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Stroke rehabilitation: Clinical predictors of resource utilization
Abstract
To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission.
Statistical analysis of data prospectively collected from stroke rehabilitation patients.
Large, urban, academic freestanding rehabilitation facility.
A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation.
Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD).
Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis.
Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001).
Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.
... but less likelihood to be discharged to the community (OR = 0.997, 95% CI = 0.994-0.999). In addition to medical conditions (Appelros, 2007;Elwood et al., 2009;Galynker et al., 1997;Harvey et al., 1998;Saxena, Koh, Ng, Fong, & Yong, 2007) and functional status at IRF admission (Brock et al., 1997;Franchignoni, Tesio, Martino, Benevolo, & Castagna, 1998;Harvey et al., 1998;Stillman et al., 2009), other patient characteristics and nonmedical factors influence the duration of IRF stay, including patients' socioeconomic status and family structure , caregiver characteristics and IRF discharge planning program (Tan, Chong, Chua, Heng & Chan, 2009), and incentives for cost containment and support inpatients' home environments (Stineman et al., 2001). ...
... but less likelihood to be discharged to the community (OR = 0.997, 95% CI = 0.994-0.999). In addition to medical conditions (Appelros, 2007;Elwood et al., 2009;Galynker et al., 1997;Harvey et al., 1998;Saxena, Koh, Ng, Fong, & Yong, 2007) and functional status at IRF admission (Brock et al., 1997;Franchignoni, Tesio, Martino, Benevolo, & Castagna, 1998;Harvey et al., 1998;Stillman et al., 2009), other patient characteristics and nonmedical factors influence the duration of IRF stay, including patients' socioeconomic status and family structure , caregiver characteristics and IRF discharge planning program (Tan, Chong, Chua, Heng & Chan, 2009), and incentives for cost containment and support inpatients' home environments (Stineman et al., 2001). ...
... IRF LOS contributes directly to the poststroke care cost. Studies have reported that patient severity (Appelros, 2007;Elwood et al., 2009;Harvey et al., 1998), negative symptoms (Galynker et al., 1997), medical complications (Saxena et al., 2007), and functional status at IRF admission (Brock et al., 1997;Franchignoni et al., 1998;Harvey et al., 1998;Stillman, Granger, & Niewczyk, 2009;) are the major determinants of IRF LOS. Some other nonmedical patient characteristics and organization factors are associated with duration (CMS, 2013). ...
PurposeTo examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes.DesignA 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.FindingsThe 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 RelevanceThe study provides evidence for the care of stroke patients at the IRF setting.
... One previous study (26) illustrated that in-hospital infection is a predictor of prolonged hospital stay in acute ischaemic stroke patients. Another study (27) illustrated that a history of pneumonia could predict higher hospital charge per day for patients admitted for inpatient rehabilitation. In our study, fever in the rehabilitation ward increased medical costs for acute stroke patients transferred to the rehabilitation ward. ...
... There are no references considering hypoalbuminaemia, hyponatraemia, or hypokalaemia as a predictor for total costs for stroke patients. However, hypoalbuminaemia has been associated with increased risks for medical complications in acute stroke patients (28) and stroke patients admitted to the rehabilitation ward (27,29), although it has not been related to length of stay (27,29). Post-stroke hyponatraemia (30) and hypokalaemia (31) are associated with poor outcomes (increased chance of death). ...
... There are no references considering hypoalbuminaemia, hyponatraemia, or hypokalaemia as a predictor for total costs for stroke patients. However, hypoalbuminaemia has been associated with increased risks for medical complications in acute stroke patients (28) and stroke patients admitted to the rehabilitation ward (27,29), although it has not been related to length of stay (27,29). Post-stroke hyponatraemia (30) and hypokalaemia (31) are associated with poor outcomes (increased chance of death). ...
Objective:
To investigate the predictors of total medical costs for first-ever ischaemic stroke patients transferred to the rehabilitation ward from the acute ward.
Patients:
A total of 311 first-ever ischaemic stroke patients (mean age 68.9 (standard deviation (SD) 12.2) years).
Methods:
Data, including common complications and medical events, from July 2002 to June 2012 were collected retrospectively from a regional hospital in Taiwan in order to study the potential predictors for medical costs. Significant variables from univariate analysis were included in a stepwise multivariate linear regression analysis.
Results:
The mean total medical cost per patient was USD 4,606.80 (SD 2,926.10). The significant predictors for cost were days of total stay (coefficient: 70.3; 95% confidence interval (CI) = 56.4-84.3), impaired consciousness (coefficient: 1,031.3; 95% CI = 490.8-1,571.8), hypoalbuminaemia in the acute ward (coefficient: 2,045.1; 95% CI = 1,054.6-3,035.7), fever (coefficient: 927.0; 95% CI = 193.3-1,660.7), hypokalaemia (coefficient: 2,698.4; 95% CI = 660.5-4,736.4), and hyponatraemia (coefficient: 1,123.3; 95% CI = 72.2-2,174.5) in the rehabilitation ward (R2 = 0.416).
Conclusion:
These findings can help clinicians to identify risk factors for total medical costs in these patients and reduce costs by minimizing some complications (hypoalbuminaemia, fever, hypokalaemia, and hyponatraemia).
... Very severely impaired patients may not have as much potential for improvement as those with moderate impairment, and those with the highest FIM scores may not show the same gains due to the ceiling effect of the FIM in highly functional patients 9 . Admission functional score (measured with the FIM or Barthel Index (BI)) have been found to be a predictor of LOS in several studies 10,[25][26][27][28][29] . Patients with more severe functional impairments require longer LOS to be ready for home discharge. ...
... It stands to reason that patients who have greater mobility are more able to participate in rehabilitation transfers and activities of daily living (ADLs). They make more rapid gains with therapy and may be ready for discharge earlier 25 . Patients who cannot mobilise need longer LOS to promote maximal functional improvement 32 . ...
Background
There is little research on length of hospital stay (LOS) in patients post stroke in South African rehabilitation facilities. As LOS is an important indicator of cost-of-care, this information may be useful to all stakeholders.
Objectives
To determine the predictors of hospital LOS in patients post stroke rehabilitation.
Methods
A retrospective file review of 243 patients.
Results
Patient functional ability was measured using the Functional Independence Measure (FIM). Predictors of LOS were determined with multiple regression analysis. The median admission and discharge FIM scores were 43 (range: 16-119) and 75 (range: 16-120) points respectively. The median LOS was 43 (range: 3-112) days. Predictors of LOS were premorbid psychiatric conditions, impaired speech, requiring oxygen support, the development of pneumonia and admission FIM motor score, with admission FIM motor score being the strongest individual predictor of LOS (41%).
Conclusion
Admission FIM score had an influence on patient outcomes and LOS. Patients with higher admission FIM motor scores may be able to participate in rehabilitation better and thus have shorter LOS. Being able to predict LOS on admission allows facility administrators to manage bed occupancy, human and clinical resources in post stroke rehabilitation.
... Three trained abstractors reviewed the medical records. Based on clinical judgment and predictors found to be significant in literature, [19][20][21][22][23][24][25][26][27] we extracted the following data from the case notes: demographics and preadmission living arrangements, stroke type, site and side, comorbidity, hospital ward class, and acute and rehabilitation LOS. Electronic medical data were extracted to derive information related to functional status at admission. ...
... A similar relationship has been found in studies performed in inpatient rehabilitation settings in the United Kingdom 34 and the United States. 22 A Taiwanese study performed by Chung et al 33 found the ability of stroke patients to engage in self-care activities to have a major impact on the rehabilitation LOS. Although others 35,36 have reported cognitive dysfunction to complicate the rehabilitation process and to prolong LOS, poor cognitive status did not independently increase the LOS in this study. ...
To determine the predictors of hospital length of stay (LOS) of stroke patients at the point of admission.
A retrospective cohort study.
An acute hospital rehabilitation center in Singapore.
Stroke patients (N=491) admitted between March 2005 and December 2006.
None.
Rehabilitation LOS was calculated as the total number of rehabilitation days before discharge. We measured the functional status of patients by using the Functional Independence Measure (FIM).
The median LOS was 29 days (mean = 30.8d). Independent clinical and sociodemographic characteristics found to significantly predict rehabilitation LOS were FIM motor score at admission, the presence of more than 3 comorbid conditions at admission, living with nonimmediate relatives before admission, and the hospital subsidy status of the patient. In particular, the admission FIM motor score explained 43% of the variation in LOS and decreased the LOS by approximately 1.1 days for each 1-point increase in score.
Patients' socioeconomic status and family structure was found to influence LOS and should be considered in allocating resources and determining treatment need. The extent of motor function of patients at admission is an important factor influencing rehabilitation LOS and is a useful tool for facilitating rehabilitation resource planning for stroke patients.
... Globally, especially in low-and middle-income countries, rehabilitation in health systems needs to be strengthened so that high-quality and affordable services are available to all people in need [42][43][44][45][46][47]. As global health coverage is recognized as the third goal of sustainable health development, countries are encouraged to ensure equitable access to high-quality and affordable health services, including rehabilitation [48][49][50][51][52][53][54]. ...
... DM is most commonly seen in patients with lacunar IS, and multivariate analysis indicates that DM is a predictor of lacunar IS. It is possible that patients with DM achieve worse functional recovery due to the risk factors and complications associated with this disease (AH, hyperlipoproteinemia and coronary heart disease), which are six times more common in these patients 33 . It has been observed that in patients with DM recovery after IS lasts longer, thereby prolonging rehabilitation treatment 34,35 . ...
Comorbidity decreases survival but it still remains unknown to what extent functional recovery after ischemic stroke is affected. The aim of this research was to determine the prevalence of the most common comorbidities in patients with ischemic stroke and to examine their predictive value on the functional status and recovery. In order to obtain relevant information for this research, we conducted a prospective study over a two-year period. It included patients with acute/ subacute ischemic stroke who had inhospital rehabilitation treatment in our institution. Functional status of the patients was evaluated by the following three aspects at the beginning and at the end of rehabilitation treatment: Rivermead Mobility Index was used for mobility, Barthel Index for independence in activities of daily living, and modified Rankin Scale for total disability. Modified Charlston Comorbidity Index was used to assess comorbidity. Multivariate analysis was applied to evaluate the impact of recorded comorbidities on the patient functional outcome. Independent predictors of rehabilitation success in our study were the value of modified Charlston Comorbidity Index, atrial fibrillation and myocardial infarction. Our study demonstrated that patients with more comorbidities had worse functional outcome after stroke, so it is important to consider the comorbidity status when planning the rehabilitation treatment.
... Historically, mechanically ventilated patients with ischemic or hemorrhagic stroke have had poor functional outcomes with reported mortality rates ranging between 40% and 80%, [2][3][4][5] and care of such patients is extremely expensive. 6,7 Effective interventions to improve survival, improve functional recovery, decrease costs, and increase cost-effectiveness are therefore of great importance. Unlike the medical and surgical critically ill, many patients with stroke who require prolonged intubation do not necessarily require mechanical ventilation, but have a need for an airway protection. ...
Background:
Tracheostomy is a common procedure in long-term ventilated critical care patients and frequently necessary in those with severe stroke. The optimal timing for tracheostomy is still unknown, and it is controversial whether early tracheostomy impacts upon functional outcome.
Method:
The Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial 2 (SETPOINT2) is a multicentre, prospective, randomized, open-blinded endpoint (PROBE-design) trial. Patients with acute ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage who are so severely affected that two weeks of ventilation are presumed necessary based on a prediction score are eligible. It is intended to enroll 190 patients per group (n = 380). Patients are randomized to either percutaneous tracheostomy within the first five days after intubation or to ongoing orotracheal intubation with consecutive weaning and extubation and, if the latter failed, to percutaneous tracheostomy from day 10 after intubation. The primary endpoint is functional outcome defined by the modified Rankin Scale (mRS, 0-4 (favorable) vs. 5 + 6 (unfavorable)) after six months; secondary endpoints are mortality and cause of mortality during intensive care unit-stay and within six months from admission, intensive care unit-length of stay, duration of sedation, duration of ventilation and weaning, timing and reasons for withdrawal of life support measures, relevant intracranial pressure rises before and after tracheostomy.
Conclusion:
The necessity and optimal timing of tracheostomy in ventilated stroke patients need to be identified. SETPOINT2 should clarify whether benefits in functional outcome can be achieved by early tracheostomy in these patients.
... Potential confounding variables considered in this analysis were identified primarily based on published literature and clinical practice guidelines [33][34][35] and included the following: age, sex, race (white, black, other), marital status (binary), payer (Medicare, Medicaid, commercial Health Maintenance Organization, non-Health Maintenance Organization, other) as a proxy for socioeconomic status, 36 admission impairment category 30 (stroke, nonstroke brain injury, other neurologic disease, spinal cord injury, orthopedic, cardiac, debility, medically complex, other), expected 30-day readmission rate based on APRDRG and SOI, 29 comorbidity AHRQ comorbidity index (which is an update to the original Elixhauser methodology 27 ), acute care hospital LOS prior to the CIIRP, CIIRP admission pain score (range, 0e10), presence of a pressure ulcer at CIIRP admission (binary), and 3 variables separately indicating a history of psychiatric disease, substance abuse, and smoking, as per the International Classification of Diseasese9th Revision coding. 17,37,38 List of abbreviations: ...
To determine whether functional status on admission to a Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) is associated with unplanned readmission to acute care.
Retrospective cohort study.
Academic hospital-based CIIRP in Baltimore, MD. Baltimore, MDnterventions: Patients' functional status, the primary exposure variable, was assessed using tertiles of the total Functional Independence Measure (FIM) score at CIIRP admission, with secondary analyses using the FIM motor and cognitive domain. A propensity score, consisting of 25 relevant clinical and demographic variables, were used to adjust for confounding in the analysis.
Readmission to acute care was categorized as: a) readmission before planned discharge from CIIRP, b) readmission within 30 days of discharge from CIIRP, and c) total readmissions (a + b), with total readmissions being the a priori primary outcome.
