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Olson J, Mo KC, Schmerler J, Harris AB, Lee JS, Skolasky RL, Kebaish KM, Neuman BJ. AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery. Clin Spine Surg 2024:01933606-990000000-00279. [PMID: 38490976 DOI: 10.1097/bsd.0000000000001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 01/22/2024] [Indexed: 03/18/2024]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus. SUMMARY OF BACKGROUND DATA Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition. METHODS Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables. RESULTS Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus. CONCLUSIONS In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Jarod Olson
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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Prochaska MT, Bogue K, Williams S, Levine S, Zhang H, Tate A, Arora V, Meltzer D. The Design and Early Results of a Structured Longitudinal Training Program for Undergraduate Students to Increase Diversity in Aging-Research. Int J Aging Hum Dev 2024:914150241231183. [PMID: 38321715 DOI: 10.1177/00914150241231183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Background: The Cultivating Health and Aging Researchers by Integrating Science, Medicine, and Aging (CHARISMA) program at the University of Chicago (UC), is an NIA-funded longitudinal clinical research training program for undergraduate students from groups underrepresented in the sciences and medicine. CHARISMA students participate in an aging-focused: 1) realistic research career experience, 2) didactic curriculum, and 3) multi-tiered mentorship program. This manuscript describes CHARISMA and early quantitative data demonstrating its success. Methods: Students apply for and are accepted into CHARISMA in year-long intervals, with programming lasting from June to May. Short-term outcomes are measured using student surveys, including an adapted 23-question version of the critical research appraisal inventory (CRAI), the Geriatrics Attitude Scale for Primary Care Residents, and questions rating the overall program, mentor, importance of aging research, and career interests. Results: Twenty-two students have completed CHARISMA. After completing CHARISMA, student aggregate CRAI scores increased (6.8 to 7.5, p = 0.04). Additionally, the substantial majority of students completing CHARISMA were definitely, very or somewhat Additionally, 87% (19/22), 73% (16/22), and 82% (18/22) of students were definitely, very, or somewhat interested in pursuing a career in medicine that serves older adults, pursuing a career in clinical research, or pursuing a career focused on aging-related research. Conclusion: Early data demonstrates that CHARISMA increases undergraduate student knowledge of and interest in aging-related clinical research.
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Affiliation(s)
- Micah T Prochaska
- The Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Kelsey Bogue
- The Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Shellie Williams
- Section of Geriatrics and Palliative Care, University of Chicago, Chicago, IL, USA
| | - Stacie Levine
- Section of Geriatrics and Palliative Care, University of Chicago, Chicago, IL, USA
| | - Hui Zhang
- The Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Alex Tate
- The Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Vineet Arora
- The Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - David Meltzer
- The Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
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Martinez M, Cerasale M, Baig M, Johnson JK, Dugan C, Brown A, Robinson M, Schram A, Greysen SR, Meltzer D, Baccile R, Arora VM. Reducing Physical Therapy Consults for Patients With High Functional Mobility in the Acute Medical Inpatient Setting: A Difference-in-Difference Analysis. Arch Phys Med Rehabil 2024; 105:125-130. [PMID: 37669704 PMCID: PMC10840724 DOI: 10.1016/j.apmr.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of clinical decision support for reducing misallocation of physical therapy (PT) consults. DESIGN A prospective quasi-experimental study. Between October 2018 and November 2021, routinely documented data on functional status and physical therapy referrals were collected from electronic medical records. SETTING Hospital Medicine and General Internal Medicine service lines at a large quaternary academic medical center. PARTICIPANTS 20,810 adult patients hospitalized on any of the included treatment (hospital medicine) or control (general internal medicine) service lines. MAIN OUTCOME MEASURE The primary outcome was "change in proportion of misallocated PT consults" measured as likelihood of PT consults for patients admitted with high functional mobility scores. Changes in the primary outcome from the pre-intervention to post-intervention period were compared in the control and treatment groups using propensity score-weighted difference-in-differences multivariable logit regression adjusting for clinically relevant covariates. INTERVENTION The intervention period was measured for 20 months and consisted of a clinical decision support tool embedded in the daily note templates for hospital medicine providers. The tool provided education on patient mobility scores and their relation to need for PT consult. The tool was rolled out without any further announcements or education. RESULTS Our cohort included 20,810 unique admissions (mean age 58.9, 55% women, 83% Black). Post-intervention, the likelihood of PT referrals for patients with high baseline mobility (AM-PAC >18) decreased by 7.3% (P<.001) for the treatment group compared with control, adjusted for age, sex, race, ethnicity, length-of-stay, and mobility change. CONCLUSION Mobility score-based clinical decision support can decrease unneeded PT consults in the inpatient setting. This could help allocate therapy time for at-risk patients while also having a positive effect on health care systems.
