact on the planning of the continuum of healthcare facilities for stroke management.

Length of stay in an Australian stroke rehabilitation unit: a pilot study

Aims

Length of stay (LOS) is an important consideration in rehabilitation, and it can be adversely affected by delayed discharge. The purpose of this prospective study was to document LOS, frequency of discharge delay, reasons for discharge delay and its impact on LOS.

Methods

Ninety-eight inpatients in a stroke rehabilitation unit were included in the study.

Findings

Sixty (61%) patients had a LOS that exceeded the Australasian Rehabilitation Outcomes Centre (AROC) benchmark LOS according to the Australian National Sub-acute and Non-acute Patient classification system. Twenty-five (26%) patients had delayed discharge resulting in a total delay of 886 days, with most of these related to delays in the provision of community services. When patients with discharge delay were factored out of analyses, LOS was still longer than AROC benchmark figures for 39 (57%) of the 69 patients without discharge delay.

Conclusions

The LOSs of the majority of patients included in this study were longer than the AROC benchmark figures, even when patients with discharge delay were factored out. Initiatives to address this problem include the implementation of a proactive computerized tool that will provide target LOSs and enable reasons for excessive LOS to be more closely examined.

Rehabilitation length of stay in patients suffering from aphasia after stroke

BACKGROUND AND PURPOSE

Few studies have assessed the relationship between aphasia and rehabilitation length of stay (LOS). The aim of the current prospective study was to evaluate LOS in patients with aphasia and its relation to functional improvement.

METHODS

The study was performed in 252 patients admitted for rehabilitation follow-up of their first stroke (126 patients with aphasia and hemiparesis [aphasia group] and 126 patients with hemiparesis but without aphasia [control group]). All patients were submitted to clinical, neurological, and neuropsychological examinations. The following tests were performed: Aachen Aphasia Test, Albert's test, anosognosia scale, Cumulative Illness Rating Scale (CIRS), Fugl-Meyer Scale, and FIM.

RESULTS

LOS was 50.7 and 46.7 days in the aphasia and control groups, respectively. There was no statistically significant difference in the LOS between aphasia and control groups (p = .056). A longer LOS was correlated with low admission aphasia score (r = -0.19). The increase in motor FIM per day obtained by therapy (LOS-Eff) was 0.54 +/- 0.3 in the aphasia group and 0.75 +/- 0.5 in the control group. The LOS-Eff was significantly poorer in the aphasia group (p = .000). A high LOS-Eff was correlated with high aphasia score (r = 0.31). In multivariate regression analyses, aphasia was an important predictor of LOS-Eff (beta = 0.18).

CONCLUSIONS

In patients with aphasia, LOS is few days longer and LOS-Eff is significantly poorer compared to patients without aphasia. Aphasia is a significant independent predictor of LOS-Eff at discharge.

A prospective study of predictors of prolonged hospital stay and disability after stroke

This study examined predictors of prolonged hospitalisation (>30 days) and significant disability (modified Rankin Scale >2) in 257 patients with acute ischaemic stroke. These patients were assessed prospectively regarding stroke severity, comorbidities and complications in hospital. Multivariate logistic regression was used to select variables that best predicted prolonged hospital stay and significant disability on discharge. Four factors significantly predicted prolonged hospital stay: older age (>65); diabetes mellitus; in-hospital infection; and significant disability on discharge. Significant disability on discharge was in turn associated with diabetes, infection, premorbid disability, stroke in progression and atrial fibrillation. Diabetes and in-hospital infection, together with other factors, can significantly predict prolonged hospital stay and disability in stroke patients. These two potentially modifiable factors are possible targets for interventions to reduce the burden of illness and healthcare costs of stroke.

