Shorter length of stay is associated with worse functional outcomes for medicare beneficiaries with stroke

Linking biomarkers with healthy lifestyle outcomes after stroke: Supplementary results of a 12-month randomized controlled trial

BACKGROUND AND AIMS

Participation in a healthy lifestyle intervention such as the Diabetes Prevention Program Group Lifestyle Balance-adapted for stroke (GLB-CVA) may reduce stroke burden. Identifying biomarkers associated with lifestyle changes may enhance an individualized approach to stroke recovery. We investigated metabolic biomarkers related to cardiovascular and neurological function in individuals with stroke in the GLB-CVA study and healthy (non-stroke) individuals.

METHODS AND RESULTS

Participants with chronic (>12 months) stroke were recruited to this wait-list randomized controlled trial if they were overweight (BMI ≥25 kg/m2). Participants were randomized to (1) the GLB-CVA program to complete 22 educational sessions addressing behavioral principals of dietary and physical activity or (2) a 6 month wait-list control (WLC). Biomarkers [Plasma irisin, vascular endothelial growth factor, lipoprotein-associated phospholipase A2 (Lp-PLA2), insulin-like growth factor 1 and brain-derived neurotrophic factor (BDNF)] were collected at baseline, 3, and 6 months. Age-matched healthy individuals were recruited for biomarker assessment. Compared to healthy adults (n = 19), participants with stroke (GLB-CVA = 24; WLC = 24) at baseline had higher tHcy levels (p < 0.001) and lower PLA2 levels (p = 0.016). No statistically significant interactions were observed for any biomarkers between the GLB-CVA and WLC or between people who achieved 5% weight loss and those who did not.

CONCLUSION

Participation in a 6-month healthy lifestyle program did not result in statistically significant changes to select metabolic biomarker levels for our participants with chronic stroke. However, participants with stroke demonstrated a unique biomarker profile compared to age-matched healthy individuals.

Physical Therapy Provider Continuity Predicts Functional Improvements in Inpatient Rehabilitation

BACKGROUND AND PURPOSE

Health care continuity has been linked to improved patient outcomes in a variety of professions and settings. Patients in inpatient rehabilitation receive a consistent dosage of physical therapy (PT) treatment; however, the providing physical therapist may vary. Despite the potential influence of PT provider continuity on functional outcomes in the inpatient rehabilitation setting, this association has not yet been studied.

METHODS

An observational retrospective chart review was conducted on 555 discharged inpatient rehabilitation patients. The relationship between the number of PT providers from whom a patient received care and Quality Indicator (QI) Mobility discharge scores was examined with Pearson product-moment correlation coefficients, initially with the entire patient group and secondarily with distinct diagnostic groups. Data from subgroups for whom a significant relationship was established were then included in a hierarchical linear regression analysis accounting for relevant covariates.

RESULTS

The number of PT providers correlated negatively with QI Mobility discharge scores ( r = -0.41, P ≤ 0.001). When controlling for QI Mobility admission scores, the "Stroke" (partial r = -0.17, P = 0.02), "Spinal Cord Injury" (partial r = -0.28, P = 0.002), and "Other Neuromuscular" (partial r = -0.35, P = 0.03) groups demonstrated significant inverse relationships. A hierarchical linear regression incorporating these 3 diagnostic groups revealed that the number of PT providers remained a significant predictor of QI Mobility discharge scores ( B = -1.50, P ≤ 0.001) when accounting for covariates.

DISCUSSION AND CONCLUSIONS

PT provider continuity is related to the functional improvement of neurologically impaired patients in inpatient rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A405 , which discusses the findings of this work in a narrative format).

Predicting length of stay with assessment of motor and process skills in subjects with acquired brain injury

BACKGROUND

The Functional Independence Measure (FIM) is a well-established predictor of length of stay (LOS) for rehabilitation. The Assessment of Motor and Process Skills (AMPS) is a more in-depth construct for measuring activities of daily living (ADL) and may therefore be a valuable adjunct when predicting LOS. This paper aimed to investigate AMPS as a candidate predictor of LOS in a statistical model including FIM.

METHODS

A cohort study of 647 patients with acquired brain injuries admitted for rehabilitation. LOS was analyzed in a multiple regression model with the motor and process/cognitive domains of AMPS and FIM.