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Affiliation(s)
- Maylyn Martinez
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL.
| | - Matthew Cerasale
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | | | - Joshua K Johnson
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH
| | - Claire Dugan
- Section of General Internal Medicine, Department of Medicine, University of Chicago, IL
| | | | - Marla Robinson
- Inpatient Therapy Services Department, University of Chicago, Chicago, IL
| | - Andrew Schram
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - S Ryan Greysen
- Section of Hospital Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David Meltzer
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Rachel Baccile
- Center for Health and Social Sciences, University of Chicago, Chicago, IL
| | - Vineet M Arora
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH
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Patel M, Gardner TA, White C, Keniston A, Maassen B, Gottenborg E. Interventions to Reduce Inappropriate Physical Therapy Consultation in the Inpatient Setting: A Quality Improvement Initiative. J Healthc Qual 2023; 45:332-339. [PMID: 37919955 DOI: 10.1097/jhq.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
ABSTRACT Physical therapy (PT) in inpatient settings is a limited and valuable resource. Inappropriate PT consultation is costly and can lead to delays in care and discharge planning. Baseline data at an academic hospital revealed that approximately one in four PT consults were inappropriate (n = 29,230) across all services, as defined by an activity measure post-acute care "6-Clicks" basic mobility score of >22. Our interdisciplinary quality improvement team used the Six Sigma methodology to address this problem. We performed a root-cause analysis that identified high-impact root causes and implemented two targeted interventions: (1) A modified electronic health record PT order with clinical-decision support, and (2) nursing role change to assume PT-ordering responsibility. The rate of inappropriate PT consults decreased from 23.9% to <10% postintervention across all inpatient units, with the nursing role change reaching statistical significance (p < .0019). Our multifaceted intervention contributed to a significant reduction in unnecessary PT consults, expediting evaluation of patients qualifying for skilled inpatient therapy.
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Capo-Lugo CE, McLaughlin KH, Ye B, Daley K, Young D, Lavezza A, Friedman M, Hoyer EH. Using Nursing Assessments of Mobility and Activity to Prioritize Patients Most Likely to Need Rehabilitation Services. Arch Phys Med Rehabil 2023; 104:1402-1408. [PMID: 37028697 DOI: 10.1016/j.apmr.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 02/03/2023] [Accepted: 03/19/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To identify nursing assessments of mobility and activity associated with lower-value rehabilitation services. DESIGN Retrospective cohort analysis of admissions from December 2016 to September 2019 SETTING: Medicine, neurology, and surgery units (n=47) at a tertiary hospital. PARTICIPANTS We included patients with a length of stay ≥7 days on units that routinely assessed patient function (n=18,065 patients). INTERVENTIONS Not applicable. MAIN OUTCOME We examined the utility of nursing assessments of function to identify patients who received lower-value rehabilitation consults, defined as those who received ≤1 therapy visit. MEASURES Patient function was assessed using 2 Activity Measure for Post-Acute Care (AM-PAC or "6 clicks") inpatient short forms: (1) basic mobility (eg, bed mobility, walking) and (2) daily activity (eg, grooming, toileting). RESULTS Using an AM-PAC cutoff value of ≥23 correctly identified 92.5% and 98.7% of lower-value physical therapy and occupational therapy visits, respectively. In our cohort, using a cutoff value of ≥23 on the AM-PAC would have eliminated 3482 (36%) of lower-value physical therapy consults and 4076 (34%) of lower-value occupational therapy consults. CONCLUSIONS Nursing assessment, using AM-PAC scores, can be used to help identify lower-value rehabilitation consults, which can then be reallocated to patients with greater rehabilitation needs. Based on our results, an AM-PAC cutoff value of ≥23 can be used as a guide to help prioritize patients with greater rehabilitation needs.
