Dataset Information

Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population.

ABSTRACT: OBJECTIVE:Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissions in the inpatient rehabilitation stroke population compared with medical comorbidities using a large, administrative data set. METHODS:A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed examining stroke patients admitted to inpatient rehabilitation facilities. A Basic Model for predicting acute care readmission risk based on age and functional status was compared with models incorporating functional status and medical comorbidities (Basic-Plus) or models including age and medical comorbidities alone (Age-Comorbidity). C-statistics were compared to evaluate model performance. FINDINGS:There were a total of 803,124 patients: 88,187 (11%) patients were transferred back to an acute hospital: 22,247 (2.8%) within 3 days, 43,481 (5.4%) within 7 days, and 85,431 (10.6%) within 30 days. The C-statistics for the Basic Model were 0.701, 0.672, and 0.682 at days 3, 7, and 30 respectively. As compared to the Basic Model, the best-performing Basic-Plus model was the Basic+Elixhauser model with C-statistics differences of +0.011, +0.011, and + 0.012, and the best-performing Age-Comorbidity model was the Age+Elixhauser model with C-statistic differences of -0.124, -0.098, and -0.098 at days 3, 7, and 30 respectively. CONCLUSIONS:Readmission models for the inpatient rehabilitation stroke population based on functional status and age showed better predictive ability than models based on medical comorbidities.

SUBMITTER: Slocum C

PROVIDER: S-EPMC4657881 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population.

Slocum Chloe C Gerrard Paul P Black-Schaffer Randie R Goldstein Richard R Singhal Aneesh A DiVita Margaret A MA Ryan Colleen M CM Mix Jacqueline J Purohit Maulik M Niewczyk Paulette P Kazis Lewis L Zafonte Ross R Schneider Jeffrey C JC

PloS one 20151123 11

<h4>Objective</h4>Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissio ...[more]

PMID: 26599009

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Project description:Importance:Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Objective:To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Design, Setting, and Participants:This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. Exposures:Inpatient rehabilitation received in IRFs vs SNFs. Main Outcomes and Measures:Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Results:Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. Conclusions and Relevance:In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Project description:ObjectiveEffective stroke care does not end with acute treatment during hospitalization, but extends through rehabilitation and secondary stroke prevention. In transitions across care environments, stroke patients are vulnerable to errors in communication of diagnosis and treatment. This study aimed to demonstrate that formalized communication between the neurology team and the rehabilitation medicine team would promote secondary stroke prevention and minimize interruptions during rehabilitation.MethodsThe intervention was a standardized verbal handoff by phone between the discharging neurology resident and the admitting rehabilitation resident regarding each patient at transfer. This retrospective cohort study compared a pre-intervention control group (September 2012 to February 2013) and a post-intervention group transferred with the handoff (September 2013 to January 2014). The outcomes measured included errors in communication of stroke severity, stroke mechanism, medications, and recommended follow-up (appointments and tests) as well as emergent brain imaging, return to the acute care facility, and readmission.ResultsThe pre- and post-intervention groups were similar with respect to number of patients (50 vs. 52) and demographics including gender (52 vs. 54% female), age (65.8 vs. 64.0?years), severity of illness as measured by the National Institutes of Health Stroke Scale (NIHSS) (10 vs. 6.5), and stroke type (84 vs. 77% ischemic). Implementation of the handoff decreased errors in communication of diagnosis (NIHSS 92 vs. 74%, p?=?0.02; stroke mechanism 54 vs. 30%, p?=?0.02). Furthermore, the handoff decreased the proportion with errors in reconciliation of critical medications (42 vs. 23%, p?=?0.04). However, the intervention did not significantly reduce interruptions of the rehabilitation program, such as emergent brain imaging (8 vs. 12%, p?=?0.55), or transfers back to the acute care hospital (26 vs. 21%, p?=?0.56).ConclusionStandardized handoffs decreased errors in communication of diagnosis and critical medications for secondary stroke prevention.

Project description:BackgroundLower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke.Patients and methodsIn a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment.ResultsOne hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R2: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02).ConclusionsHigher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.KEY MESSAGEHigher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.Higher SES is associated with significantly higher utilization of outpatient therapies.Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery. Article registration: clinicaltrials.gov NCT04119479.