RESULTS

Independence in ADL process ability and FIM cognition were associated with 31% (p < 0.001) and 38% (p < 0.001) shorter LOS, respectively, relative to patients needing total assistance. Independence in ADL motor ability was associated with a 26% (p = 0.002) shorter LOS, whereas FIM motor was not a predictor.

CONCLUSIONS

The AMPS predicts LOS for rehabilitation at a level that is at least as good as that of FIM. Conducting the AMPS early in the course of inpatient rehabilitation provides clinicians and managers with valuable information for planning LOS.

Interpreting the CPASS Trial: Do Not Shift Motor Therapy to the Subacute Phase

The Critical Periods After Stroke Study (CPASS, n = 72) showed that, compared to controls, an additional 20 hours of intensive upper limb therapy led to variable gains on the Action Research Arm Test depending on when therapy was started post-stroke: the subacute group (2-3 months) improved beyond the minimal clinically important difference and the acute group (0-1 month) showed smaller but statistically significant improvement, but the chronic group (6-9 months) did not demonstrate improvement that reached significance. Some have misinterpreted CPASS results to indicate that all inpatient motor therapy should be shifted to outpatient therapy delivered 2 to 3 months post-stroke. Instead, however, CPASS argues for a large dose of motor therapy delivered continuously and cumulatively during the acute and subacute phases. When interpreting trials like CPASS, one must consider the substantial dose of early usual customary care (UCC) motor therapy that all participants received. CPASS participants averaged 27.9 hours of UCC occupational therapy (OT) during the first 2 months and 9.8 hours of UCC OT during the third and fourth months post-stroke. Any recovery experienced would therefore result not just from CPASS intensive motor therapy but the combined effects of experimental therapy plus UCC. Statistical limitations also did not allow direct comparisons of the acute and subacute group outcomes in CPASS. Instead of shifting inpatient therapy hours to the subacute phase, CPASS argues for preserving inpatient UCC. We also recommend conducting multi-site dosing trials to determine whether additional intensive motor therapy delivered in the first 2 to 3 months following inpatient rehabilitation can further improve outcomes.

Length of Stay and Home Discharge for Patients with Inpatient Stroke Rehabilitation

OBJECTIVE

To examine temporal trends and geographic variations and predict inpatient rehabilitation (IPR) length of stay (LOS) and home discharge for stroke patients.

METHODS

Patients aged ≥18 years who were admitted to an IPR facility in Alberta, Canada, between 04/2014 and 03/2018 (years 2014-2017) were included. Predictors of LOS and home discharge were examined using 2014-2016 data and validated using 2017 data. Multivariable linear regression (MLR), multivariable negative binomial (MNB), and multivariable quantile regressions (MQR) were used to examine LOS, and logistic regression was used for home discharge.

RESULTS

We included 2686 rehabilitation admissions between 2014 and 2017. The mean LOS decreased (2014: 71 days; 2017: 62.1 days; p = 0.003) during the study period and was shortest in Edmonton (59.1 days) compared to Calgary (66 days) or other localities (70.8 days; p < 0.001). Three-quarters of patients were discharged home and this proportion remained unchanged between 2014 and 2017. Calgary patients were more likely to be discharged home than those in Edmonton (OR = 0.62; p = 0.019) or other localities (OR = 0.39; p = 0.011). The MLR and MNB models provided accurate prediction for the mean LOS (predicted = 59.9 and 60.8 days, respectively, vs. actual = 62.1 days; both p > 0.5), while the MQR model did so for the median LOS (predicted = 44.3 days vs. actual = 44 days; p = 0.09). The logistic regression resulted in 82.4% of correct prediction, a sensitivity of 91.6%, and a specificity of 50.7% for home discharge.

CONCLUSIONS

Rehabilitation LOS decreased while the proportion of home discharge remained unchanged during the study period. Both varied across health zones. Identifiable statistical models provided accurate prediction with a separate patient cohort.

Prism Adaptation Treatment of Spatial Neglect: Feasibility During Inpatient Rehabilitation and Identification of Patients Most Likely to Benefit

Objective

Spatial Neglect is prevalent among stroke survivors, yet few treatments have evidence supporting efficacy. This study examines the feasibility of Prism Adaptation Treatment (PAT) within an inpatient rehabilitation facility and the degree by which PAT improves symptoms of spatial neglect and functional independence among sub-acute survivors of right hemispheric stroke.

