Medical Complications and Prognostic Factors for Medically Unstable Conditions During Acute Inpatient Cancer Rehabilitation

Palliative Rehabilitation in Patients with Cancer: Definitions, Structures, Processes and Outcomes

PURPOSE OF REVIEW

This review examines the literature on palliative rehabilitation for patients with advanced cancer, focusing on definitions, structures, processes, and outcomes.

RECENT FINDINGS

Palliative cancer rehabilitation targets comfort and functional improvement for patients with limited rehabilitation potential across various settings. The palliative cancer rehabilitation team, typically led by a physician, coordinates symptom management and referrals to rehabilitation and other allied healthcare professionals as needed. The outcomes of palliative cancer rehabilitation varied widely by goals, settings, and interventions. Studies in hospice settings generally reported improved symptom control; inpatient rehabilitation had mixed functional outcomes; and outpatient palliative rehabilitation may contribute to enhanced functional and symptom outcomes, especially among patients with higher baseline function. Palliative cancer rehabilitation emphasizes a collaborative approach that integrates palliative care with rehabilitation interventions, aiming to enhance quality of life and address diverse patient needs. Further research and standardization are necessary to realize its full potential.

Using Performance Status to Identify Risk of Acute Care Transfer in Inpatient Cancer Rehabilitation

OBJECTIVE

To identify patient factors associated with acute care transfer (ACT) among cancer survivors admitted for inpatient medical rehabilitation.

DESIGN

An exploratory, observational design was used to analyze retrospective data from electronic medical records.

SETTING

Data were obtained from 3 separate inpatient rehabilitation hospitals within a private rehabilitation hospital system in the Northeast.

PARTICIPANTS

Medical records were reviewed and analyzed for a total of 416 patients with a confirmed oncologic diagnosis treated in 1 of the inpatient rehabilitation hospitals between January and December 2020.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of an ACT. Covariates included the adapted Karnofsky Performance Scale (KPS) for inpatient rehabilitation, demographic information, admission date, re-admission status, discharge destination, and cancer-related variables, such as primary cancer diagnosis and presence/location of metastases.

RESULTS

One in 5 patients (21.2%) were transferred to acute care. Patients with hematologic cancer had a higher risk of ACT compared with those with central nervous system (CNS) cancer. Lower functional status, measured by the adapted KPS, was associated with a higher likelihood of ACT. Patients with an admission KPS score indicating the need for maximum assistance had the highest transfer rate (59.1%).

CONCLUSIONS

These findings highlight the medical complexity of this population and increased risk of an interrupted rehabilitation stay. Considering patients' performance status, cancer type, and extent of disease may be important when assessing the appropriateness of IRF admission relative to patient quality of life. Earlier and improved understanding of the patient's prognosis will allow the cancer rehabilitation program to meet the patient's unique needs and facilitate an appropriate discharge to the community in an optimal window of time.

Post-acute Care Needs and Benefits of Inpatient Rehabilitation Care for the Oncology Patient

PURPOSE OF REVIEW

This study aims to assess recent literature published on the post-acute care needs of cancer patients, specifically focusing on the acute inpatient rehabilitation setting.

RECENT FINDINGS

The neurologic cancer population appears to be the most studied oncologic population in acute inpatient rehabilitation studies within the past 5 years. This finding is consistent with prior findings from the past several decades. Recent trends in inpatient cancer rehabilitation note a population with lower admission functional status and shorter lengths of stay compared to prior studies. Despite these findings, the percentage discharged to the community remains high. With new treatments yielding improved survival, cancer patients may live longer and risk accumulating more functional impairments. Physicians involved in their care must understand post-acute care needs and work in a multidisciplinary group to best determine post-acute disposition. This decision remains very individualized and should consider both oncologic and functional needs.

Urinary Dysfunction: Frequency, Risk factors, and Interventions in patients with Cancer during Acute Inpatient Rehabilitation

Introduction: Urinary dysfunction has a strong impact clinically, socially, and economically. Although the development of acute urinary dysfunction in hospitalized patients with cancer is common in clinical practice, its occurrence and management strategies are scant in the literature. It has been reported as one of the more common medical complications in patients with cancer undergoing acute inpatient rehabilitation. This study assessed the frequency of and risk factors for acute urinary dysfunction among these patients and identified the interventions used for management. Methods: This is a retrospective study of consecutive patients admitted to a National Cancer Institute Comprehensive Cancer Center's acute inpatient rehabilitation service from 9/1/2020 through 3/15/2021. We excluded patients that were readmissions during the study time frame. We collected patients' demographic, clinical, and functional data. We defined acute urinary dysfunction as the development of any new urinary symptom(s) or diagnosis, which involved additional work-up and/or management after admission to the acute inpatient rehabilitation service. Results: Of the 176 total patients included in this study, 47 (27%; 95% confidence interval [CI], 20-34) patients had acute urinary dysfunction. The most frequent diagnoses were urinary tract infection (32%) and neurogenic bladder (26%). The most common tests were urine cultures (32%) and urinalyses (30%). The most commonly prescribed medications were antibiotics (32%) and alpha-1 blockers (15%). Other most frequent interventions included timed voiding (34%) and intermittent catheterization with bladder scans (28%). Acute urinary dysfunction was associated with an increased length of stay on the inpatient rehabilitation service (odds ratio [OR], 1.13; 95% CI, 1.06-1.20; P<.001), surgery during the index admission (OR, 2.50; 95% CI, 1.21-5.16; P=.014), and fecal incontinence (OR, 6.41; 95% CI, 1.83-22.44; P=.004). Conclusion: Acute urinary dysfunction was noted to be a substantial problem in this cohort. This is an overlooked dimension of inpatient cancer rehabilitation that deserves more attention. Patients at risk for acute urinary dysfunction may benefit from close monitoring for medical management and rehabilitation interventions to maximize functional independence with bladder care. More research regarding acute urinary dysfunction types and management approaches in post-acute care settings for patients with cancer is justified.