Among 1515 patients, there were 347 total readmissions. Total readmissions was significantly associated with FIM scores, with adjusted odds ratios (OR) and 95% confidence intervals (CI) for lowest and middle FIM tertiles versus highest tertile of 2.6 (1.9-3.7, p<0.001) and 1.7 (1.2-2.4, p=0.002), respectively. There were similar findings for secondary analyses of readmission before planned discharge from CIIRP [3.5 (2.2-5.8, p<0.001) and 2.1 (1.3-3.5, p=0.002)], and a weaker association for readmissions after discharge from CIIRP [1.6 (1.0-2.4, p=0.047) and 1.3 (0.8-1.9, p=0.28)]. The FIM motor domain score was more strongly associated with readmissions than the FIM cognitive score.
Functional status on admission to CIIRP is strongly associated with readmission to acute care, particularly for motor aspects of functional status and readmission before planned discharge from CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.
... Linear regression, using ordinary least squares estimation, has been used to model LOS. This method has been used to model LOS following carotid endarterectomy [33], admission for stroke rehab [16], and hip and knee replacement [12]. A variation of this approach is to exclude long LOS prior to modeling [18]. ...
Investigators in clinical research are often interested in determining the association between patient characteristics and post-operative length of stay (LOS). We examined the relative performance of seven different statistical strategies for analyzing LOS in a cohort of patients undergoing CABG surgery. We compared linear regression; linear regression with log-transformed length of stay; generalized linear models with the following distributions: Poisson, negative binomial, normal, and gamma; and semi-parametric survival models.
Nine of twenty patient characteristics were found to be significantly associated with increased LOS in all models. The models disagreed upon the statistical significance of the association between the remaining patient characteristics and increased LOS. Generalized linear models with Poisson, negative binomial, and gamma distributions, and the Cox regression model demonstrated the greatest consistency. With the exception of Cox regression, all models had similar ability to predict length of stay in the actual data. However, the generalized linear models tended to have marginally lower prediction error than the linear models. Using four measures of prediction error, Cox regression had substantially higher prediction error than the other models. Generalized linear models were best able to predict patient length of stay in Monte Carlo simulations that were performed.
Researchers should consider generalized linear models with normal, Poisson, or negative binomial distributions for predicting length of stay following CABG surgery. Post-operative length of stay is a complex phenomenon that is difficult to incorporate into a simple parametric model due to a small proportion of patients having very long lengths of stay.
... Nevertheless, poor outcome may prevail because ischemic stroke is a heterogeneous disease and several factors could infl uence its rehabilitation outcome. 1,6,7 Until recently, proposals suggested that nonmodifi able and modifi able risk factors can act as predictors of stroke outcome and hence can determine the importance to identify the impact of these risk factors on functional outcome before embracing a system that limits access to rehabilitation because of such factors. Among the non-modifi able risk factors, we investigated: age, gender, race, side of stroke (right or left) and the modifi able (co-morbid medical disorders) risk factors: HTN, DM and cardiac disease in this study. ...
The incidence of stroke and the demand for rehabilitation services continues to increase. Risk factors may act as stroke outcome predictors and hence determine the type and intensity of rehabilitation. Our aim is to investigate stroke outcome predictors that will define groups with maximal or minimal benefit from rehabilitation after stroke.
Our longitudinal prospective study included 111 ischemic stroke patients, admitted consecutively to the Rehabilitation Department, Hamad Medical Corporation, Qatar, during 2000-2001. We analyzed the influence of modifiable risk factors: diabetes mellitus (DM), hypertension (HTN), ischemic heart disease (IHD) and non-modifiable factors: age, gender, race and side of lesion on stroke outcome. All patients received regular rehabilitation and underwent an evaluation on admission and discharge, using the Modified Barthel Index.
Statistical analysis demonstrated that the group of patients with IHD showed greatest improvement after 3 months of rehabilitation. The group without co-morbidities followed this, and then the HTN, DM, combined DM and HTN and combined HTN and IHD groups. The group that suffered from combined DM, HTN, and IHD did not show improvement. Non-modifiable risk factors showed no significant differences. However, younger patients showed a tendency for better improvement.
Those patients with modifiable risk factors had significant impact on rehabilitation outcome (p-value = 0.009). Those with one or 2 co-morbidities had the highest score of improvement after rehabilitation while the group of patients with more than 2 co-morbidities did not show improvement. However, non-modifiable risk factors did not play a significant role in stroke outcome.
... La edad avanzada reduce pero no anula la eficacia de la rehabilitación 320,321 . La comorbilidad (enfermedad cardíaca, insuficiencia renal, neumonía...) es también un factor predictivo negativo 299 . La influencia de la topografía lesional no ha sido demostrada en todos los estudios, pero existe un amplio acuerdo en que los pacientes que presentan infartos de pequeño tamaño y de localización subcortical alcanzan un mayor grado de recuperación motora que aquellos que han sufrido un infarto de mayor tamaño y cortical 322,323 . ...
... As patients are generally given an invoice of itemised hospital costs at the time of hospital discharge, these data were expected to be well recorded and to provide a reliable outcome measure. The following covariates were included a priori in multivariate models based on evidence of their associations with hospital utilisation: age [22], gender2324, marital status [25], living alone [26], owns health insurance [19], CV risk [19,22,25], pathological stroke type [24,27], severe Glasgow Coma Scale (GCS) score on admission (defined as 3–8 of a top score of 15) [22,2829 , received assisted feeding in- hospital [30], experienced any in-hospital complication [19,24], length of hospital stay (LOS) [19,22], and hospital characteristics [23] including size, teaching status and location. Annual household income was also included as a covariate, given the likely association with health insurance. ...
The burden of stroke is high and increasing in China. We modelled variations in, and predictors of, the costs of hospital care for patients with acute stroke in China.
Baseline characteristics and hospital costs for 5,255 patients were collected using the prospective register-based ChinaQUEST study, conducted in 48 Level 3 and 14 Level 2 hospitals in China during 2006-2007. Ordinary least squares estimation was used to determine factors associated with hospital costs. Overall mean cost of hospitalisation was 11,216 Chinese Yuan Renminbi (CNY) (≈US$1,602) per patient, which equates to more than half the average annual wage in China. Variations in cost were largely attributable to stroke severity and length of hospital stay (LOS). Model forecasts showed that reducing LOS from the mean of 20 days for Level 3 and 18 days for Level 2 hospitals to a duration of 1 week, which is common among Western countries, afforded cost reductions of 49% and 19%, respectively. Other lesser determinants varied by hospital level: in Level 3 hospitals, health insurance and the occurrence of in-hospital complications were each associated with 10% and 18% increases in cost, respectively, whilst treatment in a teaching hospital was associated with approximately 39% decrease in cost on average. For Level 2 hospitals, stroke due to intracerebral haemorrhage was associated with a 19% greater cost than for ischaemic stroke.
Changes to hospital policies to standardise resource use and reduce the variation in LOS could attenuate costs and improve efficiencies for acute stroke management in China. The success of these strategies will be enhanced by broader policy initiatives currently underway to reform hospital reimbursement systems.
... As in other studies, 27 motor FIM score at admission, which measures the extent of disability related to self-care, bowel and bladder continence, mobility and ambulation, was independently associated with delayed discharge. Caregivers of stroke patients face substantial stress 28,29 and their burden tend to increase when caring for patients with greater motor impairment. ...
This study determines the extent of, and factors associated with, delayed discharges for stroke patients from inpatient rehabilitation.
A retrospective cohort study utilising medical notes review was conducted at an inpatient rehabilitation centre in Singapore. Acute stroke patients (n = 487) admitted between March 2005 and December 2006 were studied. The primary measure was delayed discharge defined as an extension in inpatient stay beyond the planned duration. Factors associated with delays in discharge were categorised as individual, caregiver, medical and organisational.
There were a total of 172 delayed discharges (35.6%). The mean [standard deviation (SD)] length of stay was 40.5 days (SD, 19.5 days) and 25.8 days (SD, 11.4 days) for patients with delayed and prompt discharges, respectively. Mean extension of stay was 9.7 days (SD, 13.8 days). Caregiver-related reasons were cited for 79.7% of the delays whereas organisational factors (awaiting nursing home placement, investigations or specialist appointments) accounted for 17.4%. Four factors were found to be independently associated with delayed discharge: discharge to the care of foreign domestic helper, nursing home placement, lower admission Functional Independence Measure (FIM) motor score and discharge planning process.
Our study suggests that caregiver and organisational factors were main contributors of delayed discharge. Targeted caregiver training and the provision of post-discharge support may improve the confidence of caregivers of patients with greater motor disability. The use of structured discharge planning programmes may improve the efficiency of the rehabilitation service. To reduce delays, problems with the supply of formal and informal post-discharge care must also be addressed.
... For some illnesses—stroke, renal end-stage disease, chronic high-resistance flow respiratory disorders, diabetes, among others—there is a strong correlation between impairment and disability. For instance, several papers have documented a substantial correlation between motor impairment and disability after stroke [11, 16, 30, 33, 38, 42]. On the other hand, the correlation between musculoskeletal impairment and disability in the case of musculoskeletal illness in particular is consistently weak. ...
Upper extremity specific disability as measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire varies more than expected based upon variations in objective impairment influenced by depression. We tested the hypothesis that adjusting for depression can reduce the mean and variance of DASH scores. Five hundred and sixteen patients (352 men, 164 women) with an average of 58 years of age (range, 18-100) were asked to simultaneously complete the DASH and Center for Epidemiologic Studies Depression Scale (CES-D) scores at their initial visit to a hand surgeon. Pearson's correlations between each of the DASH items and the CES-D score were obtained. The DASH score was then adjusted for the influence of Depression for women and men using ordinary least-squares regression and subtracting the product of the regression coefficient and the CES-D score from the raw DASH score. The average DASH score was 24 points (SD, 19; range, 0-91), and the average CES-D score was 10 points (SD, 8; range, 0-42). Thirteen of the 30 items of the DASH demonstrated correlation greater than r = 0.20. Adjustment of these DASH items for the depression effect led to significant reductions in the mean (5.5 points; p < 0.01) and standard deviation (0.8 points; p < 0.01) of DASH scores. Adjustment for depression alone had a significant but perhaps clinically marginal effect on the variance of DASH scores. Additional research is merited to determine if DASH score adjustments for the most important subjective and psychosocial aspects of illness behavior can improve correlation between DASH scores and objective impairment.
... In general, stroke patients with a lower level of functioning [39,41,42,54– 57] , with complica- tions [41,42,49,50] and a high level of comorbidity [44,47,56] generate more hospital utilization. The same effect is found for patients with a cerebral hemorrhage [50,56] and for patients whose medical conditions require a feeding tube [57]. Patients who die during a hospital stay after a stroke tend generally to have a shorter stay, which leads to lower costs [50]. ...
In order to provide tailor-made care, governments are considering the implementation of output-pricing based on hospital case-mix measures, such as diagnosis related groups (DRG). The question is whether the current DRG classification system can provide a satisfactory prediction of the variance of costs in stroke patients and if not, in what way other variables may enhance this prediction. In this study, data from 731 stroke patients hospitalized at University Hospital Maastricht during 1996-1998 are used in the cost analysis. The DRG classification for this group uses information--in addition to the DRG classification operation or no operation--on the patient's age combined with discharge status. The results of regression analysis show that using DRGs, the variance explained in the costs amounts to 34%. Adding other variables to the DRGs, the variance explained increases to about 61%. Additional factors highly correlating with inpatient costs are the level of functioning after stroke, comorbidity, complications, and 'days of stay for non-medical reasons'. Costs decreased for stroke patients discharged during the latter part of the years studied, and if stroke patients happened to die during their hospital stay. The results do suggest that future implementation of output-pricing based on the DRG case-mix measures is feasible for stroke patients only if it is enhanced with information on complications and the level of functioning.
Objective:
The aim of this study was to determine if the arm-subscore of the Motricity Index (AMI) 1 week following stroke can predict recovery of upper extremity function according to the Action Research Arm Test (ARAT) prior to inpatient rehabilitation facility (IRF) discharge and at 3-months outpatient follow-up.
Design:
This was a prospective cohort study of patients with acute ischemic stroke admitted to a single acute care hospital and affiliated IRF between 2016 and 2018. Upper extremity dexterity of the impaired limb was assessed using the AMI and ARAT. Receiver operating characteristic (ROC) curve analysis was used to determine optimal cut-offs of the initial AMI for a good functional outcome defined as ARAT≥45.
Results:
Ninety-five patients were evaluated at median 6, 26, and 98.5 days following stroke. Median [interquartile range (IQR)] AMI at 1-week was 77 [20.3-93]. Median [IQR] ARAT scores prior to IRF discharge and at 3-months outpatient follow-up were 33 [3.5-52] and 52 [34-55.8], respectively. The optimal AMI to predict ARAT≥45 prior to IRF discharge and at 3-months outpatient follow-up were 71 and 58, respectively.
Conclusion:
Early AMI at 1-week predicts upper extremity functional capacity prior to IRF discharge and at 3-months outpatient follow-up.
Aims:
A retrospective case series was performed to determine which measures of complexity, dependency and function most accurately predict inpatient neurorehabilitation length of stay for individuals with post-acute neurological disorders.
Methods:
Sociodemographic, medical and functional variables were extracted from data submitted to the UK Rehabilitation Outcomes Collaborative. Length of stay was calculated as the total number of inpatient days, functional status was measured using Barthel Index, rehabilitation complexity was measured using Extended Rehabilitation Complexity Scale, and nursing dependency was measured using the Northwick Park Dependency Scale.
Results:
The mean rehabilitation length of stay was 70.9 days, with length of stay being 35.1 days higher in inpatients with acquired brain injury than inpatients with spinal cord injury. Diagnostic category, Barthel Index scores, Extended Rehabilitation Complexity Scale scores and Northwick Park Dependency Scale scores at admission independently predicted length of stay. Multiple regressions including diagnostic group, Barthel Index, Extended Rehabilitation Complexity Scale and Northwick Park Dependency Scale statistically significantly predicted 37.9% of the variability in length of stay (p < 0.005). Northwick Park Dependency Scale on admission was most closely correlated with inpatient length of stay.