Design

In this retrospective cohort study, 37 right hemispheric stroke patients were identified as having received at least 4 PAT sessions during their inpatient stay. Spatial neglect and functional independence levels of patients in the PAT cohort were compared to a matched active control group comprised of rehabilitation patients receiving alternative therapies to address neglect admitted during the same time period.

Results

Most patients received the full recommended 10 sessions of PAT (average sessions completed = 8.6). A higher percentage of severe neglect patients receiving PAT (69%) displayed clinically significant gains on FIM (≥22 points) compared to those receiving alternative treatments (6%). Patients with mild or moderate neglect in the PAT cohort did not exhibit greater benefit than controls.

Conclusion

Provision of PAT for treatment of spatial neglect in right hemispheric stroke patients was feasible during the inpatient rehabilitation admission. Patients with severe neglect showed the most benefit from PAT.

Clinical Trial Registration

This study was registered as a retrospective observational study on Itab Clinical Trials.gov. NCT04977219.

Young individuals with stroke in rehabilitation: a cohort study

Stroke in younger populations is a public health crisis and the prevalence is rising. Little is known about the progress of younger individuals with stroke in rehabilitation. Characterization of the course and speed of recovery is needed so that rehabilitation professionals can set goals and make decisions. This was a cohort study with data extracted from electronic medical records. Participants were 408 individuals diagnosed with stroke who participated in inpatient rehabilitation in an urban, academic medical center in the USA. The main predictor was age which was categorized as (18-44, 45-64, 65-74 and 75+). Outcomes included baseline-adjusted discharge functional independence measure (FIM) scores and FIM efficiency. In linear regression models for FIM scores, the reference category was the youngest age group. The oldest group was discharged with significantly lower FIM total (B = -8.84), mobility (B = -4.13), self-care (B = -4.07) and cognitive (B = -1.57) scores than the youngest group after controlling for covariates. The 45-64 group also finished with significantly lower FIM total (B = -6.17), mobility (B = -2.61) and self-care (B = -3.01) scores than youngest group. FIM efficiencies were similar for all ages in each of the FIM scales. Younger individuals with stroke make slightly greater functional gains compared to older individuals with stroke, but other factors, such as admission scores, are more important and the rates of recovery may be similar.

Usability of affordable feedback-based technologies to improve mobility and physical activity in rehabilitation: a mixed methods study

PURPOSE

To explore physiotherapists' views on the usability of feedback-based technologies used in physical rehabilitation.

MATERIALS AND METHODS

A mixed methods study which was nested within a randomised controlled trial to investigate the effectiveness of affordable feedback-based technologies to improve mobility and physical activity within aged care and neurological rehabilitation. Technologies included virtual reality systems, handheld device apps and wearable devices. Physiotherapists (n = 11) who were involved in prescribing technologies during the trial rated the usability of 11 different devices using the System Usability Scale (SUS), then attended a focus group. Descriptive statistics and framework analysis were used for analysis.

RESULTS

Fitbit devices (mean 89.8, SD 9.3), Fysiogaming (mean 75.6, SD 15.3) and Xbox Kinect (mean 75.5, SD 11.2) rated in the acceptable range (>70) on the SUS. Three key factors on usability emerged from the focus groups: (1) Key device features relating to practicalities (ease of set up and use, reliability, safety) and therapeutic benefit (customisation, high active practice time, useful feedback) are important for usability; (2) Usability depends on the context of use; and (3) Usability can be enhanced with technical, clinical, environmental and financial support.

CONCLUSIONS

Health service managers and clinicians should consider key device features identified, contextual factors of their service, and supports available when selecting technologies for use in clinical practice. Further collaboration between clinicians, researchers and technology developers would benefit future technology development, particularly taking into consideration the identified key device features from this study.IMPLICATIONS FOR REHABILITATIONTechnology selection should be based on key device features relating to both practicalities and therapeutic benefit.Contextual factors and available supports should also be considered when selecting technologies.Key usability features identified in this study such as ease of set up, reliability and customisability should be considered in the design of future feedback-based technologies to optimise usability in physical rehabilitation.

