Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome

OBJECTIVE: To assess whether, and to what extent, cognitive outcome relates to overall functional outcome among elderly stroke patients. DESIGN: Nonconcurrent prospective study. SETTING: Geriatric rehabilitation division at a large, urban, academic, freestanding hospital in Israel. PARTICIPANTS: Three hundred thirty-six patients aged 60 years and older admitted consecutively for rehabilitation after first acute stroke. Inclusion criteria were met by 315 patients, who were included in the final analysis. Average age was 75.3 years. The stroke was right sided in 44.1%. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The motor subscale of the FIM instrument assessed functional status. Absolute functional gain was determined by the FIM motor gain. Relative functional gain was calculated according to the Montebello Rehabilitation Factor Score. Cognitive status was assessed with the Mini-Mental State Examination (MMSE) and the FIM cognitive subscale. RESULTS: FIM scores increased significantly during rehabilitation, mainly due to improvement in motor functioning. A strong association was found between the cognitive scales (r=.853, P<.001). Better rehabilitation outcomes were observed in patients with higher admission cognitive status, adjusting for the effect of age, sex, onset to admission interval, length of stay, and severity of stroke (odds ratio = 2.0; 95% confidence interval, 1.5-2.5). CONCLUSIONS: Impaired cognitive status at admission negatively affects the rehabilitation outcome of elderly stroke patients. The utility of routinely using a cognitive test for all patients before admission to rehabilitation, preferably the MMSE, is emphasized. The time, cost, and effort involved in performing such a test are negligible, and the potential benefits are considerable.     

Functional gains and therapy intensity during subacute rehabilitation: a study of 20 facilities

OBJECTIVES: To document patient, program characteristics, and therapy service provision in subacute rehabilitation across 3 types of facilities that provide subacute rehabilitation, to examine the determinants of therapy intensity, and to evaluate the contribution of rehabilitation services to functional gains. DESIGN: A retrospective study linking administrative billing data and patients' functional assessment records. SETTING: Twenty facilities part of the Uniform Data System for Medical Rehabilitation (UDSMR) subacute database PARTICIPANTS: A total of 1976 billing records of patients with stroke, orthopedic, and debility impairments, discharged in 1996 and 1997, were retrieved and linked with the FIM trade mark instrument ratings from UDSMR subacute database. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Total therapy intensity and Rasch-transformed FIM domain gains (ie, gains in self-care, mobility, cognition). RESULTS: Therapy intensity was mostly determined by impairment and facility type, although variances explained by the predictors were small. Patients in all 3 impairment groups made functional gains; gains were related weakly, although significantly, to therapy intensity and rehabilitation duration after controlling for other variables. CONCLUSIONS: The provision of rehabilitation therapies varied across facilities. Skilled nursing facilities with subacute rehabilitation units tended to provide more therapies than subacute units in acute or rehabilitation hospitals.     

Course of functional improvement after stroke, spinal cord injury, and traumatic brain injury.

OBJECTIVE: To examine functional improvement patterns of persons with stroke, traumatic brain injury (TBI), and spinal cord injury (SCI). DESIGN: Statistical analysis of data from a multisite study evaluating rehabilitation outcomes. SETTING: Eight inpatient rehabilitation facilities. PARTICIPANTS: A total of 314 consecutive admissions of persons with stroke, SCI, and TBI who received acute medical rehabilitation between 1994 and 1998. INTERVENTION: Calibration of motor and cognitive items from the FIM instrument, grouping of cases by number of weeks of rehabilitation (length of stay [LOS] groups), and plotting of weekly averages across time. MAIN OUTCOME MEASURES: Weekly motor and cognitive functional status. RESULTS: With the exception of cognitive functioning for persons with SCI, LOS was related to initial functional status, with patients with greater disability having longer LOS (eg, initial motor status for persons with stroke was 48.3 for those with a 2-week stay, 36.8 for a 6-week stay, with the averages between decreasing monotonically). With the exception of cognitive gains for person with TBIs, the amount of functional gain during rehabilitation was essentially the same for all LOS groups (eg, the overall average total motor gain for persons with SCI is 22.3, with no patterns of increase or decrease across LOS groups); however, the rate of improvement in motor (but not cognitive) functioning differed across LOS groups, with patients with shorter stays having the greater rates of improvement (eg, the overall average weekly motor gain for persons with SCI was 3.6, with the averages by LOS group monotonically decreasing from 6.4 for those with 4-week stays to 2.7 for those with 9-week stays). CONCLUSIONS: When examined separately for persons grouped by LOS, functional status improved linearly during the rehabilitation stay, with differences in rate of improvement depending on initial functional status.     