Conclusions:
In conclusion, inpatient length of stay is predicted by diagnostic category, Extended Rehabilitation Complexity Scale, Northwick Park Dependency Scale and Barthel Index. The most influential predictor of rehabilitation length of stay was Northwick Park Dependency Scale score at admission. These results may help facilitate rehabilitation resource planning and implementation of effective commissioning plans. Implications for Rehabilitation The most accurate predicting variable for length of stay in inpatient neurological rehabilitation was nursing need as measured by the Northwick Park Dependency Scale score on admission. Service users and commissioners can be provided with more realistic predictions of length of stay derived from admission variables that can be used in planning inpatient rehabilitation. Age and gender do not seem to have an effect on the total length of stay in rehabilitation.
The Balanced Budget Act (BBA) of 1997 proposed significant changes to the manner in which health care institutions were reimbursed for treating patients experiencing stroke. The transfer rule states that acute hospitals who transfer patients to another level of care, including home care, within 3 days of discharge will not receive full DRG reimbursement unless the patient's length of stay is that of the national average. This study examines the differences among patients with different insurance coverage with respect to their age, severity, level of care, length of stay, and outcome prior to the implementation of the BBA. Future analysis of the effects of the BBA on patient utilization of stroke-related services might have significant implications for the allocation of nursing resources across various levels of care.
Background: Despite improved health education and advances in medical and surgical technologies the incidence of lower extremity amputation remained relatively stable over the years. These has an immediate bearing on raising direct and indirect costs of the health care system. Thus, the lower extremity amputation population continues to be a major challenge for rehabilitation professionals. The goal of this study was to evaluate the short-term changes in health-related quality of life as well as functional independence in lower extremity amputees undergoing multidisciplinary inpatient rehabilitation. Methods: Sixty four of seventy consecutive lower extremity amputees participated in the study. SF-36 for evaluating of the health-related quality of life and FIM as measure of the functional independence were administered on admission and at discharge from a multidisciplinary inpatient rehabilitation program. Eight subscales and both summary scores were calculated using a norm-based scaling. Summary FIM scores were linear transformed into a 0-100 scale. Results: There was improvement in all subscales of SF-36. The changes in bodily pain, both role scales and both summary scores were statistically significant. The functional independence as measured by FIM improved significantly from 69.3 to 78.4 points or 8.5 percentage points on the transformed scale. Discussion: The changes in the physical scales of the SF-36 were comparable but these in the mental scales and in terms of functional independence were lower then reported elsewhere. Both orthogonal and oblique (correlated) factor scores should be used for evaluating of SF-36. Short-term responsiveness of both measurements used in the current study have not been reported conclusively yet. Co-morbidity seems to have a major impact on the results of rehabilitation programs of amputees. Conclusions: This study has demonstrated a positive effect of a multidisciplinary in-patient rehabilitation program on the health-related quality of life and the functional independence of lower extremity amputees. Long-term follow-up data are necessary to evaluate the effectiveness of the rehabilitation. Predictors of rehabilitation success should be identified for optimising of rehabilitative intervention strategies.
One-third of the acute stroke patients in Taiwan receive rehabilitation. It is imperative for clinicians who care for acute stroke patients undergoing inpatient rehabilitation to identify which medical factors could be the predictors of the total medical costs.
The aim of this study was to identify the most important predictors of the total medical costs for first-time hemorrhagic stroke patients transferred to inpatient rehabilitation using a retrospective design.
All data were retrospectively collected from July 2002 to June 2012 from a regional hospital in Taiwan. A stepwise multivariate linear regression analysis was used to identify the most important predictors for the total medical costs.
The medical records of 237 patients (137 males and 100 females) were reviewed. The mean total medical cost per patient was United States dollar (USD) 5939.5 ± 3578.5.The following were the significant predictors for the total medical costs: impaired consciousness [coefficient (B), 1075.7; 95% confidence interval (CI) = 138.5-2012.9], dysphagia [coefficient (B), 1025.8; 95% CI = 193.9-1857.8], number of surgeries [coefficient (B), 796.4; 95% CI = 316.0-1276.7], pneumonia in the neurosurgery ward [coefficient (B), 2330.1; 95% CI = 1339.5-3320.7], symptomatic urinary tract infection (UTI) in the rehabilitation ward [coefficient (B), 1138.7; 95% CI = 221.6-2055.7], and rehabilitation ward stay [coefficient (B), 64.9; 95% CI = 31.2-98.7] (R(2) = 0.387).
Our findings could help clinicians to understand that cost reduction may be achieved by minimizing complications (pneumonia and UTI) in these patients.
OBJECTIVES: to assess incapacities and determine whether there are gender differences following an initial episode of cerebrovascular accident among survivors between the ages of 20 and 59 years old living in Recife city, hospitalized in the public health system. METHODS: in-home survey performed with a sample of survivors, investigating incapacities and alterations in the functional and productive life of these individuals. RESULTS: the sample had a balanced proportion between genders and an average age of 52 years old. Individuals were either illiterate or had an elementary education level, holding jobs in the informal or domestic service sector. Approximately 80% exhibited some incapacity. Difficulty in communication and symptoms of depression were more common among women. Functional incapacities had negative repercussions in the level of fulfillment in the lives of 70% of the interviewees. CONCLUSIONS: the percentage of cases among still young individuals that are exhibiting some type of incapacity following an early stroke episode is expressive. Strokes occur earlier and incapacities are more frequent/severe among women. Prevention and rehabilitation following a stroke are desirable with the implementation of programs that should consider gender conditions aiming at strokes' risk and incapacity control.
Purpose:
Recovery of the most basic shoulder-flexion/elbow-extension components of functional reach is critical for effective arm function following stroke. In order to understand the mechanisms of motor recovery, it is important to characterize the pattern of brain activation during the reach task.
Methods:
We evaluated 11 controls and 23 moderately to severely impaired chronic stroke survivors (>6 months), with impaired shoulder flexion and elbow extension. Measures were acquired for Arm Motor Ability Test (AMAT) and functional Magnetic Resonance Imaging (fMRI) during the basic shoulder/elbow reach.
Results:
First, in controls, lateralization of fMRI signal during the reach task was less pronounced in comparison to other tasks, and even further diminished after stroke (p < 0.05). Second, for the stroke group, centroid locations, for specific ipsilesional (contralateral to working limb) motor-sensory regions and for contralesional (ipsilateral to working arm) somatosensory and SMA regions, were significantly more distant from the centroid location of average healthy controls (p < 0.05). Third, both greater activation volume and greater degree of signal intensity were correlated with better motor function in stroke survivors.
Conclusions:
These findings can be useful in guiding the development of more targeted brain training methods for recovery of impaired reach coordination.
Background:
In today's health care environment where resources are scarce discharge planning is an important component of resource allocation. Knowledge of the factors that influence discharge disposition is fundamental to such planning. Further, return to home is an important outcome metric related to the effectiveness of a stroke rehabilitation program.
Aim:
To test the hypothesis that the patients who have a caregiver at home willing to participate in the care of the patient discharged from a stroke rehabilitation unit are more likely to be discharged home given other predictive factors being the same.
Design:
Retrospective cohort study using binary logistic regression analysis with outcome as discharge home vs. discharge not home after in-patient stroke rehabilitation.
Setting:
Hamilton Health Sciences multidisciplinary integrated stroke program unit.
Population:
During this period, 276 patients were admitted to the integrated stroke unit, of which 268 patients were living in the community prior to hospitalization. The remaining eight patients were admitted from a care facility, such as a nursing home or assisted living facility. Since a sample size of eight is too small, these patients were excluded from the analysis. As such, the analysis is based on the 268 patients who were living at home prior to the onset of stroke.
Methods:
The data points collected during the study period were age, gender, days from stroke onset to rehabilitation unit admission, pre-stroke living arrangement (lived alone vs. lived with spouse, partner, or another family member), FIMTM at admission, type of stroke, laterality of impairment, and discharge destination (i.e., private dwelling vs. nursing home, assisted living facility, or back to acute care).
Results:
As established by a number of previous studies, the most significant predictors of home as discharge destination was admission FIMTM. However, the second most important predictive factor for home discharge was prestroke living arrangement (lived alone vs lived with spouse/partner/other family member) as hypothesized by the authors.
Conclusion:
Literature is rich with studies showing functional independence to be the most important predictor of home as discharge disposition but our analysis shows that pre-stroke living arrangement, i.e., lived alone vs lived not alone is also an important predictor for patients to be discharged home after stroke rehabilitation.
Clinical rehabilitation impact:
If current discharge planning relies on the availability of a caregiver at home after discharge from in-patient stroke rehabilitation then it may be worthwhile to include these caregivers in the inpatient rehabilitation process, to prepare them for their loved one's return home. Additionally, once the patient is discharged home more resources should be made available to support caregivers in the community. This may include more home healthcare personnel training and availability along with respite care.
To determine rehabilitation lengths of stay for patients with stroke in Canada and to evaluate which factors contribute to variations in lengths of stay (LOS).
A retrospective cohort study of Canadians rehabilitating from stroke using medical, functional and sociodemographic variables extracted from the Canadian Institute for Health Information's National Rehabilitation Reporting System.
Canadian rehabilitation hospitals providing stroke rehabilitation services PARTICIPANTS: Patients with stroke (n = 11,983) admitted to rehabilitation hospitals from January 2008 through December 2009.
None.
Rehabilitation LOS were calculated nationally and regionally. Regression models incorporating sociodemographic and clinical measures were constructed to test their effect on LOS.
The median stroke rehabilitation LOS was 35 days (quartiles: 20, 54 days). LOS varied regionally within Canada. A multivariable regression model including age, FIM® Motor Function Scores at admission and geographic region explained 20% of the variation in LOS. Modeling these data using a Function Related Groups case-mix model explained 16% of the variation in LOS.
FIM® Motor Function Scores at admission along with age and geographic region best predicted rehabilitation LOS. These variables explained 20% of the variation in LOS. Despite regional differences in LOS, patient characteristics were similar between regions. Other non-patient factors not captured in these data may contribute to a greater extent in determining stroke rehabilitation LOS.
Background : In this era of accountability in health care, the need to document treatment‐related changes in health status is critical. However, few studies report outcomes in people with right cerebral hemisphere damage (RHD). Aims : The objective of this study was to document, in a single population of patients with RHD, selected functional outcomes at the termination of inpatient treatment. Of particular interest were cognitive performance and its influence on motor and overall recovery. Methods & Procedures : Functional outcomes were retrospectively examined in 101 RHD patients, at discharge from an in‐patient rehabilitation programme. The Functional Independence Measure (FIM; Center for Functional Assessment Research, 1993) was the measurement tool. The five outcomes examined were: final functional status, amount of gain, efficiency of gain, length of stay (LOS), and discharge placement. FIM scores, produced on an ordinal rating scale, were statistically transformed by the Rasch method (Rasch, 1960) to generate interval‐level data for regression analyses. Outcomes & Results : Summary by outcomes: Gains were evident in cognitive and motor realms, with greater and more efficient improvement in the latter. Regression analysis indicated that final functional status was best predicted by age, initial motor severity (FIM motor score), and initial total cognitive severity (FIM cognitive scores); amount of gain was best predicted by age, evidence of previous neurological incident, and gender; efficiency of gain by initial cognitive item scores, initial motor severity (FIM score) and age; LOS by initial motor severity (FIM score); and discharge placement by age, marital status, and initial severity (FIM status). Major predictors tended to be age and the family of cognitive FIM scores, especially Problem Solving (PS). Memory and PS were the most challenging cognitive items for these patients, as indicated by scores on admission and discharge reflecting less than functional ability. A sizeable number of patients began and ended rehabilitation with functional levels of ability in comprehension, expression, and social interaction. Significant differences existed between patients with neglect and those without, but neglect was not a significant predictor of any outcome measure. Low initial cognitive FIM scores, presence of neglect, and older age were associated with poorer performance in motor and cognitive realms. Previous neurological episodes were negatively associated with amount of gain. Number of comorbidities was not statistically associated with outcomes. Conclusions : Initial severity levels and age were the most influential factors on these outcomes. The presence of neglect had a relatively minor impact on most outcomes. Performance on the cognitive items was less impaired than motor items, and registered less gain and less efficient gain than motor items, but did predict various final status and gain‐related measurements in overall and motor realms. Analyses in this study revealed that the FIM scale is less sensitive to cognitive change than to motor change.
Rationale, aims and objectives Inpatient rehabilitation of patients following stroke can be resource intensive, with optimal models of service delivery unclear. This study investigates the dose–response curves between physiotherapy service delivery variables and balance and function clinical outcomes.
Method This was a multi-centre (15 sites), prospective, cohort study involving patients (n = 288) admitted for rehabilitation following stroke conducted across two states in Australia. Physiotherapy department resource provision variables were collected and examined for association with change in patient function and balance outcomes (Functional Independence Measure, step test, functional reach test) measured at admission and discharge from inpatient care.
Results A greater amount of log-transformed physiotherapy department resource provision was associated with greater improvement in the functional independence measure [Regression coefficient (95% CI): 4.05 (1.15, 6.95)] and functional reach test [46.43 (17.03, 75.84)], while physiotherapist time provided to patients was associated with greater improvement for the step test [0.15 (0.03, 0.28)], and functional reach [0.35 (0.19, 0.52)].
Conclusion Receiving a higher rate of physiotherapist input is an important factor in attaining a greater amount of recovery in function and balance outcomes; however, the improvement by patients who received the greatest amount of input was highly variable.
Objective:
To determine predictors of falls in stroke patients in the first 6 months after a baseline evaluation before their discharge from inpatient rehabilitation.
Design:
Prospective cohort study.
Setting:
Rehabilitation hospital, then home.
Participants:
Consecutive stroke patients (N=66) were followed at home after discharge from the rehabilitation hospital.
Interventions:
Not applicable.