The Role of Physical Therapy in Multiple Risk Factor Management Poststroke: A Scoping Review

BACKGROUND AND PURPOSE

Individuals after stroke often have multiple chronic conditions, such as hypertension, diabetes, dyslipidemia, obesity, and tobacco use. These comorbidities not only are commonly found in individuals with stroke, but also negatively affect functional outcomes and increase risk for hospital readmission and overall mortality. It is important for physical therapists to address the whole person during treatment after stroke, including comorbidities, not just the problems resulting from the stroke itself. However, it is unclear how common it is for physical therapists to address multiple diagnoses at once using a wellness model. Therefore, the purpose of this scoping review was to examine current evidence regarding the role of physical therapy in addressing modifiable risk factors for individuals after stroke, to identify gaps in research associated with physical therapy management of related comorbid diagnoses during treatment for stroke.

METHODS

A scoping review methodology was utilized searching PubMed and CINAHL databases to identify interventional research studies specifically addressing multiple modifiable risk factors utilizing physical therapy for individuals after stroke.

RESULTS

The initial search yielded 5358 articles and 12 articles met full inclusion criteria. Only 2 studies included participants with significant mobility impairments, and none included individuals with communication impairments. Only 4 of the 12 studies provided education in their design. Eight studies did not include any patient-reported outcome measures. Only 3 studies included long-term follow-up assessments.

DISCUSSION

Secondary stroke risk factors can be positively addressed using physical therapy interventions; however, more research is needed regarding individuals with moderate to severe mobility or communication deficits. Opportunities for physical therapy research to address stroke risk factors in this complex population include expanding follow-up periods, improving educational interventions, and including caregivers in study design.

CONCLUSIONS

This review highlights the need for better integration of clinical considerations into stroke rehabilitation research as a whole, along with the need for additional research regarding the role physical therapy can play in addressing multimorbidity in individuals with stroke.

Home program practices for supporting and measuring adherence in post-stroke rehabilitation: a scoping review

BACKGROUND

After stroke, individuals face a variety of impairments that impact function. Increasingly, rehabilitation for these impairments has moved into the community and home settings through the use of home programs. However, adherence to these programs is often low, limiting effectiveness.

OBJECTIVE

This scoping review investigated home program implementation and measurement of adherence with persons post-stroke to identify commonly reported practices and determine areas for further research.

METHODS

The electronic databases of PubMed, CINAHL, Scopus, Cochrane Database of Systematic Reviews, and PEDro were searched. Studies focused on post-stroke rehabilitation with an independent home program were selected. Qualitative studies, commentaries, and single-case studies were excluded. Title and abstract screenings were completed by two reviewers with a third for tie-breaking. The full-text review was completed by two reviewers using consensus to resolve any differences. Of the 1,197 articles initially found only 6% (n = 70) met criteria for data extraction. Elements for data extraction included: type of study, area of intervention, description of home program, presence of strategies to support adherence, methods to measure adherence and reported adherence.

RESULTS

Most commonly reported strategies to support home practice were the use of technology, personalization, and written directions. Only 20 studies reported achieving adherence at or greater than 75% and 18 studies did not report adherence outcomes.

CONCLUSIONS

Future investigations that directly compare and identify the most effective strategies to support adherence to home programs for this population are warranted. The implementation of guidelines for reporting adherence to home programs is recommended.

Weight Loss After Stroke Through an Intensive Lifestyle Intervention (Group Lifestyle Balance-Cerebrovascular Accident): Protocol for a Randomized Controlled Trial

BACKGROUND

Weight gain can be a consequence of stroke, or cerebrovascular accident (CVA), because of impaired mobility, behavioral and emotional disorders, and sensory losses. Weight gain increases the patient's risk of recurrent stroke and chronic diseases, such as diabetes, metabolic syndrome, and pulmonary and heart disease. Approaches to weight loss in this population are lacking, although necessary because of the unique physiological and cognitive needs of persons after a stroke. Evidence shows that intensive behavioral therapy interventions that address both physical activity and diet offer the greatest potential for weight loss. The Group Lifestyle Balance (GLB) intervention is a 12-month, evidence-based weight loss program that has been used extensively with the general population; this program was modified to meet the needs of people who have had a stroke (GLB-CVA).

OBJECTIVE

This randomized controlled trial (RCT) aims to examine the efficacy of the GLB-CVA on weight and secondary outcomes, compared with that of a waitlist control group.

METHODS

This RCT will enroll and randomize 64 patients over an 18-month period.

RESULTS

Currently, 51 people are waitlisted, with 23 out of 51 screened and 16 out of 23 eligible.