Modernising social care services for older people: scoping the United Kingdom evidence base

In common with other developed countries at the end of the 20th century, modernising public services was a priority of the United Kingdom (UK) Labour administration after its election in 1997. The modernisation reforms in health and social care exemplified their approach to public policy. The authors were commissioned to examine the evidence base for the modernisation of social care services for older people, and for this purpose conducted a systematic review of the relevant peer-reviewed UK research literature published from 1990 to 2001. Publications that reported descriptive, analytical, evaluative, quantitative and qualitative studies were identified and critically appraised under six key themes of modernisation: integration, independence, consistency, support for carers, meeting individuals' needs, and the workforce. This paper lists the principal features of each study, provides an overview of the literature, and presents substantive findings relating to three of the modernisation themes (integration, independence and individuals' needs). The account provides a systematic portrayal both of the state of social care for older people prior to the modernisation process and of the relative strengths and weaknesses of the evidence base. It suggests that, for evidence-based practice and policy to become a reality in social care for older people, there is a general need for higher quality studies in this area.

In patient stroke rehabilitation efficiency: influence of organization of service delivery and staff numbers

Background

Outcomes of inpatient stroke rehabilitation need to be reviewed in terms of optimal resource utilization (staff time, service organization, and duration of stay). We compared FIM efficiency scores between three hospitals, and also variation in FIM scores over a ten year period in one hospital undergoing reduction in staff numbers, to examine the relationship between outcome and service characteristics.

Method

This is a retrospective study comparing the mean FIM efficiency for stroke patients (FIM score – FIM admission score) divided by duration of stay for 2005 among three rehabilitation hospitals adjusting for age and baseline FIM score, and a longitudinal study of changes in mean FIM efficiency during a ten year period in one hospital, to examine the effects of different service organization and staff numbers.

Results

FIM efficiency (FIMEG) was inversely associated with age, and positively associated with admission FIM score. FIMEG was higher in the hospital with a coordinated care plan involving medical, nursing, occupational, physiotherapy staff and other healthcare providers working as a team, with a seamless interface with community rehabilitation services. Over a ten year period, reduction in staff numbers was associated with reduction in FIMEG, which may be offset to some extent by service re-engineering.

Conclusion

Within hospital organization of stroke rehabilitation services may influence outcome. A critical number of staff may be identified for the provision of services, below which rehabilitation efficiency may be affected.

Prediction of length of stay for stroke patients

OBJECTIVES

To examine the factors that influence acute and total length of stay (LOS) for stroke patients.

MATERIALS AND METHODS

The basis of this investigation was a population-based cohort of first-ever stroke patients (n = 388). Subjects were survivors of the initial hospitalization (n = 295). Age, sex, social factors, risk factors, dementia, stroke type, and stroke severity, measured with the NIH stroke scale (NIHSS), were registered.

RESULTS

Mean acute LOS was 12 days and mean total LOS was 29 days. Independent predictors of acute LOS were stroke severity, lacunar stroke, prestroke dementia, and smoking. Independent predictors of total LOS were stroke severity and prestroke activities of daily living (ADL) dependency. The NIHSS items that best correlated with LOS were paresis, unilateral neglect and level of consciousness.

CONCLUSIONS

Stroke severity is a strong and reliable predictor of LOS. The results of this study can be used as a baseline for evaluating cost-effectiveness of stroke care changes, e.g. organizational changes or evaluation of new drugs.

A systematic review of the literature on multidisciplinary rounds to design information technology

Multidisciplinary rounds (MDR) have become important mechanisms for communication and coordination of care. To guide design of tools supporting MDR, we reviewed the literature published from 1990 to 2005 about MDR on information tools used, information needs, impact of information tools, and evaluation measures. Fifty-one papers met inclusion criteria and were included. In addition to patient-centric information tools (e.g., medical chart) and decision-support tools (e.g., clinical pathway), process-oriented tools (e.g., rounding list) were reported to help with information organization and communication. Information tools were shown to improve situation awareness of multidisciplinary care providers, efficiency of MDR, and length of stay. Communication through MDR may be improved by process-oriented information tools that help information organization, communication, and work management, which could be achieved through automatic extraction from clinical information systems, displays and printouts in condensed forms, at-a-glance representations of the care unit, and storing work-process information temporarily.

Rehabilitation interventions for vegetative and minimally conscious patients

Brain injury rehabilitation is a complex and challenging task for all members of the multidisciplinary team. Medical advances have allowed more severely impaired patients to survive and consequently the number of patients in the vegetative and minimally conscious states have proportionately increased. Thus, the need for evidence-based practice and further research demonstrating the effects of specific rehabilitation interventions is required. This article reviews the current research and consensus on rehabilitation for patients in the vegetative and minimally conscious states.