Main outcome measures:
Fall occurrence within 6 months after a baseline evaluation. All patients were assessed for baseline data during their inpatient rehabilitation (1.5±1.2 wk before discharge). Data regarding cerebrovascular accident (CVA) date, number of attacks, and brain imaging results were obtained; motor function and balance impairment were examined by the Fugl-Meyer Assessment Scale. The FIM and Functional Ambulation Category were also used. Presence of urinary incontinence, drug use, fall history, postural hypotension, neglect, cognitive status, poor vision, and hearing were evaluated. Six months after the baseline evaluation, any fall occurrence was ascertained via telephone calls to the caregivers of each patient. Multivariate logistic regression analysis was used to identify risk factors.
Results:
The mean age ± SD was 64±10 years. The median time elapsed since CVA at the time of admission was 4 months. Twenty-four (36%) patients fell within the 6-month period. The fall rate was significantly higher in patients with left (47%) versus right (21%) hemispheric stroke. Left hemispheric lesion (vs right) showed a 4 times greater risk of fall within 6 months (odds ratio=4.093; 95% confidence interval, 1.082-15.482). There were no other significant differences between fallers and nonfallers with respect to the other evaluated factors.
Conclusions:
Our results suggest that the fall risk within 6 months after a baseline evaluation is greater in patients with left hemispheric lesions versus those with right hemispheric lesions.
To review the development of Rasch analysis by examining the history of its application to the Functional Independence Measure (FIMTM), and highlighting current issues in the approach.
All Rasch-based papers concerning the FIMTM were reviewed for their analytical strategy and results. Four analytical pathways were identified that accommodated the majority of these strategies. Data derived from secondary analysis of 340 in-patients undergoing rehabilitation following stroke, measured on the FIMTM Motor Scale, were fitted to the Rasch measurement model according to these 4 pathways, with 2 additional pathways to accommodate recent developments.
In the analytical pathway, where items are not re-scored, the fit to the Partial Credit parameterization was better than the Rating Scale version. Fit improved following re-scoring of disordered thresholds. When local dependency was accommodated by 4 testlets, the Partial Credit, re-scored testlet version achieved adequate summary fit with no misfit among items, and unidimensionality. All other pathways required item deletion.
The current study has shown that the FIMTM Motor Scale, as applied to a stroke rehabilitation sample, satisfies Rasch model expectations and the unidimensionality assumptions, having accommodated local dependency issues, and by using the partial credit parameterization with re-scored categories. Other analytical pathways gave less ideal solutions, and are consistent with the wide range of solutions found for the scale over the years. Consequently, the development of the Rasch approach in health outcomes can be traced in the history of analysis of the FIMTM, and that development continues to this day.
Objective This study explores the link between neurologic deficit as measured by the National Institutes of Health Stroke Scale (NIHSS), and its relationship to length of stay (LOS) and discharge destination. Design A retrospective chart review was completed of 54 patients admitted for rehabilitation after experiencing a cerebrovascular accident. Setting The study was completed in an acute inpatient rehabilitation stroke unit in a large urban tertiary care medical center. Participants Patients were included in this analysis if their record contained an NIHSS score on both admission and discharge, if they had neuroimaging documentation of an acute hemorrhagic or ischemic stroke, and if they were not transferred away from the rehabilitation unit during their stay. Of 54 cases reviewed, 47 were ultimately included. Main Outcome Measurements Independent variables included were NIHSS admission and discharge scores, change in score from admission to discharge, discharge destination, age, gender, type of stroke, and use of tissue plasminogen activator. These were examined against the dependent variable, LOS. Results Greater admission NIHSS scores predicted longer hospital stays. Mean admission and discharge scores were significantly greater for patients discharged to subacute facilities, and LOS was also longer for these patients compared with those discharged to the community. Surprisingly, age was inversely related to LOS, admission score, and discharge score. Conclusion Stroke remains one of the most common reasons for admission to acute care hospitals. The authors know of no studies that have examined the rehabilitation aspect of care incorporating the NIHSS in this manner. This study draws a connection between neurologic impairment by using the NIHSS and LOS and discharge destination in an acute inpatient rehabilitation stroke unit. In the future, multidisciplinary rehabilitation teams may consider using this measure to predict LOS and disposition at discharge from inpatient rehabilitation.
OBJETIVOS: conhecer as incapacidades e identificar se há diferenças de gênero, em sobreviventes de primeiro episódio de acidente vascular cerebral (AVC), entre 20 e 59 anos de idade, na cidade do Recife e que tenham sido hospitalizados pelo Sistema Único de Saúde. MÉTODOS: entrevista domiciliar com uma amostra de sobreviventes, investigando-se as incapacidades referidas na vida funcional e produtiva deles. RESULTADOS: amostra equilibrada entre os sexos, média de idade de 52 anos, com nível elementar de estudos ou analfabeto e trabalhando no setor de serviços, informal ou doméstico. Menos de 20% informam recuperação total após o AVC. Aproximadamente 80% apresentam algum déficit, sendo os problemas de comunicação e os sintomas depressivos mais freqüentes entre as mulheres. Após o AVC aumentou o número de desempregados e aposentados e as incapacidades repercutem negativamente na satisfação de vida de mais de 70% dos entrevistados. CONCLUSÕES: é expressivo o percentual de casos, ainda jovens, com seqüelas pós AVC, sendo este mais precoce e o quadro de incapacidades mais freqüente e/ou grave entre as mulheres. A prevenção e a reabilitação após o AVC são desejáveis, com a implantação de programas, considerando as condições de gênero, para o controle dos riscos e para as seqüelas resultantes do AVC.
With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.
A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.
A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.
This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.
To assess the association of selected clinical factors and specific medication use (proton pump inhibitors, H2 receptor antagonists [H2 blockers], and angiotensin-converting enzyme inhibitors) with presence of pneumonia in patients with stroke undergoing acute inpatient rehabilitation.
Matched case-control study in a freestanding urban academic inpatient acute rehabilitation hospital. Participants were 72 stroke survivors, consisting of 36 patients who developed pneumonia during rehabilitation hospitalization individually matched in order of decreasing priority on age, sex, stroke side, depth, and severity with 36 patients with stroke not developing pneumonia. Potential risk factors, including severe dysphagia, dietary interventions, presence of tracheostomy or feeding tube, and specific medications, were assessed for association with pneumonia during rehabilitation using separate univariate and multivariate analyses. Functional change was assessed using the functional independence measure.
Although pneumonia was associated with proton pump inhibitors or H2 blockers (odds ratio, 3.3; 95% confidence interval, 1.0-13.7), any feeding tube (odds ratio: 5.0; 95% confidence interval, 1.4-27.0), severe dysphagia (odds ratio: 15.0; 95% confidence interval, 2.3-631), and tracheostomy (odds ratio: 10; 95% confidence interval, 1.4-434.0) on univariate evaluation, none of these individual factors was significantly associated with pneumonia in a multivariate model. Risk factors were found to be highly related to each other. Odds of pneumonia did not significantly decrease with angiotensin-converting enzyme inhibitors (odds ratio: 0.9; 95% confidence interval, 0.2-3.0). Patients with pneumonia had a significantly lower functional independence measure score at discharge.
A reduction in pneumonia was not found with the use of angiotensin-converting enzyme inhibitors. Although tracheostomies, feeding tubes, proton pump inhibitor or H2 blocker use, and the presence of dysphagia were identified as risk factors for pneumonia on univariate analyses, none of these factors demonstrated an independent association with pneumonia on multivariate analyses. It may be more that the underlying impairment, rather than the assessed interventions, may confer greater risk of pneumonia in the poststroke patient.
Medical, neurologic, and psychiatric complications can interfere with optimal recovery after stroke and increase the cost of care. Ideally, preventing these complications would be the best and most cost-effective treatment. This article reviews the clinical implications and management strategies for venous thromboembolism, spasticity, and depression after stroke.
To determine the feasibility and utility of applying a case-mix adjusted algorithm for treatment across the continuum of stroke rehabilitation.
Implementation of a clinical algorithm developed through national expert panels to standardize rehabilitation assessment and treatment of veterans with stroke. Stroke patients were stratified into initial severity groups using FIM instrument-Function Related Groups (FIM-FRG) classifications and were followed up from first rehabilitation referral to completion of all active restorative functional goals. FIM-FRG assignments were used to establish case-mix adjusted outcome indicators for the continuum of rehabilitation services.
Rehabilitation services in medical and surgical units, intermediate care units, inpatient rehabilitation bed units, and outpatient settings in 10 participating Veterans Affairs (VA) medical centers.
Stroke patients (n = 421) who received rehabilitation in the 10 participating VA centers.
Patients' functional gains, length of treatment (LOT), functional status at discharge, LOT efficiency, costs, cost efficiency, and disposition location.
Two hundred twenty-three patients began rehabilitation while in acute medical or surgical units, 171 in inpatient rehabilitation units, 24 in intermediate care, and the remainder while in other settings. With cases compiled across all settings, average total rehabilitation costs for patients in the lowest FRG class (most severe disabilities) were more than twice those for patients assigned to the highest FRG class (least severe disabilities). FIM gains were greatest in the subset of younger stroke patients with the most severe disabilities.
Implementing a standard algorithm of rehabilitation care that includes outcome indicators adjusted to patients' disability severity is feasible. The algorithm's utility is evident because it encompasses rehabilitation care provided across the full continuum, promotes access to care by advocating assessment of all stroke patients, encourages early initiation of treatment, and promotes a smooth transition though various levels of care while encouraging cost containment.
Given the pressure on healthcare budgets, assessing the cost of managing a disease has become a major research focus; yet collection of these data are labor intensive and difficult. Understanding the predictors of cost provides an efficient means of incorporating such information in decision-making concerning new therapies.
Data from two 12-week multinational trials that collected information on a variety of neurological, functional, and cost parameters for 1341 ischemic stroke patients were examined by means of multiple linear regression. Because the intent is for the model to be predictive, only patient characteristics that can be known at the time of patient presentation or shortly thereafter were evaluated for inclusion in the model.
The Barthel Index was the strongest predictor of cost in all models evaluated. Other major predictors, either directly or through their impact on survival, were stroke subtype, neurological impairment, congestive heart failure, and country. A good model fit was obtained, judging by the model statistics (model F:=84, 3 df, P:<0.0001) and the accuracy of the predictions (<3% difference between mean actual and predicted cost).
Through the use of key patient characteristics, this regression model allows for prediction of the cost of stroke care, which may be helpful in the context of therapeutic decisions and budgetary planning purposes. It also provides insight into how specific treatments, through their impact on clinical characteristics, can modify the cost of stroke treatment.
The aims of this study were to examine the frequency, types, and clinical factors associated with medical complications that occur during inpatient rehabilitation and to identify risk factors for complications that require a transfer to an acute care facility.
A cohort of 1029 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke information, impairment, preexisting medical conditions, and admission laboratory abnormalities were recorded. Medical complications, defined as new or exacerbated medical problems, were documented for each patient. Complications that required transfer off rehabilitation were noted. Univariate and multiple logistic regression analyses were used to determine factors that were associated with risk of medical complications and risk of transfer off rehabilitation.
Seventy-five percent of patients experienced >/=1 medical complication during rehabilitation. Significant factors for the development of any medical complication included greater neurological deficit (odds ratio [OR], 4.10; confidence interval [CI], 1.88 to 8.91), hypoalbuminemia (OR, 1.71; 95% CI, 1.15 to 2.52), and history of hypertension (OR, 1.81; 95% CI, 1.27 to 2.59). Nineteen percent of patients had a medical complication that required transfer to an acute care facility. Significant factors for transfers were elevated admission white blood cell counts (OR, 1.92; 95% CI, 1.32 to 2.79), low admission hemoglobin levels (OR, 1.89; 95% CI, 1.32 to 2.68), greater neurological deficit (OR, 2.46; 95% CI, 1.37 to 4.39), and a history of cardiac arrhythmia (OR, 1.79; 95% CI, 1.18 to 2.67).
Medical complications are common among patients undergoing stroke rehabilitation. A significant number of these medical complications may require a transfer to an acute facility.
With the Health Reform 2000, the Australian Refined Diagnosis Related Groups (AR-DRG), Version 4.1 have been chosen as the basis for the future German costing system for hospitals. With regard to Stroke Severity (Barthel Index [BI]) we investigated to what extent the grouping according to AR-DRGs can reproduce healthcare expenditures for such patients. Options to adapt and optimize the system are discussed.
632 patients who had suffered a cerebrovascular accident and were discharged from conservative acute care in 1999, were classified according to the AR-DRGs. For the grouping we alternatively used data from the current hospital information system and a stroke database for quality assurance. The results were also compared with the clinical profiles for the public hospital sector of the corresponding DRGs in Australia (1997-98).
On average 0.99 additional diagnoses per case were documented in the hospital information system, compared to 3.65 in the stroke database. In the stroke database 177 cases (36.8%) were assigned to the DRG with the highest cost weight. 53.7% of these patients suffered a serious stroke (BI < 30). Grouping on the basis of hospital information system data led only to 14 cases (2.8%) assigned to the DRG with the highest cost weight.
Type and extent of additional diagnoses are crucial for the grouping process. From a clinical and economic point of view, measures of disability and impairment should be assigned to the grouping process to improve homogeneity under both aspects. Scores can also serve for determining reliable outcome parameters. For the development of an outcome related reimbursement system, procedures must be included in the definition of medical DRGs. In future, DRGs, which cover overlapping healthcare sectors, should be developed for patients with poststroke rehabilitation.
To evaluate the practice patterns for stroke care in rural emergency departments (ED).
The authors prospectively evaluated clinical practice decisions for all ED patients in two non-urban East Texas communities using active and passive surveillance methods. Data collected included demographics, risk factors, symptoms, and treatment. Data analysis consisted of descriptive statistics and logistic regression analysis.
During the study period, 429 patients presented with validated strokes. Risk factors included hypertension (65%), previous stroke (41%), coronary artery disease (33%), diabetes (25%), current smoking (17%), and atrial fibrillation (11%). In the ED, neurology consultation occurred in 32%, head CT in 88%, and ECG in 85%. Heparin was used in 9%, and 5% received aspirin. Blood pressure was lowered in 19% from a mean high of 189(+/-38)/97(+/-26), average reduction 34 points (18%) systolic. Motor symptoms were more likely to prompt a neurology consultation (OR = 2.47). Heparin was used more commonly for patients with atrial fibrillation (OR = 2.93). Socioeconomic factors did not alter care. IV recombinant tissue plasminogen activator was used in 1.4% of ischemic stroke cases.