CONCLUSIONS

It is anticipated that the findings from this RCT will contribute to the evidence base regarding weight loss strategies for people living with stroke.

CLINICAL TRIAL

ClinicalTrials.gov NCT03873467; https://clinicaltrials.gov/ct2/show/NCT03873467.

The Transition from the Hospital to an Inpatient Rehabilitation Setting for Neurologic Patients

Transitions of care from acute hospitalization to postacute rehabilitation settings evolved as a function of cost-saving changes to the Medicare Prospective Payment System. Restricted criteria for inpatient rehabilitation facility admission limited access for patients with severe physical and cognitive deficits. Once used as a resource-intense supplement to hospital care, skilled nursing facilities have metamorphosed into rehabilitation settings with limited nursing staff, lower intensity of therapies, and decreased community discharge rates. A collaborative approach to care transitions, using acute and postacute health care providers, provides the opportunity to improve this process. Early physiatry consultation is a strategy for patients with neurologic disease.

Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study

Background

Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs.

Methods

Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures.

Results

Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation.

Conclusions

tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation.

Trial registration

NCT02460809 (ClinicalTrials.gov).

The use of the functional independence measure in elderly

OBJECTIVES

To analyze in scientific publications how the Functional Independence Measure (FIM) has been employed to evaluate the elderly.

METHODS

Integrative review of periodical publications between 2011 and 2015, available online in full-text in Portuguese, English and Spanish.

RESULTS

129 articles were found; after the application of the criteria, they resulted in 21. The studies were categorized into two groups: A) follow or compare scores in FIM (cohort studies, case-control, clinical trials), focusing on rehabilitation, evaluation of programs and changes in the functional level after procedures/interventions; and B) measure/associate the functionality of the elderly (cross-sectional studies), focused on evaluation protocols in elderly health and associations to the caregiver burden, hospital stay, balance, satisfaction with life, cognition and clinical/socio-demographic aspects.

CONCLUSION

The FIM was used in several scenarios of healthcare for the elderly, particularly in rehabilitation and outpatient clinics or health centers.

Measuring Inpatient Rehabilitation Facility Quality of Care: Discharge Self-Care Functional Status Quality Measure

OBJECTIVE

To describe the calculation and psychometric properties of the discharge self-care functional status quality measure implemented in the Centers for Medicare & Medicaid Services' (CMS) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program on October 1, 2016.

DESIGN

Medicare fee-for-service (FFS) patients from 38 IRFs that participated in the CMS Post-Acute Care Payment Reform Demonstration were included in this cohort study. Data came from the Continuity Assessment Record and Evaluation Item Set, IRF-Patient Assessment Instrument, and Medicare claims. For each patient, we calculated an expected discharge self-care score, risk-adjusted for demographic and baseline clinical characteristics. The performance score of each IRF equaled the percentage of patient stays where the observed discharge self-care score met or exceeded the expected score. We assessed the measure's discriminatory ability across IRFs and reliability.

SETTING

IRFs.

PARTICIPANTS

Medicare FFS patients aged ≥21 years (N=4769).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Facility-level discharge self-care quality measure performance score.

RESULTS

A total of 4769 patient stays were included; 57% of stays were in women, and 12.1% were in patients aged <65 years. Stroke was the most common diagnosis (21.8%). The mean±SD performance score was 55.1%±16.6% (range, 25.8%-100%). About 54% of IRFs had scores significantly different from the percentage of stays that met or exceeded the expected discharge self-care score in the overall demonstration sample. The quality measure showed strong reliability, with intraclass correlation coefficients of .91.

CONCLUSIONS

The discharge self-care quality measure showed strong discriminatory ability and reliability, representing an important initial step in evaluation of IRF self-care outcomes. A wide range in performance scores suggested a gap in quality of care across IRFs. Future work should include testing the measure with nationwide data from all IRFs.

Importance and Difficulties of Pursuing rTMS Research in Acute Stroke

Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients' length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.

Framing new pathways in transformative exercise for individuals with existing and newly acquired disability

PURPOSE

This paper describes a continuum of customized exercise options for people with an existing and newly acquired disability or diagnosis referred to as the Transformative Exercise Framework.

BACKGROUND

The period directly after rehabilitation is a critical juncture where many individuals return to life with high rates of sedentary behavior. After rehabilitation discharge, people with newly acquired disability or diagnoses often never make the transition into usage of community-based exercise services that are tailored, safe and effective.