Project description:IntroductionStroke and its long-term consequences pose major challenges for the lives of those affected and healthcare systems. Neurological rehabilitation therefore primarily attempts to improve function in order to increase independence in activities of daily living, and to enable social participation. There is only scarce data on dynamics of functional recovery after patients discharge from inpatient neurological rehabilitation. Even less is known about the patient's perspective on long-term recovery from stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) aims to address this knowledge gap by providing new insights into the dynamics and extent of functional recovery from stroke beyond inpatient rehabilitation treatment.MethodsWe provide the protocol for an observational, longitudinal, multicenter study conducted in an Universitary Stroke Center in cooperation with five Neurological Rehabilitation Centers in Northern Germany. Patients who suffered from ischemic or hemorrhagic stroke will be enrolled by the end of inpatient rehabilitation and followed up to 1 year. In addition, a group of chronic stroke patients and a group of craniocerebral trauma patients will be enrolled as a comparison group. Data on stroke characteristics, vascular risk factors, co-morbidities, social support, and demographics will be recorded. Comprehensive clinical evaluation will be performed at baseline, three, six, and twelve months after enrollment. The assessments and scores used reflect the three components of the International Classification of Functioning, Disability and Health (ICF), some of them are tests regularly used in rehabilitation settings. Tests of motor function, cognition, and mood are included, as are tests of self-reported health-related quality of life. Primary outcome measure is a hand motor score, built by the sum of the hand items of the Fugl-Meyer Assessment as an objective measurement of hand function at 12?months after enrollment. Predictors of the primary outcome will be analyzed using linear regression analysis.PerspectiveThe results of IMPROVE will inform about the long-term dynamics of functional stroke recovery after patients' discharge from inpatient rehabilitation and will provide insights into the association of clinical and demographic factors with recovery of function.Trial registrationThe protocol is registered at ClinicalTrials.gov (NCT04119479).

Project description:ObjectivesTo identify, appraise and synthesise existing design evidence for inpatient stroke rehabilitation facilities; to identify impacts of these built environments on the outcomes and experiences of people recovering from stroke, their family/caregivers and staff.DesignA convergent segregated review design was used to conduct a systematic review.Data sourcesOvid MEDLINE, Scopus, Web of Science and Cumulative Index to Nursing and Allied Health Literature were searched for articles published between January 2000 and November 2020.Eligibility criteria for selecting studiesQualitative, quantitative and mixed-methods studies investigating the impact of the built environment of inpatient rehabilitation facilities on stroke survivors, their family/caregivers and/or staff.Data extraction and synthesisTwo authors separately completed the title, abstract, full-text screening, data extraction and quality assessment. Extracted data were categorised according to the aspect of the built environment explored and the outcomes reported. These categories were used to structure a narrative synthesis of the results from all included studies.ResultsTwenty-four articles were included, most qualitative and exploratory. Half of the included articles investigated a particular aspect of the built environment, including environmental enrichment and communal areas (n=8), bedroom design (n=3) and therapy spaces (n=1), while the other half considered the environment in general. Findings related to one or more of the following outcome categories: (1) clinical outcomes, (2) patient activity, (3) patient well-being, (4) patient and/or staff safety and (5) clinical practice. Heterogeneous designs and variables of interest meant results could not be compared, but some repeated findings suggest that attractive and accessible communal areas are important for patient activity and well-being.ConclusionsStroke rehabilitation is a unique healthcare context where patient activity, practice and motivation are paramount. We found many evidence gaps that with more targeted research could better inform the design of rehabilitation spaces to optimise care.Prospero registration numberCRD42020158006.

Project description:Background and Purpose- Therapeutic strategies that capitalize on the intrinsic capacity for neurological recovery early poststroke to improve locomotion are uncertain. Emerging data suggest that task-specific stepping practice provided at higher cardiovascular intensities may be critical dosage parameters that could maximize locomotor recovery. The purpose of this investigation was to determine the comparative effectiveness of providing high-intensity training on locomotor capacity early poststroke as compared with usual care. Methods- A quasi-experimental design was used to compare changes in stepping activity (StepWatch), walking, and balance outcomes during usual care (n=56) versus high-intensity stepping intervention (n=54) in inpatient stroke patients. Primary outcomes assessed weekly included self-selected and fastest gait speed, 6-minute walk test, and the Berg Balance Scale, with secondary outcomes of Swedish Postural Assessment Scale for Stroke-Norwegian version, Functional Ambulation Category, 30-s sit-to-stand, strength (average manual muscle testing), and Barthel Index. Regression analyses identified relationships between demographics, baseline function, and training activities (steps per day; duration achieved, 70%-85% maximum heart rates) and primary outcomes at discharge. Results- Following implementation of high-intensity stepping, average steps per day (5777±2784) were significantly greater than during usual care (3917±2656; P<0.001). Statistically different and clinically meaningful changes in self-selected speed (0.39±0.28 versus 0.16±0.26 m/s) and fastest gait speed (0.47±0.41 versus 0.17±0.38 m/s; both P<0.001) were observed following high-intensity interventions versus usual care and at every assessment throughout the length of stay. Changes in Berg Balance Scale and 6-minute walk test were also statistically and clinically different between groups, while secondary measures of Functional Ambulation Category and strength were also different at discharge. Primary predictors of improved walking capacity were steps per day, baseline impairments, and age. Conclusions- Provision of high-intensity stepping training applied during inpatient rehabilitation resulted in significantly greater walking and balance outcomes. This training paradigm should be further tested in other contexts to determine the generalizability to real-world and community settings.

Dataset Information

Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population.

Publications

Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population.

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