Acute stroke care in this representative non-urban community frequently does not follow published guidelines or clinical trial results. Whereas a high percentage of patients receive CT, aggressive blood pressure treatment occurs commonly and at pressures below current recommendations. The use of heparin is common, more so than aspirin treatment. These facts argue for educational interventions aimed at non-urban physicians to improve evidence-based medical practice.
Stroke is a heavy economic burden on the individuals, society and health services in China, where health expenditure is rising rapidly. The purpose of the present study is to examine health services and demographic factors associated with inpatient charges for cerebral infarction in China, focusing on hospital charges of insured and uninsured patients.
The study subjects were 545 patients with a principal diagnosis of cerebral infarction stroke who were discharged from the China-Japan Friendship Hospital from January 1, 1997 through December 31, 1998. Demographic, clinical and administrative data were retrospectively collected from the medical record and financial database. The influence of social and medical factors on total charges was analyzed with stepwise multiple regression model.
Of 545 subjects, 429 (79%) were the insured patients and 116 (21%) were the uninsured patients. Length of hospital stay (LOHS) for the insured patients (median, 32 days) was significantly longer (P<0.001) than that for the uninsured (median, 23 days). The hospital charges per discharge for the insured was significantly higher (geometric mean, 10407 yuan) (P<0.0001) than that for the uninsured patients (geometric mean, 5857 yuan). With stepwise multiple regression, factors associated independently with the hospital charge were: longer hospital stay, insurance status, increased number of head magnetic resonance imaging (MRI) and computerized tomography (CT), infection in hospital stay, and more severe condition of stroke.
Inpatient charge for cerebral infarction stroke was positively associated with being the insured. The findings suggest an overuse of health care resources in insured patients and limited use of resources by those who are not.
The aim of this study was to investigate the relationship between the volume of lesion (VOL) in patients with stroke and the associated length of hospital stay (LOS), as well as longer-term functional outcome. Computerised tomography (CT) scans were used to measure the volume, region and type of lesion, volume being measured by planimetry. LOS and other patient details were obtained from the Dundee Stroke Database. The total LOS was associated with the VOL on univariate analysis (p = 0.004) and after adjustment for the other variables (p = 0.006) due to a larger lesion being associated with longer stay in hospital. Patient follow-up confirmed that the VOL was also highly significant when related to functional outcome measures of impairment, disability and handicap at one year, as determined by Orgogozo (p = 0.03), Barthel (p < 0.01) and Rankin scores (p < 0.01) respectively. The VOL is related to the length of stay in hospital and outcome at one year. This is of particular interest with the increasing use of thrombolysis and development of neuroprotectant agents designed to limit VOL.
To compare the mobility status (admission and discharge status, change in status) between patients with stroke and traumatic brain injury (TBI) during inpatient rehabilitation and to determine the relationship between mobility status and outcome variables including length of stay (LOS).
Prospective study.
Free-standing tertiary rehabilitation center.
A total of 210 patients with stroke (n = 136) and TBI (n = 74) consecutively admitted for inpatient rehabilitation.
Not applicable.
Clinical Outcome Variable Scale (COVS), a 13-item scale of mobility status (measured on admission and discharge from inpatient rehabilitation), and rehabilitation LOS.
With age and time since injury controlled in the model, the TBI group showed a significantly higher mobility status on admission and discharge over the stroke group, but the change (improvement) in mobility status did not differ. The admission mobility status accounted for 61% and 60% of variability of the discharge mobility status for the stroke and TBI groups, respectively. The admission mobility status accounted for 40% and 50% of the variability in rehabilitation LOS for the stroke and TBI groups, respectively. Either the admission mobility status or the physical therapist's prediction of the discharge status could be used to determine the actual discharge mobility status, although the physical therapist's predictions were more accurate than using a statistical model.
The TBI group showed a higher mobility status at admission and discharge from inpatient rehabilitation than the stroke group; however, the rate of improvement (improvement in mobility status per day) did not differ between groups. Admission mobility status using the COVS was an excellent predictor of discharge mobility status and rehabilitation LOS in stroke and TBI patients.
To investigate the level of cardiovascular stress of physical therapy (PT) and occupational therapy (OT) sessions of a contemporary stroke rehabilitation program and to identify therapeutic activities that elicit heart rate responses adequate to induce a training effect.
A descriptive, longitudinal study with heart rate and activity monitoring of PT and OT sessions at biweekly intervals, 2 to 14 weeks poststroke.
An acute inpatient stroke unit and inpatient and outpatient stroke rehabilitation units.
A consecutive sample of 20 patients with ischemic stroke who participated in inpatient and outpatient stroke rehabilitation.
Observation of routine PT and OT sessions for patients poststroke without influencing the extent and content of the sessions.
Time per session in which heart rate was within the calculated target heart rate zone.
Time per PT session spent in target heart rate zone was low (2.8+/-0.9 min), and per OT session was negligible (0.7+/-0.2 min) over the course of rehabilitation.
The PT and OT sessions between 2 and 14 weeks poststroke did not elicit adequate cardiovascular stress to induce a training effect.
Many stroke survivors have to cope with impairments and disabilities that may result in the occurrence of handicap situations. The purpose of the study was to explore bio-psycho-social predictors of handicap situations six months after discharge from an intensive rehabilitation programme.
At discharge from a rehabilitation programme, participants were evaluated with instruments measuring motor, sensory, cognitive, perceptual, affective and psychosocial impairments and disabilities that may play a role in the development of handicap. Some other demographic and clinical variables, and those related to rehabilitation, were also collected. Six months later, they were re-assessed in their own environment in order to document their handicap level with the Assessment of Life Habits (LIFE-H).
One hundred and thirty-two stroke patients participated in the discharge evaluation and 102 of them also participated in the handicap measurement. Relationships between handicap level and impairments and disabilities were all statistically significant. Multiple regression analyses indicated that affect, lower extremity co-ordination, length of stay in rehabilitation, balance, age and comorbidity at the end of an intensive rehabilitation programme are the best predictors of handicap situations six months later (adjusted R(2): 68.1%).
In spite of its exploratory nature, this study revealed that, among a substantial number of personal characteristics, some were more related to a handicap measure and have greater predictive value. Other studies should be carried out to validate these findings and to consider more environmental factors in order to better understand factors related to the development of handicap situations.
To evaluate exercise capacity of patients with a poststroke interval of less than 1 month.
Prospective, cohort, observational study.
Exercise testing laboratory in a tertiary care hospital.
Twenty-nine patients (mean age +/- standard deviation, 64.9+/-13.5 y) with a poststroke interval of 26.0+/-8.8 days.
Not applicable.
Peak exercise capacity (VO(2)peak) was measured by open-circuit spirometry during maximal effort treadmill walking with 15% body-weight support.
Mean VO(2)peak was 14.4+/-5.1 mL. kg(-1). min(-1) or 60%+/-16% of age- and sex-related normative values for sedentary healthy adults.
Exercise capacity approximately 1 month after stroke was compromised. Further research is needed to elucidate the physiologic basis of this low capacity.
Studies of stroke trends have focused primarily on incidence, mortality, and hospitalization rates. There has been little evaluation of changes over time in the common patient characteristics, medical comorbidities, and functional outcomes of patients. The present study evaluated changes during a 7-year period. We found that while demographic variables, stroke severity, and most stroke characteristics remained relatively stable, disability levels at admission and discharge decreased and frequencies of both medical tube usage and many secondary medical complications increased over time. These changes have important implications for the clinical management of stroke patients in rehabilitation and for the organization and financing of stroke rehabilitation programs.
Stroke is a heavy economic burden on individuals, society, and health services in Japan, where health expenditures are rising rapidly. The objective of the present study was to examine medical services and demographic factors associated with increased inpatient charges for ischemic stroke in Japan.
The study subjects were 316 patients with a principal diagnosis of acute ischemic stroke who were discharged from the National Kyushu Medical Center Hospital from 1 July 1995 through 31 June 1999. Demographic, clinical, and administrative data were retrospectively collected from medical records and the hospital Clinical Financial Information System (CFIS). The influence of social and medical factors on total charges was analyzed using the stepwise multiple regression model.
Among the total subjects, the mean (median) length of hospital stay (LOHS) was 33 (30) days (range, 2-155 days). The mean (median) hospital charge per patient was US dollars 9020 (dollars 7974) with a range of dollars 336-54,509. The distribution of charges was 42% for fundamental, 17% for injection therapies, 13% for radiological test, 11% for other laboratory examinations, 3% for drugs, and 3% for operations. Stepwise multiple regression analysis revealed that LOHS was the key determinant of the hospital charge (partial R2=0.5993, P=0.0001). Operations (P=0.0001) and angiography (P=0.03) were also independent but less contributory determinants of the hospital charge.
LOHS was strongly, positively associated with inpatient charges for ischemic stroke in Japan. This implies that significant charge reductions are more likely to rely on shortening LOHS, which probably can be achieved by altering reimbursement policies.
Background:
resource use by different types of patients is of increasing interest to health care services all over the world. Case-mix systems that group together individuals with similar patterns of resource use have been developed to address these questions. Resource Utilization Groups version III (RUG-III) was developed in the USA to address the issue in the care of elderly people and has been validated in a number of countries.
Method:
this paper synthesizes the results of RUG-III validation studies performed in the USA, Japan, Spain, Sweden and England and Wales, showing the consistency of the system in spite of different skill-mix and total time spent with patients. Data from the validation studies of five countries were compared. Percentage of time given by trained nurses and mean nursing time per patient was compared overall and between selected RUG-III groups.
Results:
mean time per patient ranged from 84.4 min per day in Japan, to 155.6 min in England and Wales. Trained nurse time ranged from 7.5% of total time in the USA to 53.2% of total time in England and Wales. The inter-group relationship was very similar in all countries. The RUG-III system appears robust in a wide variety of settings and countries. Future research should address the relationship between skill-mix and total time spent with patients with respect to outcome and quality of care.
We designed a 15-item neurologic examination stroke scale for use in acute stroke therapy trials. In a study of 24 stroke patients, interrater reliability for the scale was found to be high (mean kappa = 0.69), and test-retest reliability was also high (mean kappa = 0.66-0.77). Test-retest reliability did not differ significantly among a neurologist, a neurology house officer, a neurology nurse, or an emergency department nurse. The stroke scale validity was assessed by comparing the scale scores obtained prospectively on 65 acute stroke patients to the patients' infarction size as measured by computed tomography scan at 1 week and to the patients' clinical outcome as determined at 3 months. These correlations (scale-lesion size r = 0.68, scale-outcome r = 0.79) suggested acceptable examination and scale validity. Of the 15 test items, the most interrater reliable item (pupillary response) had low validity. Less reliable items such as upper or lower extremity motor function were more valid. We discuss methods for improving the reliability and validity of brief examination scales to be used in stroke therapy trials.
There is a paucity of information on functional benefits of inpatient rehabilitation of patients with end-stage renal disease (ESRD). This study examined admission and discharge Functional Independence Measure (FIM) scores of 45 ESRD patients admitted over a 33-month span to determine if these patients made functional gains similar to 2,324 concurrently admitted general rehabilitation patients without ESRD. FIM scores were transformed and reported as scaled (0 to 100) motor and cognitive subscores by the Rasch method. FIM scores were compared using multiple linear regression to control for differences in rehabilitation diagnosis and other confounding factors between the ESRD and other patients. ESRD subgroups were compared using one-way analysis of variance. The mean discharge motor FIM score unadjusted for confounders was lower in ESRD than general rehabilitation patients (45.18 vs 50.63), and the difference after regression analysis (7.63 points lower in the ESRD group) was significant (p < .01). The mean motor FIM score gain after regression analysis for the two groups showed only a near significant (p = .06) difference, with the gain among ESRD patients being 3.15 points lower. Discharge settings were similar, with 89% of ESRD patients and 87% of patients without ESRD being discharged home. ESRD patients on hemodialysis had similar FIM scores to patients with renal transplantation. ESRD patients with stroke had significantly lower (p < .05) discharge motor and cognitive scores than ESRD patients with generalized weakness or amputation. In addition, stroke patients with ESRD showed significantly lower motor FIM score gains than stroke patients without ESRD (5.09 vs 11.08; p = .002).(ABSTRACT TRUNCATED AT 250 WORDS)
The Functional Independence Measure (FIM) is an 18-item, 7-level scale developed to uniformly assess severity of patient disability and medical rehabilitation functional outcome. FIM interrater reliability in the clinical setting is reported here. Clinicians from 89 US inpatient comprehensive medical rehabilitation facilities newly subscribing to the uniform Data System for Medical Rehabilitation from January 1988-June 1990 evaluated 1018 patients with the FIM. FIM total, domain and subscale score intraclass correlation coefficients (ICC) were calculated using ANOVA; FIM item score agreement was assessed with unweighted Kappa coefficient. Total FIM ICC was 0.96; motor domain 0.96 and cognitive domain 0.91; subscale score range: 0.89 (social cognition) to 0.94 (self-care). FIM item Kappa range: 0.53 (memory) to 0.66 (stair climbing). A subset of 24 facilities meeting UDSMR data aggregation reliability criteria had Intraclass and Kappa coefficients exceeding those for all facilities. It is concluded that the 7-level FIM is reliable when used by trained/tested inpatient medical rehabilitation clinicians.