Translation of Karnofsky Performance Status (KPS) for use in inpatient cancer rehabilitation

BACKGROUND

Better tools are needed to predict functional decline and oncologic prognosis in inpatient cancer rehabilitation. The Karnofky Performance Status (KPS) is a widely used scale of functional performance in oncology, although the scale differs from current rehabilitation terminology. Use of the KPS in inpatient rehabilitation may support a shared method of communication between cancer rehabilitation providers and the primary oncology teams.

OBJECTIVE

To establish interrater reliability for translation of the KPS for use in inpatient cancer rehabilitation.

DESIGN

Retrospective interrater reliability review.

SETTING

A large inpatient rehabilitation hospital system.

PARTICIPANTS

Fifty randomized charts were chosen for review from a larger database of all patients admitted to an inpatient cancer rehabilitation program in 2020.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The KPS scale was translated into common inpatient rehabilitation grading consistent with the Continuity and Assessment Record and Evaluation (CARE) Item Set to support its use in this specialty area. Additionally, a list of best practice guidelines and scoring instructions were created to assist raters in determining appropriate levels within the scale. Members of the inpatient cancer rehabilitation team scored all patients within the larger database (n = 424) throughout 2020. A blinded rater completed retrospective chart reviews to score the 50-chart sample. A two-way random effects model was used to calculate an intraclass correlation coefficient (ICC) for the KPS scores at each of three time points (premorbid, admission, and discharge).

RESULTS

The KPS interpretation for rehabilitation proved to be statistically reliable for the 50-chart sample. The premorbid KPS interrater reliability was acceptable (ICC = 0.67; 95% confidence interval [CI]: 0.40-0.82), admission KPS reliability was good (ICC = 0.88, 95% CI: 0.78-0.93), and discharge reliability was excellent (ICC = 0.96; 95% CI: 0.91-0.98).

CONCLUSION

The KPS translation at three time points (premorbid, admission, and discharge) during the inpatient rehabilitation continuum has acceptable interrater reliability.

Frequency and Characteristics of Medical Complications in Rehabilitation Settings: A Scoping Review

OBJECTIVE

To synthesize the available evidence on medical complications occurring in adult patients in subacute inpatient rehabilitation, and to describe the impact on subacute length of stay and readmission to acute care.

DESIGN

Scoping review.

SUBJECTS

Adult patients, within the inpatient rehabilitation environment, who experienced medical complications, clinical deterioration and/or the requirement of transfer to acute care.

METHODS

A systematic search of MEDLINE and CINAHL electronic databases was undertaken to identify primary research studies published in English and French during the period 2000-2021. Study reporting followed the standards indicated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR).

RESULTS

A total of 47 studies were identified for inclusion. Key results included differences in the type and frequency of complications according to admission type, the proportion of patients experiencing at least 1 complication, and complications associated with transfer to acute care.

CONCLUSION

Patients admitted for inpatient rehabilitation are at high risk of medical complications and may not be medically stable during their admission, requiring care by clinicians with expertise in functional rehabilitation, and ongoing management by members of the multidisciplinary team with expertise in acute general medicine, infectious diseases and recognition and response to clinical deterioration.

Palliative Rehabilitation in Acute Inpatient Rehabilitation: Prognostic Factors and Functional Outcomes in Patients with Cancer

BACKGROUND

Prognosis has a vital role for patients with cancer undergoing palliative rehabilitation in acute inpatient rehabilitation. This study aimed to identify the proportion of patients who survived <2 months after discharge and the associated prognostic factors.

MATERIALS AND METHODS

This was a secondary analysis of a retrospective study of 163 consecutive patients admitted to acute inpatient rehabilitation from September 1, 2017, to February 28, 2018 at a cancer center. Baseline demographics, clinical characteristics, and putative prognostic factors, including Activity Measure for Post-Acute Care (AM-PAC) functional scores, were analyzed.