METHODS

Narrative review.

RESULTS

The Transformative Exercise Framework supports a patient-to-participant, rehab-to-wellness model that emphasizes a linkage between physical and occupational therapists and community-based exercise trainers. The four focus areas - Rehabilitation, Condition-specific Exercise, Fitness and Lifetime Physical Activity - emphasize a range of options for people with newly acquired disability and diagnoses, or for people with existing disability and/or chronic health conditions who have a new injury, secondary condition or are severely deconditioned.

CONCLUSION

The concept of transformative exercise is to support people with disabilities and diagnoses with a seamless restore-improve-prevent continuum of programs and services. This continuum connects individuals to rehabilitation and exercise professionals in a dynamic framework, which maximizes the expertise of both sets of professionals and provides the most effective interventions to achieve the greatest gains in health and function and/or to avoid future health decline. Implications for Rehabilitation Patients discharged from rehabilitation should be transformed into participants in lifelong physical activity through a continuum of health services, which we refer to as Transformative Exercise. Transformative exercise is a continuum of individually tailored exercise strategies/programs that aims to improve the function of underperforming systems, which inhibit community and/or lifelong physical activity participation. The Transformative Exercise Framework can be used by a therapist or exercise trainer to design a program that maximizes performance and time and is based on a specific process for identifying short and long term goals.

Inpatient Rehabilitation Outcomes in Patients With Stroke Aged 85 Years or Older

BACKGROUND

In the United States, people 85 years of age or older have a growing number of strokes each year, and this age group is most at risk for disability. Inpatient rehabilitation facilities (IRFs) adhere closest to post-acute stroke rehabilitation guidelines and have the most desirable outcomes compared with skilled nursing facilities. As stroke is one of the leading causes of disability, knowledge of postrehabilitation outcomes is needed for this age group, although at present such information is limited.

OBJECTIVE

The purpose of this study was to describe functional and discharge outcomes after IRF rehabilitation in people with stroke aged 85 years or older.

DESIGN

A serial, cross-sectional design was used.

METHODS

Inpatient Rehabilitation Facility-Patient Assessment Instrument data were analyzed beginning in 2002 for the first 5.5 years after implementation of the prospective payment system and included 71,652 cases. Discharge function, measured using the Functional Independence Measure (FIM), and community discharge were the discharge outcome measures. Sample description used frequencies and means. Generalized estimating equations (GEEs) with post hoc testing were used to analyze the annual trends for discharge FIM and community discharge by age group (85-89, 90-94, 95-99, and ≥100 years). Risk-adjusted linear and logistic GEE models, with control for cluster, were used to analyze the association between both outcome measures and age group.

RESULTS

Over 5.5 years, mean discharge FIM scores decreased by 3.6 points, and mean achievement of community discharge decreased 5.5%. Approximately 54% of the sample achieved community discharge. Continuous and logistic GEEs revealed factors associated with discharge outcomes.

LIMITATIONS

Results obtained using an observational design should not be viewed as indicating causation. The lack of control for a caregiver may have altered results.

CONCLUSIONS

The very elderly people admitted to IRF stroke rehabilitation made functional gains, and most were able to return to the community.

Association Between Time to Rehabilitation and Outcomes After Traumatic Spinal Cord Injury

OBJECTIVE

To examine the relations between time to rehabilitation after spinal cord injury (SCI) and rehabilitation outcomes at discharge and 1-year postinjury.

DESIGN

Retrospective cohort study.

SETTING

Facilities designated as Spinal Cord Injury Model Systems.

PARTICIPANTS

Patients (N=3937) experiencing traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a model system within 24 hours of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rasch-transformed FIM motor score at discharge and 1-year postinjury, discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores at 1-year postinjury.

RESULTS

After accounting for health status, a 10% increase in time to rehabilitation was associated with a 1.50 lower FIM motor score at discharge (95% confidence interval [CI], -2.43 to -0.58; P=.001) and a 3.92 lower CHART Physical Independence score at 1-year postinjury (95% CI, -7.66 to -0.19; P=.04). Compared to the mean FIM motor score (37.5) and mean CHART Physical Independence score (74.7), the above-mentioned values represent relative declines of 4.0% and 5.3%, respectively. There was no association between time to rehabilitation and discharge to a private residence, 1-year FIM motor score, or the CHART mobility score.