Social dimensions to functional gain in pediatric patients

Rehabilitation hospitals recognize the need for holistic patient care and employ professionals who are concerned with the social dimensions of functional independence. However, there have been few empirical studies of the relationship between social variables and functional gain. Functional assessment data for 66 pediatric patients admitted to an inpatient rehabilitation program were analyzed. Regressing residual gain scores on social variables from the Patient Evaluation and Conference System (a patient tracking data base) showed significance (p less than .01) in pediatric functional gain. Patients whose families were less able to support their independent living before admission made the greatest functional gains. Family support for disabled pediatric patients affected functional gain, affirming the importance of rehabilitation professionals' involvement with the patient's social needs throughout the rehabilitation process.     

Racial/ethnic differences in FIM scores and length of stay for underinsured patients undergoing stroke inpatient rehabilitation

OBJECTIVE: To explore racial/ethnic differences in FIM data from admission to discharge in underinsured patients undergoing inpatient stroke rehabilitation. DESIGN: This is a retrospective analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database of an inpatient rehabilitation unit of a county hospital in a large urban city. Data included 171 adult patients admitted to the stroke rehabilitation unit between January 2000 and October 2003. Main outcome measures included admission and discharge total FIM score, FIM gain, FIM efficiency, and length of stay (LOS). Data were analyzed using chi analyses, t tests, univariate analysis of variance, binary logistic regression, and hierarchical multiple regression. RESULTS: Data from 68 Hispanic, 83 black, and 20 white patients were included in the study. Univariate tests revealed that race/ethnicity groups differed significantly on admission FIM score (F=5.38, P<0.005), FIM gain (F=4.35, P<0.014), and FIM efficiency (F=3.42, P<0.035). Post hoc pairwise comparisons revealed that Hispanics had lower admission FIM scores than blacks (58.9 vs. 68.9). However, Hispanics had higher FIM gain scores than blacks (26.8 vs. 21.5). Race/ethnicity was not significantly related to age, gender, side of stroke, type of stroke, time from onset of stroke to rehabilitation admission, discharge FIM score, or LOS. Multiple regression analyses revealed that after controlling for all other available factors, race/ethnicity accounted for a significant amount of additional variance in admission FIM score (5.8%) and FIM efficiency (4.6%), but not in discharge FIM score, FIM gain, or LOS. Race/ethnicity was not predictive of discharge disposition. CONCLUSIONS: Differences in functional independence at admission to poststroke rehabilitation and the average daily improvement in function are related, in part, to patients' race/ethnicity. Differences in change in functional independence from admission to discharge (FIM gain) are not related to race/ethnicity once other factors, particularly admission FIM score, are taken into account. Future studies should identify reasons why Hispanics have lower admission FIM scores because demographic and stroke-related variables were not related to ethnicity yet have outcomes similar to blacks and whites at discharge.     

功能独立性评价量表作为康复治疗前后和随访的功能评价指标

目的　应用功能独立性评价 (FIM )量表评定美国某医疗单位康复医学科 1年中住院患者康复治疗的疗效 ,以及随访情况 ;同时与美国康复医学统一数据系统 (UDSMR) 1995年和 1996年资料相比较。方法　统计 1999年 7月 1日至 2 0 0 0年 6月 30日美国华盛顿大学附属HarborviewMedicalCenter(HMC)康复医学科 2 87例患者的资料 ,包括 :患者入院、出院和随访 (出院 3个月 )FIM的评分 ,FIM效率(每天进步的分数 )及FIM进步程度等。结果　HMC康复医学科患者住院期间FIM进步程度为 37.7% ,UDSMR为 31.6 % ( 1995 )和 32 % ( 1996 ) ;HMC随访期间进步 7.8% ,UDSMR为 10 .5 % ( 1995 )和 10 .1%( 1996 ) ;HMC的FIM效率为 1.6 ,UDSMR为 1.7( 1995 )和 1.8( 1996 )。结论　各种功能障碍患者经过康复治疗 ,功能情况都有较大提高 ,出院后功能情况仍有一定程度进步。FIM量表作为康复治疗患者住院期间和随访期间功能评价指标 ,是一种较理想的评价指...     