Postadmission function best predicts acute hospital outcomes after stroke

OBJECTIVE

This study was conducted to determine the relative value of selected variables for predicting three acute hospital outcomes (length of stay, charges, discharge destination) after stroke.

DESIGN

Data were obtained prospectively from 92 patients admitted with ischemic stroke to an acute care hospital. The relationship between five independent variables (age, sex, National Institutes of Health Stroke Scale [NIHSS] scores, prestroke Barthel Index scores, and postadmission Barthel Index scores) and the three outcome variables (hospital length of stay, hospital charges, and hospital discharge destination) were examined.

RESULTS

Significant bivariate correlations were found between two predictors (NIHSS scores and Barthel Index scores) and all three outcome variables. Regression analysis showed that once postadmission Barthel Index scores were accounted for, no other variable added to the prediction of hospital length of stay or discharge destination. The NIHSS score added to the explanation of hospital charges provided by postadmission Barthel Index scores.

CONCLUSIONS

Postadmission Barthel Index scores were the best predictor of the three outcomes measured in this study.

Predicting the cost of hospital stay for stroke patients: the use of diagnosis related groups

In order to provide tailor-made care, governments are considering the implementation of output-pricing based on hospital case-mix measures, such as diagnosis related groups (DRG). The question is whether the current DRG classification system can provide a satisfactory prediction of the variance of costs in stroke patients and if not, in what way other variables may enhance this prediction. In this study, data from 731 stroke patients hospitalized at University Hospital Maastricht during 1996-1998 are used in the cost analysis. The DRG classification for this group uses information--in addition to the DRG classification operation or no operation--on the patient's age combined with discharge status. The results of regression analysis show that using DRGs, the variance explained in the costs amounts to 34%. Adding other variables to the DRGs, the variance explained increases to about 61%. Additional factors highly correlating with inpatient costs are the level of functioning after stroke, comorbidity, complications, and 'days of stay for non-medical reasons'. Costs decreased for stroke patients discharged during the latter part of the years studied, and if stroke patients happened to die during their hospital stay. The results do suggest that future implementation of output-pricing based on the DRG case-mix measures is feasible for stroke patients only if it is enhanced with information on complications and the level of functioning.

Discharge function and length of stay for patients with stroke are predicted by lower extremity muscle force on admission to rehabilitation

OBJECTIVE

We sought to determine the relative value of lower extremity muscle strength as a predictor of discharge function and length of stay of patients with stroke.

METHODS

We studied 72 patients undergoing inpatient rehabilitation after a stroke and documented their outcome using length of stay and function [as measured by the Functional Independence Measure (FIM) at discharge].

RESULTS

Knee-extension force and the total force of four lower extremity muscle actions (hip flexion, knee extension, knee flexion, and ankle dorsiflexion) were correlated significantly with discharge FIM and length of stay. The correlations involving the actions of the weaker side were higher. Admission FIM was also correlated significantly with discharge FIM and length of stay. Previous stroke and age were correlated significantly with discharge FIM but not length of stay. The set of variables offering the best explanation of discharge FIM (R = 0.867) was admission FIM, admission FIM squared, age, and total force of the weaker side. The set of variables offering the best explanation of length of stay (R = 0.812) was knee-extension force of the weaker side squared, admission FIM, admission FIM squared, and age.

CONCLUSIONS

Lower extremity muscle force of the weaker side on admission has value as a predictor of function at discharge and length of stay for patients with stroke admitted to inpatient rehabilitation. Muscle force, therefore, is a reasonable target of measurement and treatment. Knowledge of muscle force on admission can assist clinicians, patients, families, and others to anticipate patient outcomes after rehabilitation.

Delayed discharges from Oxford city hospitals: who and why?

OBJECTIVE

To determine the extent and characteristics of discharge delays of younger patients from acute hospital beds in Oxford, England.

DESIGN

Three-month prospective analysis of patients deemed to have delayed discharge.