CONCLUSIONS

Earlier rehabilitation after traumatic SCI may improve patients' functional status at discharge.

Does Using Complementary Health Insurance Affect Hospital Length of Stay? Evidence from Acute Coronary Syndrome Patients

BACKGROUND

Length of stay (LOS) is used as an indicator to show the efficacy of hospitals. An increase in hospitalized days is not cost effective and decreases the efficacy of hospitals. Using insurance has some side effects. One of these side effects is increasing the LOS. In this study we attempt to discover the effects of complementary health insurance (CHI) on LOS in patients with acute coronary syndrome (ACS).

METHODS

In this cross-sectional study, 260 patients were surveyed. By using Poisson regression, the effects of using complementary health insurance on LOS were examined. The effects of confounders were also controlled in the model.

RESULTS

The results of this study demonstrated that the relationship between use of CHI and LOS is direct. In addition, an increase in age and income also increases the LOS. The average LOS was 4.13 days, while it was 5.31 for CHI users, and 3.81 for CHI nonusers.

CONCLUSION

Government budget is restricted and ACS treatments are costly. Decreasing LOS in ACS patients can help to spend the budget more effectively.

Length of Stay at Inpatient Rehabilitation Facility and Stroke Patient Outcomes

PURPOSE

To examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes.

DESIGN

A secondary data analysis of the Uniform Data System for Medical Rehabilitation database.

METHODS

Stroke patients discharged from IRFs in the United States between 2009 and 2011 were identified and divided into mild (n = 639), moderate (n = 2,065), and severely (n = 2,077) impaired groups. Study outcomes included cognition and motor functional gains measured by the Functional Independence Measure (FIM) instrument and discharge to the community.

FINDINGS

The average LOS was 8.9, 13.9, and 22.2 days for mild, moderate, and severely impaired stroke patients, respectively. After controlling for FIM admission and other important covariates, a longer LOS was associated with a modest increase in cognition gain (β = 0.038, p = .0045) for the moderately impaired patients, and a modest increase in cognition (β = 0.13, p < .0001) and motor gains (β = 0.25, p < .0001) as well as a tendency for discharge to the community (OR = 1.01, 95% CI = 1.00-1.02) among the severely impaired patients. However, a longer LOS showed a negative association with functional gains among the mildly impaired patients as well as discharge to community for both mild and moderately impaired patients.

CONCLUSION

The association of IRF LOS and patient outcomes varied by stroke impairment severity, positively for more severely impaired patients and negatively for mildly impaired patients.

CLINICAL RELEVANCE

The study provides evidence for the care of stroke patients at the IRF setting.

Acceleration metrics are responsive to change in upper extremity function of stroke survivors

OBJECTIVES

To (1) determine whether acceleration metrics derived from monitoring outside of treatment are responsive to change in upper extremity (UE) function; and secondarily to (2) compare metric values during task-specific training and while in the free-living environment, and (3) establish metric associations with an in-clinic measure of movement capabilities.

DESIGN

Before-after observational study.

SETTING

Inpatient hospital (primary purpose); outpatient hospital (secondary purpose).

PARTICIPANTS

Individuals (n=8) with UE hemiparesis <30 days poststroke (primary purpose); individuals (n=27) with UE hemiparesis ≥6 months poststroke (secondary purpose).

INTERVENTION

The inpatient sample was evaluated for UE movement capabilities and monitored with wrist-worn accelerometers for 22 hours outside of treatment before and after multiple sessions of task-specific training. The outpatient sample was evaluated for UE movement capabilities and monitored during a single session of task-specific training and the subsequent 22 hours outside clinical settings.

MAIN OUTCOME MEASURES

Action Research Arm Test (ARAT) and acceleration metrics quantified from accelerometer recordings.

RESULTS

Five metrics improved in the inpatient sample, along with UE function as measured on the ARAT: use ratio, magnitude ratio, variation ratio, median paretic UE acceleration magnitude, and paretic UE acceleration variability. Metric values were greater during task-specific training than in the free-living environment, and each metric was strongly associated with ARAT score.

CONCLUSIONS

Multiple metrics that characterize different aspects of UE movement are responsive to change in function. Metric values are different during training than in the free-living environment, providing further evidence that what the paretic UE does in the clinic may not generalize to what it does in everyday life.