Effect of functional gain on satisfaction with medical rehabilitation after stroke

OBJECTIVE: To examine the association between gain in motor and cognitive functional status with patient satisfaction 3-6 mo after rehabilitation discharge. DESIGN: Patient satisfaction and changes in functional status were examined in 18,375 patients with stroke who received inpatient medical rehabilitation. Information was obtained from 144 hospitals and rehabilitation facilities contributing records to the Uniform Data System for Medical Rehabilitation and the National Follow-up Services. RESULTS: Data analysis revealed significant (P < 0.05) differences in satisfaction responses based on whether information was collected from patient self-report or from a family member proxy, and the two subsets were analyzed separately. Logistic regression revealed the following significant predictors of satisfaction for data collected from stroke patients: cognitive and motor gain, rehospitalization, who the patient was living with at follow-up, age, and follow-up therapy. In the patient-reported data subset, compared with patients who showed improved cognitive or motor functional status, those with no change, respectively, had a 31% and 33% reduced risk of dissatisfaction. In addition, rehospitalized patients had a higher risk of dissatisfaction. For the proxy reported data subset, significant influences on satisfaction were health maintenance, rehospitalization, stroke type, ethnicity, cognitive FIM gain, length of stay, and follow-up therapy. CONCLUSIONS: Ratings of satisfaction with rehabilitation services were affected by change in functional status and whether the information was collected from patient rating or proxy response.     

Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture?

OBJECTIVES: To determine the effect of cognitive status at admission on functional gain during rehabilitation of elderly hip-fractured patients. DESIGN: Cohort study. SETTING: A hospital geriatric rehabilitation department. PATIENTS: Two hundred twenty-four elderly patients admitted consecutively for rehabilitation after surgery for hip fracture. MEASUREMENTS: Cognitive status was assessed by the Mini-Mental State Examination and the cognitive subscale of the Functional Independence Measure (cognFIM); functional status was assessed by the motor subscale of FIM; absolute functional gain was determined by the motor FIM gain (deltamotFIM); and relative functional gain (based on the potential for improvement) by the Montebello rehabilitation factor score (MRFS). RESULTS: A significant increase in FIM scores (19.7) occurred during rehabilitation, mainly due to motor functioning (19.1). When the relative functional gain (as measured by both motor MRFS efficacy [r = .591] and efficiency [r = .376] was compared with the absolute gain (as measured by deltamotFIM [r = .304]), a stronger association between cognFIM and the relative measures was found. In addition, motor FIM efficacy and efficiency were significantly lower in the cognitively impaired patients (p<.01). A better rehabilitation outcome was seen in patients with higher admission cognitive status, adjusting for the effects of age, sex, length of stay, and type of fracture (odds ratio = 2.2, 95% confidence interval 1.5-3.7). CONCLUSIONS: Impaired cognitive status at admission lowered the rehabilitation outcome of elderly hip fracture patients. Cognitive impairment was strongly and directly associated with functional gain in these patients. Absolute motor gain appeared to be independent of cognitive status, whereas the relative motor gain depended on it. These findings support the implementation of comprehensive rehabilitation for selected cognitively impaired elderly hip fracture patients.     

Inpatient Stroke Rehabilitation Lengths of Stay in Canada Derived From the National Rehabilitation Reporting System, 2008 and 2009

Objective

To determine rehabilitation length of stay (LOS) for patients with stroke in Canada, and to evaluate which factors contribute to variations in LOS.

Design

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.

Setting

Canadian rehabilitation hospitals providing stroke rehabilitation services.