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Affiliation(s)
- Carmen E Capo-Lugo
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Kevin H McLaughlin
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Bingqing Ye
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kelly Daley
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel Young
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, Nevada, United States
| | - Annette Lavezza
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
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Johnson JK, Young DL, Guo N, Tereshchenko LG, Martinez M, Hohman JA, Rothberg MB. Physical therapy provision for patients with pneumonia in US hospitals. J Hosp Med 2023; 18:787-794. [PMID: 37602532 DOI: 10.1002/jhm.13179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/07/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Physical therapy (PT) appears beneficial for hospitalized patients. Little is known about PT practice patterns and costs across hospitals. OBJECTIVE To examine whether receiving PT is associated with specific patient and hospital characteristics for patients with pneumonia. We also explored the variability in PT service provision and costs between hospitals. METHODS We included administrative claims from 2010 to 2015 in the Premier Healthcare Database, inclusive of 644 US hospitals. We examined associations between receiving at least one PT visit and patient (age, race, insurance, intensive care utilization, comorbidity status, and length of stay) and hospital (academic status, rurality, size, and location) characteristics. Exploratory measures included timing and proportion of days with PT visits, and per-visit and per-admission costs. RESULTS Of 768,010 patients, 49% had PT. After adjustment, older age most significantly increased the probability of receiving PT (+38.0% if >80 vs. ≤50 years). Higher comorbidity burden, longer length of stay, and hospitalization in an urban setting were also associated with higher probability. Hospitalization in the South most significantly decreased the probability (-9.1% vs. Midwest). Patients without Medicare and Non-White patients also had lower probability. Median (interquartile range) days to first visit was 2 (1-4). Mean proportion of days with a visit was 35% ± 20%. Median per-visit cost was $88.90 [$56.70-$130.90] and per-admission was $224.00 [$137.80-$369.20]. CONCLUSION Both clinical (intensive care utilization and comorbidity status) and non-clinical (age, race, rurality, location) factors were associated with receiving PT. Within and between hospitals, there was high variability in the number and frequency of visits, and costs.
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Affiliation(s)
- Joshua K Johnson
- Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Rehabilitation and Sports Therapy, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel L Young
- Department of Physical Therapy, University of Nevada-Las Vegas, Las Vegas, Nevada, USA
| | - Ning Guo
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Maylyn Martinez
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jessica A Hohman
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, Ohio, USA
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Rauzi MR, Ridgeway KJ, Wilson MP, Jolley SE, Nordon-Craft A, Stevens-Lapsley JE, Erlandson KM. Rehabilitation Therapy Allocation and Changes in Physical Function Among Patients Hospitalized Due to COVID-19: A Retrospective Cohort Analysis. Phys Ther 2023; 103:pzad007. [PMID: 37172130 PMCID: PMC10071586 DOI: 10.1093/ptj/pzad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/03/2022] [Accepted: 12/28/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Limited staffing and initial transmission concerns have limited rehabilitation services during the COVID-19 pandemic. The purpose of this analysis was to determine the associations between Activity Measure for Post-Acute Care (AM-PAC) mobility categories and allocation of rehabilitation, and in-hospital AM-PAC score change and receipt of rehabilitation services for patients with COVID-19. METHODS This was a retrospective cohort study of electronic health record data from 1 urban hospital, including adults with a COVID-19 diagnosis, admitted August 2020 to April 2021. Patients were stratified by level of medical care (intensive care unit [ICU] and floor). Therapy allocation (referral for rehabilitation, receipt of rehabilitation, and visit frequency) was the primary outcome; change in AM-PAC score was secondary. AM-PAC Basic Mobility categories (None [21-24], Minimum [18-21], Moderate [10-17], and Maximum [6-9]) were the main predictor variable. Primary analysis included logistic and linear regression, adjusted for covariates. RESULTS A total of 1397 patients (ICU: n = 360; floor: n = 1037) were included. AM-PAC mobility category was associated with therapy allocation outcomes for floor but not patients in the ICU: the Moderate category had greater adjusted odds of referral (adjusted odds ratio [aOR] = 10.88; 95% CI = 5.71-21.91), receipt of at least 1 visit (aOR = 3.45; 95% CI = 1.51-8.55), and visit frequency (percentage mean difference) (aOR = 42.14; 95% CI = 12.45-79.67). The secondary outcome of AM-PAC score improvement was highest for patients in the ICU who were given at least 1 rehabilitation therapy visit (aOR = 5.31; 95% CI = 1.90-15.52). CONCLUSION AM-PAC mobility categories were associated with rehabilitation allocation outcomes for floor patients. AM-PAC score improvement was highest among patients requiring ICU-level care with at least 1 rehabilitation therapy visit. IMPACT Use of AM-PAC Basic Mobility categories may help improve decisions for rehabilitation therapy allocation among patients who do not require critical care, particularly during times of limited resources.