MEASURES

The primary measure was the number of days from the patient being no longer in need of acute medical inpatient care to eventual discharge. Additional assessments included demographic data, primary diagnosis, Motricity Index, Short Orientation-Memory-Concentration Test (SOMC), Barthel Index and contextual data.

SETTING

The major acute hospitals serving the county of Oxfordshire (560,000 people).

SUBJECTS

Fifty patients aged 18-70 years identified by referrals, delayed discharge lists and ward visits whose discharge from hospital had been delayed.

RESULTS

The mean (standard deviation, SD) delay period was 36.1 (26.8) days. The mean prevalence and incidence of discharge delays for each three-day period was 19.7 (SD 1.7) and one (SD 1.7) respectively. Most (88%, n = 44) had a primary neurological diagnosis. Twenty-four (48%) patients had Motricity Index scores of less than 50% in one or more limbs and 16 (32%) in two or more limbs. Twenty-six (52%) patients had cognitive impairment (SOMC <18/28). Thirty-nine (78%) patients had a Barthel Index score of less than 15/20 and 24 (48%) of less than 10/20. The period of discharge delay did not correlate with SOMC, Motricity or Barthel Index scores. Only nine had appropriate accommodation available.

CONCLUSION

Patients whose discharge is delayed were common; most had a neurological disability and cognitive impairment; and accommodation was unsuitable or absent for most. Reorganizing services to give patients access to specialized disability services might both improve the care of these patients and increase the efficiency of the health service.

Predicting discharge outcomes for stroke patients in Australia

OBJECTIVE

This study aimed to describe discharge outcomes and explore their correlates for patients rehabilitated after stroke at an Australian hospital from 1993 to 1998.

DESIGN

Data on length of stay, discharge functional status, and discharge destination were retrospectively obtained from medical records. Patients' actual rehabilitation length of stay was compared with the Australian National Sub-Acute and Non-Acute Patient predicted length of stay. The change in length of stay over the 5-yr period from 1993 to 1998 was documented.

RESULTS

Patients' mean converted motor FIM scores improved from 53.1 at admission to 74.1 at discharge. Lower admission-converted motor FIM scores were related to longer length of stay, lower discharge-converted motor FIM scores, and the need for a change in living situation on discharge.

CONCLUSION

The results of this study provide Australian data on discharge outcomes after stroke to assist in the planning and delivery of appropriate interventions to individual patients during rehabilitation.

Ratings of physical function obtained by interview are legitimate for patients hospitalized after stroke

This study was conducted to examine the legitimacy of Barthel Index (BI) scores and subset of Functional Independence Measure (FIM) scores obtained by interview from patients hospitalized after stroke. This study included 82 patients with stroke. Interviews by a trained study coordinator were conducted to obtain BI and FIM subset (transfer, locomotion, feeding) scores from patients or a knowledgeable proxy. In addition, therapists' observational FIM scores on subset items recorded in the medical record were retrieved. The reliability, responsiveness, and validity of the BI and FIM subset were examined using Cronbach's alpha, effect size calculations, Wilcoxon tests, Spearman (r(S)) correlations, and regression analysis. Statistical analysis indicated that the post-stroke interview BI (.952) and FIM subset (.939) scores had excellent internal consistency. Large effect sizes and Wilcoxon test results between the prestroke and poststroke interview scores for the BI and FIM subset (z, -3.739 to -6.168) indicated that these 2 instruments were responsive to changes in patients' physical function status that accompanied stroke. Excellent correlations were found between BI and FIM interview scores poststroke (r(s), .913 to .971). The FIM subset interview scores and therapists' scores showed correlations that were moderate to good (r(s), .508 to .754). Length of stay correlated significantly with both the interview BI score (r(s), -.604) and the interview FIM subset score (r(s), -.583). Length of stay was correlated also with the National Institutes of Health Stroke Scale scores (r(s), .484). The regression analysis depicted the BI interview scores as the best predictor of the length of stay. Results provide support for the use of functional scores obtained by interview from hospitalized stroke patients. Both the BI and the FIM subset examined in this study are legitimate for this purpose.