Participants

Patients with stroke (N=11,983) admitted to rehabilitation hospitals from January 2008 through December 2009.

Interventions

None.

Main Outcome Measures

Rehabilitation LOSs were calculated nationally and regionally. Regression models incorporating sociodemographic and clinical measures were constructed to test their effect on LOS.

Results

The median stroke rehabilitation LOSs was 35 days (quartiles: 20d, 54d). LOSs 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 LOSs. Modeling these data using a Function-Related Groups case-mix model explained 16% of the variation in LOSs.

Conclusions

FIM motor function scores at admission along with age and geographic region best predicted rehabilitation LOS. These variables explained 20% of the variation in LOSs. Despite regional differences in LOSs, patient characteristics were similar between regions. Other nonpatient factors not captured in these data may contribute to a greater extent in determining stroke rehabilitation LOS.     

Rehabilitation outcomes in cognitively impaired patients admitted to skilled nursing facilities from the community

OBJECTIVE: To examine the outcomes of patients with varying levels of cognitive impairment who received rehabilitation in skilled nursing facilities (SNFs). DESIGN: A retrospective analysis of the records of people admitted to SNFs for rehabilitation. SETTING: Seven SNFs in Colorado. PARTICIPANTS: Community-dwelling persons (N=7159), 65 years of age and older, admitted for rehabilitation after a hospitalization or decline in function between May 1998 and May 2002. Interventions Not applicable. MAIN OUTCOME MEASURES: Cognitive impairment was assessed using a 4-level categorization of the FIM instrument cognitive score at admission. Functional gain was measured using the FIM. Community discharge was measured as the proportion of patients discharged to home, board and care, or assisted living facility. Rehabilitation progress was measured as the number of FIM points gained per day. RESULTS: Significant functional gains were made during rehabilitation in motor and cognitive FIM scores, regardless of cognitive impairment. The most cognitively impaired patients required more rehabilitation intervention, achieved less FIM gain, and were less likely to be discharged to the community. The strongest predictors of FIM gain were the amount of therapy hours and admission cognitive FIM score. The strongest predictors of discharge to the community were the discharge total FIM score and age. The strongest predictors of adequate rehabilitation progress were medical complexity and admission cognitive FIM score. CONCLUSIONS: Patients with cognitive impairment were able to recover function with rehabilitation intervention. Patients with a more serious cognitive impairment received more rehabilitation intervention than patients with less impairment. Outcomes were predicted by admission and rehabilitation measures that were qualitatively different from other discharge outcomes. Health care professionals need to consider these factors as they create a rehabilitation plan of care for patients with cognitive impairment.     

A functional diagnostic complexity index for rehabilitation medicine: measuring the influence of many diagnoses on functional independence and resource use

OBJECTIVE: To develop an index that weights diagnostic information (International Classification of Diseases, 9th revision, Clinical Modification, or ICD-9-CM codes) by the extent to which it is expected to affect functional status and inpatient rehabilitation length of stay (LOS). DESIGN: Eleven nationally prominent physiatrists assigned ICD-9-CM codes to ordinal categories by expected effect on functional recovery. A resulting functional diagnostic complexity index score was calculated for each patient by combining the ranked values of each ICD-9-CM code in the discharge record. Analyses were stratified across the 20 rehabilitation impairment categories (RICs) of the Functional Independence Measure-Function Related Groups. DATA: Patients (182,254) discharged from 465 inpatient rehabilitation units in larger hospitals and free-standing rehabilitation hospitals in 1995. RESULTS: High degrees of diagnostic complexity were associated with low levels of functional independence at admission within each of 20 RICs (Spearman R = .06 to .25). Depending on RIC, patients in the highest (compared with the lowest) complexity category had up to a 35% increase in rehabilitation LOS after accounting for the primary medical reason for rehabilitation and severity of disabilities at admission. CONCLUSION: This prototype index of medical complexity offers a promising approach for analyzing the cumulative effects of diagnoses on patients' initial functional status and rehabilitation LOS.     

Rehabilitation of older Chinese patients with different cognitive functions: how do they differ in outcome?