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Affiliation(s)
- Michelle R Rauzi
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado USA
| | - Kyle J Ridgeway
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado USA
- Inpatient Rehabilitation Therapy Department, University of Colorado Hospital, University of Colorado Health, Aurora, Colorado, USA
| | - Melissa P Wilson
- Department of Biomedical Informatics, University of Colorado, Aurora, Colorado, USA
| | - Sarah E Jolley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Amy Nordon-Craft
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado USA
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado USA
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Kristine M Erlandson
- Division of Infectious Diseases, Department of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
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Tommasini F, Marques-Vidal P, Kayser B, Tasheva P, Ionescu A, Méan M. Steps parameters of elderly patients hospitalised for an acute medical illness in a Swiss University Hospital: a monocentric observational pilot-study. Swiss Med Wkly 2022; 152:40012. [PMID: 36534909 DOI: 10.57187/smw.2022.40012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Objective mobility goals for elderly hospitalised medical patients remain debated. We therefore studied steps parameters of elderly patients hospitalised for an acute illness, to determine goals for future interventional trials and medical practice. METHODS Observational study conducted from February to November 2018 in a medical ward of the Lausanne University Hospital, Switzerland. We measured the step parameters of consecutive medical patients aged ≥65 years admitted for an acute medical illness using a wrist accelerometer (Geneactiv). We also collected demographic, somatic and functional factors. RESULTS Overall, 187 inpatients had their step parameters (daily step count, walking cadence and bout duration) measured with accelerometers worn for a mean of 3.6 days (standard deviation [SD] 3.2). Elderly inpatients (81.5 years, SD 8.5) walked a median of 603 steps daily (interquartile range [IQR] 456-809), at a median cadence of 100 steps/minute (IQR 99-101) with median walking bouts of 33 seconds (IQR 27-37) and with 70% of the walking bouts lasting less than 30 seconds. Patients walking ≥600 steps were younger (80.4 years, SD 8.9 vs 82.8 years,SD 7.9, p = 0.050) and had a longer length of stay (7.8 days, SD 5.1 vs 6.1 days, SD 4.1, p = 0.011) than those walking <600 steps. Patients at high risk of bed sores walked less (564 steps, IQR 394-814 vs 626, IQR 526-840) than those with a lower risk of sores. CONCLUSION During a hospitalisation for an acute medical illness, patients aged ≥65 years walk a mere 603 steps daily and most of the time for periods of less than 30 seconds. This information should be used to build up future interventional trials or to set mobility goals for patients hospitalised in Swiss hospitals.
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Affiliation(s)
- Francesco Tommasini
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Pedro Marques-Vidal
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Bengt Kayser
- Institute of Sport Sciences, University of Lausanne, Switzerland
| | - Plamena Tasheva
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | | | - Marie Méan
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
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Schmerler J, Mo KC, Olson J, Kurian SJ, Skolasky RL, Kebaish KM, Neuman BJ. Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery. Spine J 2022; 23:746-753. [PMID: 36509380 DOI: 10.1016/j.spinee.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/12/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND CONTEXT Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients. PURPOSE To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery. DESIGN Retrospective review. PATIENT SAMPLE Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained. OUTCOME MEASURES The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute. METHODS Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM. RESULTS LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM. CONCLUSIONS Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jarod Olson
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shyam J Kurian
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Mo KC, Schmerler J, Olson J, Musharbash FN, Kebaish KM, Skolasky RL, Neuman BJ. AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery. Spine J 2022; 22:1884-1892. [PMID: 35870798 DOI: 10.1016/j.spinee.2022.07.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/26/2022] [Accepted: 07/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery. PURPOSE To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery. STUDY DESIGN Retrospective review PATIENT SAMPLE: Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included. OUTCOME MEASURES Non-home discharge disposition METHODS: Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify the optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold. RESULTS Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge. CONCLUSIONS First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.