RESULTS

Of 163 patients, 27 (17%; 95% CI, 11-23) died within 60 days of discharge. These patients were more likely to be male (OR = 2.83; 95% CI, 1.16-6.92; P = .017); have longer hospital stays (OR = 1.02; 95% CI, 1-1.04; P = .015); receive ≥ weekly packed red blood cell (OR = 5.31; 95% CI, 1.86-15.1; P = .003) or platelet (OR = 4.57; 95% CI, 1.44-14.5; P = .014) transfusions; have lower AM-PAC daily activity scores upon discharge (OR = 0.90; 95% CI, 0.83-0.97; P = .006); and have lower AM-PAC basic mobility scores upon admission (OR = 0.91; 95% CI, 0.85-0.98; P = .018) and discharge (OR = 0.88; 95% CI, 0.82-0.94; P = <.001). Multivariate analysis showed that the male sex (OR = 2.71; 95% CI, 1.03-7.15; P = .037) was independently associated with ≤2 months survival, whereas AM-PAC basic mobility score at admission of >33 (OR = 0.24, 95% CI, 0.07-0.79; P = .022) was less likely.

CONCLUSION

Approximately 1 in 6 patients who completed acute inpatient rehabilitation died within 2 months of discharge, had poorer baseline functional status, and were less likely to regain function than those who lived longer.

Analysis of Adherence to Acute Inpatient Rehabilitation in Patients with Cancer

Importance: The need for cancer rehabilitation is expected to continue to dramatically increase with the aging population and increasing number of cancer survivors. These survivors experience a wide range of physical limitations and symptoms that negatively affect their health and quality of life. Research is needed to determine the rate of adherence, reasons for non-adherence, and interventions to improve adherence to acute inpatient rehabilitation among patients with cancer.

Objective: To evaluate the rate of adherence and reasons for non-adherence to acute inpatient rehabilitation in patients with cancer.

Design, Setting, and Participants: This was a secondary analysis of a retrospective study that assessed medical complications in 165 patients with cancer who had a median length of stay of 11 days (interquartile range of 8-14) in acute inpatient rehabilitation. We reviewed the records of all consecutive patients who underwent acute inpatient rehabilitation from September 1, 2017 through February 28, 2018 at a large academic, quaternary National Cancer Institute-designated Cancer Center.

Main Outcomes and Measures: We calculated the rehabilitation session adherence rate and descriptively summarized the reasons for non-adherence.

Results: There were 78/165 (47%) patients that had 1 or more incomplete rehabilitation sessions due to medical complications. These patients had a median of 2 (interquartile range of 1-4) incomplete rehabilitation sessions. We noted other reasons for incomplete rehabilitation sessions in 146/165 (89%) patients, who had a median of 3 (interquartile range of 2-4) incomplete rehabilitation sessions. The median total number of days with incomplete rehabilitation sessions in the entire cohort was 2 (interquartile range 1-3).

Conclusion and Relevance: Among patients with cancer undergoing acute inpatient rehabilitation, the adherence rate to 1-hour long intensive rehabilitation sessions were low due to medical complications and other reasons. This in turn affected compliance with the 3 hours of rehabilitation a day requirement for acute inpatient rehabilitation. Patients with cancer undergoing acute inpatient rehabilitation are medically complex and further research at multiple institutions with larger cohorts may be beneficial in further assessing adherence rates and reasons for non-adherence to improve participation in acute inpatient rehabilitation.

Thirty-day hospital readmission rate, reasons, and risk factors after acute inpatient cancer rehabilitation

Objectives

To evaluate the 30‐day hospital readmission rate, reasons, and risk factors for patients with cancer who were discharged to home setting after acute inpatient rehabilitation.

Design, Setting, and Participants

This was a secondary retrospective analysis of participants in a completed prospective survey study that assessed the continuity of care and functional safety concerns upon discharge and 30 days after discharge in adults. Patients were enrolled from September 5, 2018, to February 7, 2020, at a large academic quaternary cancer center with National Cancer Institute Comprehensive Cancer Center designation.

Main Outcomes and Measures

Thirty‐day hospital readmission rate, descriptive summary of reasons for readmissions, and statistical analyses of risk factors related to readmission.

Results

Fifty‐five (21%) of the 257 patients were readmitted to hospital within 30 days of discharge from acute inpatient rehabilitation. The reasons for readmissions were infection (20, 7.8%), neoplasm (9, 3.5%), neurological (7, 2.7%), gastrointestinal disorder (6, 2.3%), renal failure (3, 1.1%), acute coronary syndrome (3, 1.1%), heart failure (1, 0.4%), fracture (1, 0.4%), hematuria (1, 0.4%), wound (1, 0.4%), nephrolithiasis (1, 0.4%), hypervolemia (1, 0.4%), and pain (1, 0.4%). Multivariate logistic regression modeling indicated that having a lower locomotion score (OR = 1.29; 95% CI, 1.07–1.56; p = 0.007) at discharge, having an increased number of medications (OR = 1.12; 95% CI, 1.01–1.25; p = 0.028) at discharge, and having a lower hemoglobin at discharge (OR = 1.31; 95% CI, 1.03–1.66; p = 0.031) were independently associated with 30‐day readmission.

Conclusion and Relevance

Among adult patients with cancer discharged to home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation.

Research is needed to determine the rates of and risk factors for 30‐day hospital readmission after acute inpatient cancer rehabilitation to understand the nature of this problem and to decrease costs associated with readmissions. Among adult patients with cancer discharged to a home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation. Cancer rehabilitation patients may have unique risk factors for readmission.