Luk JK, Chiu PK, Chu LW. Rehabilitation of older Chinese patients with different cognitive functions: how do they differ in outcome?

Objective

To examine the effect of cognition on functional and motor gain in older Chinese patients undergoing geriatric inpatient rehabilitation.

Design

A retrospective cohort study.

Setting

Geriatric rehabilitation units of 2 convalescence hospitals in Hong Kong.

Participants

Older Chinese patients (N=778).

Interventions

Comprehensive geriatric assessment and inpatient rehabilitation by a multidisciplinary team.

Main Outcome Measures

Cognitive status was assessed with the Cantonese version of the Mini-Mental State Examination (C-MMSE). We measured the absolute functional gain and motor gain by using the Barthel Index and Elderly Mobility Scale (EMS) and expressed it as Barthel Index efficacy and EMS efficacy. Relative efficacy was assessed by the Montebello Rehabilitation Factor Score (MRFS). Relative efficiency was deduced by relative efficacy divided by the hospital length of stay (LOS).

Results

There were significant differences in the total Barthel Index and EMS on admission and at discharge, with lower discharge scores in low C-MMSE groups. The change of Barthel Index (Barthel Index efficacy) and EMS (EMS efficacy) during rehabilitation did not differ among different C-MMSE groups. Significant differences were observed in Barthel Index MRFS efficacy and efficiency as well as EMS MRFS efficacy and efficiency in different cognitive groups; those with better cognitive function had better results. Multivariate analysis showed that LOS (odds ratio [OR]=1.02, P=.002) and diagnosis of musculoskeletal problems (OR=2.24, P=.007) were positive predictors for a Barthel Index MRFS efficacy of .25 or higher. C-MMSE was not an independent predictor for a Barthel Index MRFS efficacy of .25 or higher. LOS (OR=1.02, P=.003), admission C-MMSE (OR=1.04, P=.001), body mass index (OR=1.05, P=.006), and diagnosis of musculoskeletal disorders (OR=1.75, P=.04) were significant positive predictors for an EMS MRFS efficacy of .25 or higher, whereas urinary incontinence was a negative predictor for EMS MRFS efficacy (OR=0.69, P=.04).

Conclusions

There was a strong association between admission cognition and relative change in functional and motor efficacy and efficiency. Cognitive function was not associated with absolute functional and motor gain. Cognitive function was an independent predictor for satisfactory mobility outcome but not for functional outcome. Older patients with impaired cognitive function could still benefit from rehabilitation.     

Cost of inpatient rehabilitation care in the Department of Veterans Affairs

We investigated the determinants of inpatient rehabilitation costs in the Department of Veterans Affairs (VA) and examined the relationship between length of stay (LOS) and discharge costs using data from VA and community rehabilitation hospitals. We estimated regression models to identify patient characteristics associated with specialized inpatient rehabilitation costs. VA data included 3,535 patients discharged from 63 facilities in fiscal year 2001. We compared VA costs to community rehabilitation hospitals using a sample from the Uniform Data System for Medical Rehabilitation of 190,112 patients discharged in 1999 from 697 facilities. LOS was a strong predictor of cost for VA and non-VA hospitals. Functional status, measured by Functional Independence Measure (FIM) scores at admission, was statistically significant but added little explanatory value after controlling for LOS. Although FIM scores were associated with LOS, FIM scores accounted for little variance in cost after controlling for LOS. These results are most applicable to researchers conducting cost-effectiveness analyses.     

Recovery of functional status after right hemisphere stroke: relationship with unilateral neglect

OBJECTIVE: To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke. DESIGN: Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up. SETTING: Urban, acute inpatient rehabilitation facility. PATIENTS: Fifty-two consecutive admissions of adult right-handed patients with a single, right hemispheric stroke, confirmed by computed tomography scan. MAIN OUTCOME MEASURES: The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale(R). RESULTS: Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing. CONCLUSIONS: Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors.     