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Affiliation(s)
- Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Jarod Olson
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA.
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11
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Describing the Value of Physical Therapy in a Complex System Using the Socio-Ecological Model. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Martinez M, Falvey JR, Cifu A. Deconditioned, disabled, or debilitated? Formalizing management of functional mobility impairments in the medical inpatient setting. J Hosp Med 2022; 17:843-846. [PMID: 35818341 PMCID: PMC9796863 DOI: 10.1002/jhm.12910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Maylyn Martinez
- Department of Medicine, Section of Hospital MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation ScienceUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- Department of Epidemiology and Public HealthUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Adam Cifu
- Department of Medicine, Section of General Internal MedicineUniversity of ChicagoChicagoIllinoisUSA
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13
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Bandovas JP, Leal B, Reis-de-Carvalho C, Sousa DC, Araújo JC, Peixoto P, Henriques SO, Vaz Carneiro A. Broadening risk factor or disease definition as a driver for overdiagnosis: A narrative review. J Intern Med 2022; 291:426-437. [PMID: 35253285 PMCID: PMC9314822 DOI: 10.1111/joim.13465] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).
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Affiliation(s)
- João Pedro Bandovas
- Department of General Surgery, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Beatriz Leal
- Department of Anesthestics, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
| | - Catarina Reis-de-Carvalho
- Department of Obstetrics, Gynecology and Reproductive Medicine, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - David Cordeiro Sousa
- Vision Sciences Study Center, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Vitreoretinal Unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - João Cruz Araújo
- Family Medicine Department, Unidade de Saúde Familiar Gualtar, Braga, Portugal
| | - Pedro Peixoto
- Department of Family Medicine, Unidade de Saúde Familiar do Mar, Póvoa de Varzim, Portugal
| | | | - António Vaz Carneiro
- Institute for Evidence Based Healthcare, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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14
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Hiser S, Urbanek J, Young DL, McLaughlin KH, Colantuoni E, Brotman DJ, Needham DM, Hoyer E. Improving patient selection for use of consumer grade physical activity monitors in the hospital. Braz J Phys Ther 2022; 26:100447. [PMID: 36183578 PMCID: PMC9530475 DOI: 10.1016/j.bjpt.2022.100447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Bedrest is toxic for inpatients and consumer grade physical activity monitors offer an economical solution to monitor patient ambulation. But these devices may not be accurate in debilitated hospitalized patients who frequently ambulate very slowly. OBJECTIVE To determine whether measures of physical capacity can help identify inpatients for whom wearable physical activity monitors may accurately measure step count. METHODS Prospective observational study of 54 adult inpatients with acute neurological diagnoses. Patients were assessed using 2 physical capacity assessments (Activity Measure for Post-Acute Care Inpatient Mobility Short Form [AM-PAC IMSF] and Katz Activities of Daily Living [ADL] scale). They also completed a 2-minute walk test (2MWT) wearing a consumer grade physical activity monitor. RESULTS The wearable activity monitor recorded steps (initiated) in 33 (61%) of the inpatients, and for 94% of inpatients with gait speeds >0.43 m/s. Physical capacity assessments correlated well with gait speed, AM-PAC IMSF r = 0.7, and Katz ADL r = 0.6, p < 0.05. When the physical activity monitor initiated, the mean absolute percent error (SD) comparing device calculated steps to observed steps, was 10% (13). AM-PAC IMSF (T-score >45) and Katz ADL (>5) cutoff scores identified inpatients for whom physical activity monitors initiated with a sensitivity of 94 and 91%, respectively. CONCLUSIONS Physical capacity assessments, such as AM-PAC, and Katz ADL, may be a useful and feasible screening strategy to help identify inpatients where wearable physical activity monitors can measure their mobility.
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Affiliation(s)
- Stephanie Hiser
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacek Urbanek
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel L. Young
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Physical Therapy, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Kevin H. McLaughlin
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel J Brotman
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M. Needham
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erik Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD, USA.
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