This study examined the value of serum albumin level as a predictor of medical complications and functional outcomes in 79 patients, age 65 years or older, who underwent comprehensive inpatient interdisciplinary rehabilitation for a first-time, unilateral, thromboembolic stroke. We recorded serum albumin levels at the time of admission to an inpatient rehabilitation unit, reports of the medical complications during rehabilitation, and Modified Barthel Index (MBI) Scores on admission and discharge. The mean (+/- SD) serum albumin level for all patients was 3.3 +/- 0.4g/dL. Forty-two patients (53%) had a total of 69 medical complications during rehabilitation. Mean serum albumin levels were 3.2 +/- 0.4g/dL for the group with complications and 3.5 +/- 0.3g/dL for the group without complications (t = -4.34, p < 0.001). Of the 37 patients with albumin levels > or = 3.5g/dL, only 32% had complications; of the 28 patients with levels from 3.0 to 3.4g/dL, 68% had complications; of the 14 patients with levels < or = 2.9g/dL, 79% experienced complications (chi 2 = 12.4, p = 0.002). There were positive correlations between serum albumin levels and the discharge MBI Self-Care Subscores, Mobility Subscores, and Total Scores (p < 0.001). There were also correlations between serum albumin levels and the Mobility and Total MBI Improvement Scores (p = 0.002 and p = 0.008, respectively). The relationship between serum albumin levels discharge destination approached statistical significance. Neither age nor side of lesion were related to serum albumin level, medical complication rate, or functional outcomes. Serum albumin levels appear to be related to medical complication rate and functional outcome in geriatric stroke patients. This suggests that older stroke patients with hypoalbuminemia may warrant closer medical attention or therapeutic intervention before and during rehabilitation.
Efforts are currently underway to develop a prospective payment system for inpatient medical rehabilitation. In this study, a clinically based, condition-specific patient classification scheme was developed that includes 33 patient groupings, referred to as Functional Related Groups (FRGs). Each FRG is comprised of patients with similar clinical characteristics and resource use, as measured by length of stay. From a policy perspective, the FRGs minimize the adverse incentives that may develop in the selection of patients for admission to the rehabilitation facility. The FRGs, therefore, may be used as a basis in the development of a prospective reimbursement system for rehabilitation services.
Medicare's system for the payment of rehabilitation hospitals is based on limits derived from a hospital's average allowable charges per patient discharged during a base year. Thereafter, payments are capped but hospitals receive incentive payments if charges per patient are reduced in succeeding years. We hypothesized that per-patient charges would increase during the base year and then decrease in subsequent years. Hospitals would thus have higher reimbursement limits and receive incentive payments for reducing their charges.
We analyzed Medicare claims data for 190,921 discharges from 69 rehabilitation hospitals from 1987 through 1994. We compared total charges, length of stay, and interim payments before, during, and after each hospital's base year.
After we controlled for inflation and temporal and seasonal trends, mean charges per patient discharged increased from $25,131 for patients discharged before the base year to $32,167 for patients discharged in the base year (a 28 percent increase, P<0.001) and the mean length of stay increased from 22.1 to 26.7 days (a 21 percent increase, P<0.001). After the base year, mean charges decreased to $29,307 (a 9 percent decrease) and the mean length of stay decreased to 24.0 days (a 10 percent decrease) (P<0.001 for both comparisons). Analysis of data on patients according to diagnosis -- for example, spinal cord injury, brain injury, stroke, amputations and deformities, hip fracture, and arthritis and joint disorders -- showed similar findings for each, with increases in charges and length of stay in the base year, followed by smaller reductions thereafter. For-profit hospitals had greater increases than nonprofit hospitals in their per-patient charges (mean increase, $7,434 vs. $2,929; P<0.001) and length of stay (mean increase, 4.6 vs. 2.3 days, P<0.001) during the base year.
Although Medicare's reimbursement system for rehabilitation hospitals put an upper limit on total payments, its design was associated with substantial extra costs, including significantly increased payments to hospitals and doctors and increased numbers of hospital days for the average patient.
The National Institutes of Health (NIH) Stroke Scale has been used in clinical trials to assess neurological outcome after investigational therapy for acute stroke. We used the NIH Stroke Scale to study the degree and time course of recovery in patients with acute stroke who were treated with conventional therapy.
We serially assessed 50 patients with ischemic stroke who presented within 24 hours of onset of symptoms. Patients were grouped by stroke subtype. Major neurological improvement was defined as a decrease in the stroke score by 4 points or more.
The mean NIH stroke score for all patients improved significantly by 7 to 10 days and at last follow-up (average, 44 days). Major neurological improvement was seen in 5 of 41 patients (12%; 95% confidence interval [CI], 2% to 22%) by 24 hours, 11 of 40 patients (28%; 95% CI, 14% to 41%) by 48 hours, and 19 of 37 patients (51%; 95% CI, 35% to 67%) by follow-up. The subgroup of patients with middle cerebral artery territory embolism showed a similar pattern of improvement; in contrast, patients with lacunar infarcts did not show significant change in scores during the study period. The score on admission did not correlate with the degree of subsequent improvement or deterioration.
A significant percentage of patients with acute ischemic stroke treated with conventional therapy show early improvement as assessed by the NIH Stroke Scale. The degree and time course of recovery may be influenced by stroke type.
Objectives:
To measure hospital stay for acute stroke care and to describe health services and demographic factors associated with longer length of stay (LOS).Design:
Observational, retrospective consecutive case series.Setting:
Large tertiary-care teaching hospital in Massachusetts.Patients:
The patient population comprised 745 patients aged 65 years and older admitted with ischemic stroke from 1982 through 1995.Main Outcome Measures:
Hospital LOS (1-5, 6-10, and > 10 days) as well as total charges and discharge location.Results:
Median LOS was 7 days (range, 1-289 days), and median total charges were $8740 (range, $522-$135 172); LOS explained 62% of the variance in total charges. Insurance status was a major factor in determining LOS: after possible confounders were controlled for, patients enrolled in a health maintenance organization were significantly less likely to have long hospital stays (odds ratio [OR], 0.45; 95% confidence interval, 0.31-0.66) than were conventional Medicare enrollees, while the LOS of patients with other insurance coverage was no different from that of Medicare patients. Longer LOS was significantly associated with greater comorbidity (OR, 1.52 for a Charlson comorbidity index >2), institutionalization prior to hospital admission (OR, 1.83), and unmarried status (OR, 1.37) and was inversely associated with year of admission (OR, 0.30 in years 1991-1995 vs 1982-1986). Age, sex, and race were not associated with LOS. Discharge to a nursing home or inpatient rehabilitation site was not associated with type of insurance coverage (OR, 1.10; 95% confidence interval, 0.72-1.69 for patients in a health maintenance organization vs conventional Medicare patients).Conclusions:
There is marked variability in length of hospital stay for ischemic stroke among the elderly, even after underlying patient differences are controlled for. Managed care may result in increased efficiency of in-hospital care and improved discharge planning for these patients; further study of the ultimate clinical outcomes of such care is needed.
Background and Methods:
Although studies have demonstrated that medical rehabilitation patients have many complications that warrant attention, none has attempted to categorize complications by severity. This retrospective cohort study examined the incidence, types, and severity of problems that interrupt rehabilitation and the major risk factors for these events.Results:
Of 1075 patients, 359 (33.4%) had acute medical complications on rehabilitation considered severe enough to interrupt treatment. Of the 359 patients, 158 (44%) required an unexpected transfer off rehabilitation. The most common reasons for unexpected transfer were surgical causes (22.8%), followed by infection or fever (17.1%) and by thromboembolic events (16.5%). Logistic regression revealed that major risk factors for complications requiring transfer were a primary diagnosis of deconditioning or nontraumatic spinal cord injury (adjusted odds ratio, 2.7; confidence interval, 1.8 to 4.2), severity of initial disability (adjusted odds ratio, 1.2; confidence interval, 1.1 to 1.3 for every 10-point drop in a Modified Barthel Index), and number of comorbid conditions (adjusted odds ratio, 1.1; confidence interval, 1.0 to 1.2). Risk factors for any complication were similar, but there was an interaction between comorbidity and the degree of functional impairment; in patients who were severely functionally impaired, the number of comorbidities was not as strongly associated with the risk of complications as it was in patients who were less functionally impaired.Conclusion:
There is a complex relationship among the type of underlying medical impairment, severity of functional limitation, comorbidity, and unanticipated medical or surgical complications that interrupt rehabilitation. The interruptions vary both in type and in severity.(Arch Intern Med. 1994;154:2185-2190)
The extent to which clinicians perceive patients who are undergoing rehabilitation after stroke as similar to other patient groups was investigated using the Functional Independence Measure (FIM) among 27,699 rehabilitation inpatients. Earlier work demonstrated that the first 13 items of the FIM represent a measure of motor function and that the last 5 items represent a measure of cognitive function. The FIM was used for patients with stroke in a manner similar to that for most other impairment groups on the motor items. Patients with stroke were, however, unlike many impairment groups in their ratings on the cognitive items. Tables showing raw score to scaled measure conversions are provided for 2 sets of impairment groups on the motor items and 3 sets of impairment groups on the cognitive items. Clinicians can be confident that the measures derived from the FIM are linear across the range of the instrument and are attuned to the uniqueness of patients with stroke and other specific impairments. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In a 6-month period, 40 consecutive patients with a diagnosis of cerebral infarction had computed tomography (CT) scanning. The purpose of this study was to evaluate the association between the location and size of the lesion on CT scan and the functional status of the patient on discharge and follow-up. The results of the CT scan were divided into the following major groups: deep (involving the basal ganglia, internal capsule and thalamus), superficial large and superficial small (involving the cerebral hemisphere up to and including the external capsule) and normal. At discharge, patients were divided into 2 major functional groups: group A, minimal assist to independent in transfers and ambulation; and group B, moderate to maximal assist in transfers and maximal assist in ambulation. Ten of 11 patients with small superficial lesions were in group A, and 10 of 13 patients with deep lesions were in group B. Of 10 patients with large superficial lesions, 5 were in group A and 5 in group B. All 6 patients with normal CT scans results were in group A. Thus, results of CT scanning appear to be associated with degree of functional recovery.
Predictors of functional outcome were developed in a group of 114 stroke patients consecutively admitted to a tertiary rehabilitation center. These predictors included a pool of medical data, the age of the patient, psychological tests and the patient's educational level. None of these predictor items showed a correlation with outcome high enough to allow precise prediction of individual outcome. They did, however, provide general indicators for those patients with severe functional impairment who are more likely to gain from a rehabilitation program. The group of medical predictors indicated that a patient with a more extensive, severe lesion, with signs of congestive heart failure, generalized arteriosclerosis, gross perceptual deficit, a lower level of education, and who is older, is less likely to improve in the rehabilitation program. Since a prediction on an individual basis was not possible, it was concluded that even the most severely involved patient should be provided with a therapeutic rehabilitation trial. There was no correlation between severity of the functional impairment at admission and the gains obtained in the rehabilitation program. The same predictors were used to predict whether the patient went home or to an institution. It was found that family income and involvement in support of the patient predicted this outcome, whereas medical data did not. Since family involvement can sometimes be changed by a therapeutic team, this predictor may also present a major target for therapeutic intervention.
A comparison of outcome and length of stay (LOS) between a control group of 248 unscreened patients (reported in Part 1) and a second group of 318 patients, medically and socially screened prior to admission, — all discharged from the same 30-bed stroke unit over a 33 month period — showed that preadmission medical, neurological, and social service screening did not improve overall outcome or reduce length of stay (LOS). A program aimed at identifying and treating perceptual and cognitive dysfunction did improve functional status and discharge disposition in patients having perceptual but not cognitive deficits. A detailed analysis of the factors influencing outcome and LOS confirmed and extended earlier findings that: 1) severe weakness on admission and long onset-admission intervals were adversely related to outcome as were the presence of perceptual or cognitive dysfunction, poor motivation, a homonymous hemianopsia, multiple neurologic deficits, and poor functional status on discharge; and 2) dysphasia, the presence of a hemisensory loss, age (under 80) and/or the presence of ASHD/hypertension/diabetes were unrelated to outcome. It was again demonstrated that most patients — even those with unfavorable prognostic signs — significantly improved after appropriate treatment programs.
In the search for an appropriate payment system for medical rehabilitation hospitals and units, the use of a functional status measure (FSM) has emerged as a recurring theme. Conceptually, functional status measurement is important because the primary goal of medical rehabilitation is to enhance patient function and independence. Studies indicate that functional status and functional gain are among the best predictors of resource utilization at rehabilitation facilities. This article examines conceptually the use of FSMs in payment for medical rehabilitation in two different types of payment systems--as a means of classifying patients for purposes of determining the applicable payment amount (ie, a "classification system"), and as a means of justifying that payment, or continued payment, for services is appropriate (ie, a "justification system"). Several payment models using an FSM are described and analyzed. An agenda for future research is proposed.
Thrombolytic agents hold theoretical promise as therapy for cerebral infarction. This study was designed to evaluate the safety of tissue plasminogen activator, to accomplish urgent patient treatment, and to estimate potential efficacy of tissue plasminogen activator.
Following neurological evaluation and computed tomography of the brain, patients with acute ischemic stroke were evaluated and treated with intravenous tissue plasminogen activator under an open-label, dose-escalation design within 90 minutes from symptom onset. End points examined included symptomatic and asymptomatic intracranial hematoma, systemic hemorrhage, and neurological outcome at 2 hours, 24 hours, and 3 months.
Seventy-four patients were treated within 90 minutes of symptom onset over seven dose tiers of tissue plasminogen activator, ranging from 0.35 mg/kg to 1.08 mg/kg. Intracranial hematoma with associated neurological deterioration occurred in three patients and was related to increasing doses of tissue plasminogen activator (p = 0.045). Intracranial hematoma did not occur in any of the 58 patients treated with less than or equal to 0.85 mg/kg. Major neurological improvement occurred in 22 patients (30%) at 2 hours from the initiation of tissue plasminogen activator and in a total of 34 patients (46%) at 24 hours, but major neurological improvement was not related to increasing doses of tissue plasminogen activator or to stroke type.
Patients with acute stroke can be evaluated and treated within 90 minutes. Tissue plasminogen activator for acute ischemic infarction is not without risk, but the potential for clinical benefit justifies a randomized clinical trial. To date, differences in hemorrhagic risk or neurological benefit of tissue plasminogen activator for particular ischemic stroke types are not apparent.