Who makes the most progress in inpatient rehabilitation? An analysis of functional gain

This study describes the functional gain made by 6,194 inpatients in 22 rehabilitation facilities in 1985 and 1986. Functional gain was measured by the Revised Level of Rehabilitation Scale (LORS-II). Results showed that age, length of stay, and functional ability at admission were all factors in patient progress, but not always in the way expected. Younger patients and those with a longer length of stay generally made more progress, but there were variations by impairment group. A curvilinear relationship between functional status at admission and functional gain was observed for several impairment groups. Head injury patients made the most functional gains. However, orthopedic patients made the most gains of all impairment groups when length of stay, age, functional ability at admission, and consistency of progress were considered.     

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system

BACKGROUND: Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system. OBJECTIVE: The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences. DESIGN: This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system. SUBJECTS: The study included 55,438 stroke patients. MEASURES: Study measures were LOS, functional status at discharge, and community discharge. RESULTS: The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05). CONCLUSIONS: While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.     

Mini-Mental State Examination, cognitive FIM instrument, and the Loewenstein Occupational Therapy Cognitive Assessment: relation to functional outcome of stroke patients

OBJECTIVES: To compare 3 cognitive tests, used on admission, for predicting discharge functional outcome and to assess the efficacy of these tests in predicting functional outcome at discharge in stroke patients undergoing rehabilitation. DESIGN: Cohort study. SETTING: Geriatric rehabilitation department of a tertiary care hospital in Israel. PATIENTS: Sixty-six patients undergoing acute inpatient comprehensive rehabilitation after first clinical stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASUREMENTS: Cognitive status was assessed with the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), the Mini-Mental State Examination (MMSE), and the cognitive subscale of the FIM instrument. The FIM motor subscale was used to assess functional outcome status. Functional gain was determined by the motor FIM gain (efficacy), and the relative (to potential) functional gain was determined by the Montebello Rehabilitation Factor Score. Efficiency was calculated by efficacy divided by the length of hospital stay. RESULTS: A significant increase in total FIM scores (34.8 points) occurred during rehabilitation mainly because of improvement in motor functioning (31.5 points). Significant improvement in global cognitive status was documented by all 3 tests. Intertest correlation coefficients ranged between.47 and.67. The LOTCA showed somewhat higher correlation coefficients with most of the parameters of functional motor outcomes. Correlation between the MMSE and FIM cognitive subscale and these outcome parameters were nearly identical. CONCLUSION: The LOTCA is slightly better than the MMSE and the FIM cognitive subscale in predicting functional status change after stroke rehabilitation but it is a time-consuming and exhausting instrument to use. The FIM cognitive subscale requires a better overall understanding of the patient's situation at time of administration and therefore is less convenient for the initial assessment. The similar correlation of all 3 tests with functional outcomes and the simplicity of administration of the MMSE suggests its use in the initial assessment of stroke patients.     

Influence of admission hematocrit on inpatient rehabilitation outcomes after total knee and hip arthroplasty

OBJECTIVE: To examine admission hematocrit (Hct) status on inpatient rehabilitation outcomes after total knee (TKA) and hip arthroplasty (THA). DESIGN: This study was a retrospective, exploratory analysis. Patients (n = 400) were stratified by admission hematocrit levels: normal (Hct >or=36-41%, World Health Organization criteria for normal Hct in women and men), low (Hct between the operational 30% cutoff and 36-41%), and very low (Hct <30%). Functional Independence Measure (FIM) scores and specific lower-body FIM motor scores, FIM efficiency, length of stay (LOS), and total hospital charges were analyzed. RESULTS: Regardless of arthroplasty joint, all improved total FIM score, motor FIM score, and specific lower-body activity FIM scores (walking, wheelchair, dressing, transfers, stairs) by discharge (all P < 0.05). LOS was 28.9-31% longer in the TKA-very low Hct and THA-very low Hct groups than in the normal Hct groups (P = 0.026). Total hospital charges were 32.6-45.6% higher in the TKA-very low Hct and THA-very low Hct groups than in the normal Hct groups (P < 0.05). Hct was a significant contributor to the variance of linear regression models for LOS and total charges (P < 0.05). CONCLUSIONS: Although very low Hct at admission does not impede functional gains, it is related to longer LOS and greater hospital charges. Rehabilitation teams should consider this when preparing plans of care, rehabilitation goals, and plans for discharge.