The purpose of this paper is twofold: 1) to identify stroke patients who generated substantial charges during inpatient rehabilitation, but did not seem to benefit from that experience and 2) to identify factors that can predict which patients will fall into this group using only variables known at admission to rehabilitation. High cost stroke patients during inpatient medical rehabilitation are examined to determine how they differ from low cost patients and to identify a subset who did not appear to benefit from rehabilitation. This paper is based on longitudinal charge data involving 73 former stroke rehabilitation patients discharged from three Boston area rehabilitation facilities in 1984. Medical charges are presented on initial acute and rehabilitation inpatient stays and on care received in the 12 months after discharge. Among these 73 stroke patients, charges for inpatient medical rehabilitation amounted to nearly 1.8 million dollars, excluding physician fees and out-of-pocket expenses. Of this total, 57.6% was accured by only 33% of the patients. Fourteen patients, who were both rehabilitation cost outliers and apparent rehabilitation "failures," were identified. Rehabilitation charges for these 14 amounted to $673,232 or 37.5% of the total rehabilitation charges for all 73 patients.
The interobserver reliability of a rating scale employed in several multicenter stroke trials was investigated. Twenty patients who had a stroke were rated with this scale by four clinical stroke fellows. Each patient was independently evaluated by one pair of observers. The degree of interrater agreement for each item on the scale was determined by calculation of the kappa statistic. Interobserver agreement was moderate to substantial for 9 of 13 items. This rating system compares favorably with other scales for which such comparisons can be made. However, the validity of this system must be established.
We examined the effectiveness of using diagnosis related groups (DRGs), Severity of Illness Index (SII), age and function at admission to predict inpatient charges for medical rehabilitation. Data from our sample of 199 indicate that DRGs alone explained approximately 12 per cent of the variation in charges for inpatient rehabilitation while SII explained 26 per cent of the variation. SII, DRG, and age together yielded the highest regression coefficient, accounting for nearly 39 per cent of the variation in total charges; SII and age accounted for 36 per cent of the variation. Within DRG categories, SII was the only important predictor of inpatient charges accounting for 23 per cent of the variation in charges among stroke patients (DRG 014) and 28 per cent of the variation in charges among hip fracture patients (DRG 210). Function at admission was not a useful predictor of inpatient rehabilitation charges within DRGs. These results suggest that SII and age may be useful in developing a DRG-based prospective payment system for inpatient medical rehabilitation.
The frequency of clinically significant coronary artery disease (CAD) among stroke patients and the impact of CAD on stroke rehabilitation were studied in 132 patients with first thrombotic or embolic stroke who participated in comprehensive rehabilitation. Sixty-one patients (46%) had a history of CAD, and 16 of the 61 also had congestive heart failure (CAD-CHF). Patients with CAD, and especially those with CAD-CHF, had significantly longer intervals from stroke onset to rehabilitation admission (p less than 0.001), and once in rehabilitation they experienced three times as many cardiac complications (p less than 0.001). While all patient groups improved function during rehabilitation, those with CAD and CAD-CHF improved significantly less than did those without CAD (p less than 0.01). Patients with CAD did least well with rolling, moving in bed, transferring from a wheelchair to bed, and walking. CHF not only adversely influenced overall function and mobility task performance but also affected the potential for achieving functional gains. These data suggest that specific measures of function and rehabilitation are affected by CAD and that the levels of achievement for patients with CAD-CHF are limited.
In a 13-month period, 41 selected patients with cerebrovascular accidents were studied utilizing computerized tomography of the brain and the Barthel index in an attempt to correlate findings with final rehabilitation outcome. Parameters that were studied included age, sex, lesion size and location, and functional status on admission, during hospitalization, and at discharge. Multiple regression analysis assessed impact of the five independent variables on functional outcome as measured by predischarge Barthel scores. Initial Barthel scores emerged as the most reliable predictor factor, explaining 64% of the variability. The study suggested that computerized tomography scans of the brain are presently not as reliable predictors as sequential functional assessments and should be considered as an adjunct measure.
Although studies have demonstrated that medical rehabilitation patients have many complications that warrant attention, none has attempted to categorize complications by severity. This retrospective cohort study examined the incidence, types, and severity of problems that interrupt rehabilitation and the major risk factors for these events.
Of 1075 patients, 359 (33.4%) had acute medical complications on rehabilitation considered severe enough to interrupt treatment. Of the 359 patients, 158 (44%) required an unexpected transfer off rehabilitation. The most common reasons for unexpected transfer were surgical causes (22.8%), followed by infection or fever (17.1%) and by thromboembolic events (16.5%). Logistic regression revealed that major risk factors for complications requiring transfer were a primary diagnosis of deconditioning or nontraumatic spinal cord injury (adjusted odds ratio, 2.7; confidence interval, 1.8 to 4.2), severity of initial disability (adjusted odds ratio, 1.2; confidence interval, 1.1 to 1.3 for every 10-point drop in a Modified Barthel Index), and number of comorbid conditions (adjusted odds ratio, 1.1; confidence interval, 1.0 to 1.2). Risk factors for any complication were similar, but there was an interaction between comorbidity and the degree of functional impairment; in patients who were severely functionally impaired, the number of comorbidities was not as strongly associated with the risk of complications as it was in patients who were less functionally impaired.
There is a complex relationship among the type of underlying medical impairment, severity of functional limitation, comorbidity, and unanticipated medical or surgical complications that interrupt rehabilitation. The interruptions vary both in type and in severity.
Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.
Research in recent years has revealed factors that are important predictors of physical and functional rehabilitation: demographic variables, visual and perceptual impairments, and psychological and cognitive factors. However, there is a remaining uncertainty about prediction of outcome and a need to clinically apply research findings. This study was designed to identify the relative importance of medical, functional, demographic, and cognitive factors in predicting length of stay in rehabilitation, functional outcome, and recommendations for postdischarge continuation of services.
The influence of these factors was determined by comparing diagnostic, medical, demographic, functional, and neuropsychological information that was retrospectively obtained by reviewing the records of 86 patients admitted for comprehensive rehabilitation due to stroke (n = 36) or orthopedic injury (n = 50). Multiple linear regression with statistical adjustment to control for overprediction of variance was used to predict outcomes.
The study revealed the primary importance of higher-order cognitive impairments (comprehension, judgment, short-term verbal memory, and abstract thinking) in extending length of stay and increasing referrals for outpatient therapies and home services after discharge for the cerebrovascular accident patients in comparison with orthopedic cohorts.
The need is discussed for early, comprehensive assessment of deficits in cognition that affect a stroke survivor's ability to participate in a rehabilitation program and remediation that facilitates functional improvement by building on residuals of impaired abilities or teaching compensatory behaviors.
The National Institutes of Health (NIH) Stroke Scale has been used in clinical trials to assess neurological outcome after investigational therapy for acute stroke. We used the NIH Stroke Scale to study the degree and time course of recovery in patients with acute stroke who were treated with conventional therapy.
We serially assessed 50 patients with ischemic stroke who presented within 24 hours of onset of symptoms. Patients were grouped by stroke subtype. Major neurological improvement was defined as a decrease in the stroke score by 4 points or more.
The mean NIH stroke score for all patients improved significantly by 7 to 10 days and at last follow-up (average, 44 days). Major neurological improvement was seen in 5 of 41 patients (12%; 95% confidence interval [CI], 2% to 22%) by 24 hours, 11 of 40 patients (28%; 95% CI, 14% to 41%) by 48 hours, and 19 of 37 patients (51%; 95% CI, 35% to 67%) by follow-up. The subgroup of patients with middle cerebral artery territory embolism showed a similar pattern of improvement; in contrast, patients with lacunar infarcts did not show significant change in scores during the study period. The score on admission did not correlate with the degree of subsequent improvement or deterioration.
A significant percentage of patients with acute ischemic stroke treated with conventional therapy show early improvement as assessed by the NIH Stroke Scale. The degree and time course of recovery may be influenced by stroke type.
See https://www.rasch.org/memo50.htm
The Functional Independence Measure (FIM) records the severity of disability of rehabilitation patients. The necessarily curvilinear relationship between the finite range of recorded FIM raw scores and the conceptually infinite range of additive disability measures is resolved through Rasch analysis. The analysis of admission and discharge FIM ratings of 14,799 patients shows that the 18 FIM items define two statistically and clinically different indicators. Thirteen items define disability in motor functions. Five items define disability in cognitive functions. Additive measures for each indicator have the same characteristics at admission and discharge, so that these measures can be used to assess change in patient status.
The Functional Independence Measurement (FIM) is a new functional status instrument for use among rehabilitation inpatients, but its validity and reliability have been only partially established. Because of its rapid dissemination, we sought further evidence concerning the FIM's internal consistency, responsiveness over time, and construct validity. We examined Uniform Data System (UDS) data on 11,102 general rehabilitation inpatients from the Pacific Northwest. Mean age was 65 and 51% were male. The most common diagnoses were stroke (52%), orthopedic conditions (10%), and brain injury (10%). Internal consistency of the FIM was calculated using Cronbach's alpha. To assess FIM responsiveness, we examined differences between admission and discharge FIM scores. For construct validation purposes, we hypothesized that the FIM would vary with age, comorbidity, discharge destination, and impairment severity. Comorbidity was quantified with the Charlson Comorbidity Index. The FIM had a high overall internal consistency (discharge FIM alpha = .93). The FIM registered significant functional gains during rehabilitation (33% FIM score improvement, p < .001), as do many other functional status indicators. The greatest and least functional improvements were observed for traumatic brain injury and low back pain (53% and 8% FIM score improvement, respectively). The FIM discriminates patients on the basis of age, comorbidity, and discharge destination. Severity differences could be distinguished among spinal cord injury and stroke patients. We conclude that the FIM has high internal consistency and adequate discriminative capabilities for rehabilitation patients. It is a good indicator of burden of care, and demonstrates some responsiveness, but its capacity to measure change over time needs further examination and comparison with competing scales.
This study was conducted to scale the Functional Independence Measure (FIM) with Rasch Analysis and to determine the similarity of scaled measures across impairment groups. The results show that the FIM contains two fundamental subsets of items: one measures motor and the second measures cognitive function. Rasch analysis of the Uniform Data System for Medical Rehabilitation patient sample yielded interval measures of motor and cognitive functions. The validity of the FIM was supported by the patterns of item difficulties across impairment groups. Adequate clinical precision of the FIM was demonstrated, though suggestions for improvement emerged. The frequency of misfit between patients and the performance scales varied across impairment groups, but was acceptable. The results of this project will enable clinicians and researchers to plan cost-effective treatment by providing a valid measure of disability.
To assess the effects of swallowing management in patients with acute nonhemorrhagic stroke placed on a clinical pathway, and to evaluate whether swallow function on admission can be used as a predictor of length of stay (LOS) and outcome disposition.
Intervention study to reduce complications of dysphagia in patients with acute stroke.
Urban community hospital.
Data were collected on 124 patients with acute nonhemorrhagic stroke admitted from January to December 1993.
A swallow screen was completed within one day of admission and before any oral intake.
Dysphagia and functional independence measure (FIM) scores on admission, occurrence of aspiration pneumonia, LOS, outcome disposition and cost effectiveness analysis.
Thirty-nine percent of all patients (p < .05) failed the initial swallow screen and required altered dietary texture and intervention. No patients developed aspiration pneumonia. Of those with dysphagia, 21% recovered intact swallowing by discharge; 19% required gastrostomy tube placement. Patients with dysphagia had lower admission FIM scores than nondysphagia patients. The LOS was longer for the dysphagia group (8.4 +/- 0.9 days) compared with patients without dysphagia (6.4 +/- 0.6 days, p < .05). Patients with dysphagia were less likely to be discharged to home (27%) than were nondysphagia patients (55%), and twice as likely to be discharged to a nursing home (p < .05).
This study demonstrates that early swallow screening and dysphagia management in patients with acute stroke reduces the risk of aspiration pneumonia, is cost effective, and assures quality care with optimal outcome.
To determine associations between the nutritional status of inpatient rehabilitation (rehab) unit stroke patients and (1) length of stay (LOS) and (2) functional outcome using Modified Barthel Index (MBI). Secondary objective-to determine whether hypoalbuminemia was equally related to outcome measures. A priori hypothesis-LOS and MRI are adversely related to malnutrition.
inception cohort study.
Tertiary care center.
49 consecutive "middle-band" patients (4 declined).
LOS and MRI at admission (T1), 1 month (T2), and discharge (T3).
LOS was significantly related to overall malnutrition, T1 and T2MBI scores, T1 dysphagia, T1 enteral feeding (all p<.01), T1 malnutrition, peripheral vascular disease (negative relationship), and diabetes mellitus history (all p<.05). In analysis of covariance, adjusting for T1 MBI, overall rehab malnutrition was related to LOS (p=.011). Other covariates were not significant. T1 malnutrition was related to lower T2 MBI scores(p=.038). Lower T1 MBI scores was related to T2 malnutrition (p=.032). Diabetics (p=.005) and right hemispheric lesion patients(p=.015) had lower T1 MBI scores. Hypoalbuminemia was unrelated to LOS and MBI scores. Although malnourished and adequately nourished functionally dependent patients improved equally in MBI scores by discharge, prolonged LOS in the malnourished lowered their functional improvement rate ([T3 MBI - T1 MBI]/LOS) (p=.047).
Malnutrition was the most potentially modifiable variable relating to LOS and functional outcome. Close attention to nutrition status may help to optimize stroke patients' rehab potential and use of health care resources.
To measure hospital stay for acute stroke care and to describe health services and demographic factors associated with longer length of stay (LOS).
Observational, retrospective consecutive case series.
Large tertiary-care teaching hospital in Massachusetts.
The patient population comprised 745 patients aged 65 years and older admitted with ischemic stroke from 1982 through 1995.
Hospital LOS (1-5, 6-10, and >10 days) as well as total charges and discharge location.
Median LOS was 7 days (range, 1-289 days), and median total charges were $8740 (range, $522-$135172); LOS explained 62% of the variance in total charges. Insurance status was a major factor in determining LOS: after possible confounders were controlled for, patients enrolled in a health maintenance organization were significantly less likely to have long hospital stays (odds ratio [OR], 0.45; 95% confidence interval, 0.31-0.66) than were conventional Medicare enrollees, while the LOS of patients with other insurance coverage was no different from that of Medicare patients. Longer LOS was significantly associated with greater comorbidity (OR, 1.52 for a Charlson comorbidity index >2), institutionalization prior to hospital admission (OR, 1.83), and unmarried status (OR, 1.37) and was inversely associated with year of admission (OR, 0.30 in years 1991-1995 vs 1982-1986). Age, sex, and race were not associated with LOS. Discharge to a nursing home or inpatient rehabilitation site was not associated with type of insurance coverage (OR, 1.10; 95% confidence interval, 0.72-1.69 for patients in a health maintenance organization vs conventional Medicare patients).
There is marked variability in length of hospital stay for ischemic stroke among the elderly, even after underlying patient differences are controlled for. Managed care may result in increased efficiency of in-hospital care and improved discharge planning for these patients; further study of the ultimate clinical outcomes of such care is needed.
Clinical trials routinely use stroke scales to compare baseline characteristics of treatment groups. It is unclear which stroke scale provides the most prognostic information. This often leads to collection of multiple scales in clinical trials. We aimed to determine which of several commonly used scales best predicted outcome.
A single observer scored consecutive admissions to an acute stroke unit on the National Institutes of Health Stroke Scale (NIHSS), the Canadian Neurological Scale, and the Middle Cerebral Artery Neurological Score. Guy's prognostic score was determined from clinical data. Outcome at 2, 3, 6, and 12 months was categorized as good (alive at home) or poor (alive in care or dead). Predictive accuracy of the variables was compared by receiver operating characteristic curves and stepwise logistic regression.
Of the 408 patients studied, 373 had confirmed acute stroke and completed follow-up. The three stroke rating scales each predicted 3-month outcome with an accuracy of .79 or greater. The NIHSS provided the most prognostic information: sensitivity to poor outcome, .71 (95% confidence interval [CI], .64 to .79); specificity, .90 (95% CI, .86 to .94); and overall accuracy, .83 (95% CI, .79 to .87). Logistic regression showed that the NIHSS added significantly to the predictive value of all other scores. No score added useful information to the NIHSS. A cut point of 13 on the NIHSS best predicted 3-month outcome.
Baseline NIHSS best predicts 3-month outcome. The Canadian Neurological Scale and Middle Cerebral Artery Neurological Score also perform well. Baseline assessments in clinical trials only need to include a single stroke rating scale.
This study was undertaken to identify factors predicting stroke inpatient rehabilitation length of stay in an acute inpatient rehabilitation program, including occupational therapy, physical therapy, and speech therapy. A cohort of 152 patients suffering from stroke (76 women and 76 men) voluntarily participated in this study. They were recruited from a general hospital in which they had received physical rehabilitation. The functional status of patients was observed by a physiotherapist, using the Functional Independence Measure(SM). The functional status was observed on patient admission to rehabilitation and at 1 wk from admission. Post-stroke biologic characteristics, including physical, neuropsychological, and clinical characteristics, as well as sociodemographic characteristics were also collected. A path analysis, using successive multiple linear regressions, was adopted to predict length of stay in rehabilitation. Significant predictors of length of stay were age, functional status at 1 wk post-rehabilitation admission, perceptual status, and balance status. These predictors accounted for 43.6% of the total variance in the rehabilitation length of stay. Indirect predictors of length of stay were identified as the following: functional status at admission, rehabilitation program, motor status, communication problems, and medical complications. Functional, biologic, and sociodemographic characteristics should be considered simultaneously in the prediction of length of stay as well as for the better understanding of the stroke rehabilitation process.
To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes.
Inception cohort stratified by provider type and followed prospectively for 6 months.
A total of 92 hospital-based units and freestanding facilities from 17 states.
A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994.
At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments.
On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, -0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and .009 for hip fracture) than for traditional nursing home patients.
Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.
To develop standardized comorbidity measures for use in stroke outcome research.
Retrospective review of medical records to analyze comorbidities and to study reliability and validity of the newly developed measures, comorbidity index (CI), and weighted comorbidity index (w-CI).
Tertiary rehabilitation center in Japan.
106 stroke patients, age 56.5 +/- 13.2 yr, admitted and discharged during the year from May 1994 to December 1995. The median days of duration of stroke, onset to admission, and length of stay (LOS) were 199, 83, and 105.5, respectively. The median admission and discharge Functional Independence Measure (FIM) raw scores were 85 and 110, respectively.
Assessment of interrater reliability with intraclass correlation coefficient (ICC) for total scores and weighted kappa for subscores; assessment of concurrent validity by relating the measures to Charlson's comorbidity index, total numbers of medications, laboratory studies, therapeutic interventions, consultations, and days of interruption (Spearman's rank correlation method); study of predictive validity with discharge FIM score and LOS as dependent variables.
The ICCs were .896 for CI and .997 for w-CI, and weighted kappa ranged from .615 to 1.00. CI and w-CI correlated significantly with Charlson index and the above indices of validity. They also correlated negatively with discharge FIM scores and positively with LOS. With stepwise multiple regression analysis, 79.8% of the variance of discharge FIM scores could be explained by w-CI, days from onset to admission, admission FIM score, and deviation in tape bisection task.
The newly developed comorbidity measures are reliable and valid for use in stroke outcome research.
The scale of stroke impairment characteristics by Brott and associates, the National Institutes of Health (NIH) Stroke Scale, has been used widely in various studies of stroke outcome; however, the measurement properties of the items applied to patients during medical rehabilitation have not been evaluated thoroughly. This study evaluated the extent to which scale items cohere to define a unidimensional construct and have a useful range for application to patients during medical rehabilitation.
Rating scale (or Rasch) analysis of the 15 NIH Stroke Scale items was conducted using the BIGSTEPS computer program to evaluate (1) the range of impairment assessed by the items, (2) the items' coherence with an underlying construct of impairment, and (3) range of impairment measured in rehabilitation patients. We sought to maximize the range of impairment measured by conducting analyses recursively; at each subsequent step, the worst fitting item was deleted or rescored. The sample comprised 1291 admission and discharge records from 693 rehabilitation inpatients with stroke.
Thirteen items arrayed the sample across a sufficient range of impairment. The limb ataxia item fit poorly and was deleted; lower ratings for this item were associated with higher scores on the total scale. Pupillary response was also deleted because ratings reflected poor congruence with the total score. Best language was rescored because intermediate ratings were inconsistently related to the total score. Patients with hemorrhagic strokes had poorer fitting measures than did patients with ischemic strokes.
The items in a revised NIH Stroke Scale worked well together to define the severity of impairment resulting from stroke that is observed during medical rehabilitation. Directions regarding limb ataxia should be modified to indicate untestability due to hemiplegia.
Stroke represents a major economic challenge to society. The direct cost of stroke is largely determined by the duration of hospital stay, but internationally applicable estimates of the direct cost of acute stroke care and rehabilitation on cost-efficient stroke units are not available. Information regarding social and medical factors influencing the length of hospital stay (LOHS) and thereby cost is needed to direct cost-reducing efforts.
We determined the direct cost of stroke in the prospective, consecutive, and community-based stroke population of the Copenhagen Stroke Study by measuring the total LOHS in the 1197 acute stroke patients included in the study. All patients had all their acute care and rehabilitation on a dedicated stroke unit. Neurological impairment was measured by the Scandinavian Stroke Scale. Local nonmedical factors affecting the LOHS, such as waiting time for discharge to a nursing home after completed rehabilitation, were accounted for in the analysis. The influence of social and medical factors on the LOHS was analyzed in a multiple linear regression model.
The average LOHS was 27.1 days (SD, 44.1; range, 1 to 193), corresponding to a direct cost of $12.150 per patient including all acute care and rehabilitation. The LOHS increased with increasing stroke severity (6 days per 10-point increase in severity; P < .0001) and single marital status (3.4 days; P = .02). Death reduced LOHS (22.0 days; P < .0001). Age, sex, diabetes, hypertension, claudication, ischemic heart disease, atrial fibrillation, former stroke, other disabling comorbidity, smoking, daily alcohol consumption, and the type of stroke (hemorrhage/infarct) had no independent influence on LOHS.
Acute care and rehabilitation of unselected patients on a dedicated stroke unit takes on average 4 weeks. In general, comorbidity such as diabetes or heart disease does not increase LOHS. Efforts to reduce costs should therefore aim at reducing initial stroke severity or improving the rate of recovery.
Geriatric rehabilitation is intended to maintain or restore function, maximize life satisfaction, enhance psychologic well-being, and maintain the social status of older persons. For clinical services to operate efficiently and equitably, payment must be based on rules that are clinically sound and thus reinforce the objectives of the services provided. This article presents a theoretical basis for casemix measurement in medical rehabilitation, contrasts structure of the functional independence measure-function-related groups (FIM-FRGs) intended for casemix measurement to the diagnosis-related groups (DRGs) and resource utilization groups (RUG) III systems designed for acute and long-term care settings, focuses on special issues of relevance to the rehabilitation of older persons, and provides four challenges in an effort to stimulate discussion.
Increasing numbers of Medicare beneficiaries have been enrolling in health maintenance organizations (HMOs) because HMO participation reduces out-of-pocket expenses, and the federal government views HMOs as a way to contain Medicare costs. However, results comparing outcomes and quality of care in HMOs vs fee for service (FFS) have been mixed, and outcomes after stroke have not been adequately assessed.
To compare discharge destinations and survival rates following stroke in Medicare HMOs with similar FFS settings.
An observational study for 2 groups evaluating stroke patients' discharge destinations and survival times from the date of hospital admission.
A total of 19 HMOs were selected from 12 states. The FFS sample was drawn from the same geographic areas.
The sample included 402 HMO patients from 71 hospitals and 408 FFS patients from 60 hospitals. PROCESS AND OUTCOME MEASURES: Data were abstracted from medical records on demographics, clinical characteristics of stroke, comorbid illnesses, and discharge destinations following hospitalization. Data on survival were obtained from Medicare files and included 25 to 37 months of follow-up (median, 30.4 months, HMO; 31.1 months, FFS) from the date of hospital admission.
There were 109 patients who died during the hospitalization (49 HMO, 12.2%; 60 FFS, 14.7%), and a total of 410 patients had died by the end of follow-up (191 HMO, 47.5%; 219 FFS, 53.7%). Approximately one fourth of both groups had do-not-resuscitate orders (HMO, 25.4%; FFS, 27.9%; P=.68). After controlling for age, marital status, and characteristics of dependency at discharge, HMO patients were more likely than FFS patients to be sent to nursing homes (HMO, 41.8%; FFS, 27.9%; P=.001) and less likely to be discharged to rehabilitation hospitals or units (HMO, 16.2%; FFS, 23.4%; P=.03). At follow-up, no significant differences in relative risk of dying were found between HMO and FFS groups (relative risk, 0.96; 95% confidence interval, 0.73-1.26; P=.77).
Patients in Medicare HMOs who experience strokes are more likely to be discharged to nursing homes and less likely to go to rehabilitation facilities following the acute event. However, they have similar survival patterns compared with comparable patients in FFS settings after adjusting for other factors.
To describe the association between impairment and disability during stroke rehabilitation and to examine the effects of rehabilitation by studying the degree of disability reduction experienced by stroke patients who did not have significant reductions in impairment levels.
Statistical analysis of items from a database of prospectively collected information on stroke patients admitted for rehabilitation.
Large urban academic freestanding rehabilitation facility.
Four hundred two patients consecutively admitted for comprehensive acute stroke inpatient rehabilitation.
The National Institutes of Health Stroke Scale (NIHSS) was used to measure impairment and the Functional Independence Measure (FIM) was used to measure disability. Motor and cognitive subscales of the FIM instrument were evaluated. Raw NIHSS and FIM scores were converted to linear measures using Rasch analysis.
Relationships were studied between converted NIHSS and the two FIM subscales for admission, discharge, and change scores using linear regression analysis. In a second analysis, two groups of patients were identified; the 342 patients who experienced no substantial reduction of impairment comprised the "no impairment reduction (NIR) group," and the 60 patients who had a significant reduction of impairment level comprised the "impairment reduction (IR) group." Multivariate analysis of variance was used to determine and compare the amount of change in motor and cognitive FIM measures over time for each of the two groups.
NIHSS correlated significantly with motor and cognitive FIM subscores for admission, discharge, and change measures; R2 values ranged between .02 and .36. Both the NIR group and the IR group experienced significant decreases in disability during rehabilitation. The differences in discharge FIM measures between the two groups were relatively small.
Although stroke-related impairment and disability are significantly correlated with each other, reduced impairment level alone does not fully explain the reduced disability that occurs during rehabilitation. Even patients without substantial impairment reduction demonstrate disability reduction during rehabilitation, suggesting that rehabilitation has an independent role in improving function beyond that explained by neurologic recovery alone.
To determine typical outcome "benchmarks" for 18 functional tasks in patients undergoing stroke rehabilitation. The benchmarks are intended to serve as points of reference to which the outcomes of patients with similar impairments and degrees of disability can be compared.
Records from 26,339 stroke patients discharged from 252 inpatient facilities across the United States that submitted 1992 data to the Uniform Data System for Medical Rehabilitation.
Stroke impairment was detailed as the presence or absence of hemiparesis resulting from stroke and the side(s) of involvement. Within each of five stroke impairment categories, patients were further classified by the Functional Independence Measure-Function-Related Groups (FIM-FRGs) into nine syndromes by degree of disability (admission motor and cognitive FIM scores) and by age. Outcomes were determined for each stroke syndrome at patients' discharge from medical rehabilitation.
Patients' median performance levels on each of the 18 items making up the FIM, length of stay, and community discharge rates.
The majority of patients whose admission motor FIM scores were above 37 were able to eat, groom, dress the upper body, and manage bladder and bowel functions independently by discharge. In addition to these tasks, most of those whose motor FIM scores were above 55 were able to dress the lower body, bathe, and transfer onto a chair/bed or toilet. The majority of patients whose initial motor FIM scores were above 62 points and whose cognitive FIM scores were above 30 gained independence in most tasks, including stair climbing and tub transfers. Community discharge rates ranged from 51.6% for the group of patients with the most severe disabilities to 99.2% for the group with the least severe disabilities.
The clinician can apply these benchmarks to guideline development and quality improvement, and in establishing patient goals.
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