Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: II. Participation outcomes

Haley SM, Gandek B, Siebens H, Black-Schaffer RM, Sinclair SJ, Tao W, Coster WJ, Ni P, Jette AM. Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: II. Participation outcomes.

Objectives

To measure participation outcomes with a computerized adaptive test (CAT) and compare CAT and traditional fixed-length surveys in terms of score agreement, respondent burden, discriminant validity, and responsiveness.

Design

Longitudinal, prospective cohort study of patients interviewed approximately 2 weeks after discharge from inpatient rehabilitation and 3 months later.

Setting

Follow-up interviews conducted in patient’s home setting.

Participants

Adults (N=94) with diagnoses of neurologic, orthopedic, or medically complex conditions.

Interventions

Not applicable.

Main Outcome Measures

Participation domains of mobility, domestic life, and community, social, & civic life, measured using a CAT version of the Participation Measure for Postacute Care (PM-PAC-CAT) and a 53-item fixed-length survey (PM-PAC-53).

Results

The PM-PAC-CAT showed substantial agreement with PM-PAC-53 scores (intraclass correlation coefficient, model 3,1, .71-.81). On average, the PM-PAC-CAT was completed in 42% of the time and with only 48% of the items as compared with the PM-PAC-53. Both formats discriminated across functional severity groups. The PM-PAC-CAT had modest reductions in sensitivity and responsiveness to patient-reported change over a 3-month interval as compared with the PM-PAC-53.

Conclusions

Although continued evaluation is warranted, accurate estimates of participation status and responsiveness to change for group-level analyses can be obtained from CAT administrations, with a sizeable reduction in respondent burden.     

Identifying outcomes from the nursing outcomes classification as indicators of quality of care in Korea: a modified delphi study

BACKGROUND: The evaluation of patient outcomes as a measure of quality control of patient care is being adopted in Korean hospitals. Since nursing care contributes to the bulk of patient care, it is important to identify nursing-sensitive patient outcomes, hereafter referred to as 'nursing outcomes', that will be useful in the evaluation of nursing care. OBJECTIVE: This study was conducted to identify nursing outcomes included within the Nursing Outcomes Classification (NOC) that are most sensitive for the evaluation of nursing care in Korean hospitals as well as being observable and measurable. DESIGN: Delphi technique modified for this study was used to gain a consensus from Korean nursing experts. SETTINGS: Participants were recruited from general hospitals in Korea. PARTICIPANTS: Two hundred and thirty nurses working for Quality Improvement (QI) and Continuous Quality Improvement (CQI) programmes were chosen as the nurse experts for this study. METHODS: Three rounds of data collection from all participants was undertaken. In the first data collection, the sensitivity of 260 NOC nursing outcomes (Johnson, et al., 2000. Iowa Outcomes Projects: Nursing Outcomes Classification (NOC). C.V. Mosby, St. Louis) was examined, and more highly nursing sensitive ones were selected. In the second and third data collection phases, nursing outcomes which are most useful for the evaluation of nursing care were selected. RESULTS: Vital Signs Status, Knowledge: Infection Control, Pain Control, Safety Behavior: Fall Prevention, and Infection Status were identified as the five most useful nursing outcomes for the evaluation of nursing care in hospitals. CONCLUSIONS: The nursing outcomes identified highly useful for the evaluation of nursing care in this study can be used effectively for the quality management of nursing care in Korea.     

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: I. Activity outcomes

OBJECTIVE: To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home. DESIGN: Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit. SETTING: Follow-up visits conducted in patients' home setting. PARTICIPANTS: Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66). RESULTS: AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77-.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval. CONCLUSIONS: Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.     

Identifying nurse-sensitive indicators for stand-alone high acuity areas: A systematic review

Background

Nurse-sensitive patient outcomes that are suitable for general medical and surgical settings are well developed. Indicators developed for general ward settings may not be suitable for stand-alone high acuity areas; therefore, a different set of indicators is required.

Studying outcomes of intensive care unit survivors: measuring exposures and outcomes

Background Measurement of long-term outcomes and the patient and intensive care unit (ICU) factors predicting them present investigators with unique challenges. There is little systematic guidance for measuring these outcomes and exposures within the ICU setting. As a result measurement methods are often variable and noncomparable across studies.Methods We use examples from the critical care literature to describe measurement as it relates to three key elements of clinical studies: subjects, outcomes and exposures, and time. Using this framework we review the principles and challenges of measurement and make recommendations for long-term outcomes research in the field of critical care medicine.Discussion Relevant challenges discussed include: (a) selection bias and heterogeneity of ICU research subjects, (b) appropriate selection and measurement of outcome and exposure variables, and (c) accounting for the effect of time in the exposure-outcome relationship, including measurement of baseline data and time-varying variables.Conclusions Addressing these methodological challenges will advance research aimed at improving the long-term outcomes of ICU survivors.Electronic Supplementary Material Electronic supplementary material to this paper can be obtained by using the Springer Link server located at .This research was supported by National Institutes of Health (ALI SCCOR Grant # P050 HL 73994-01). D.M.N. is supported by Clinician-Scientist Awards from the Canadian Institutes of Health Research and the University of Toronto, and a Detweiler Fellowship from the Royal College of Physicians and Surgeons of Canada.     

Outcomes of rehabilitation services for nursing home residents

OBJECTIVE: To examine survival and community discharge outcomes related to rehabilitation services among patients admitted to nursing homes before the implementation of the Balanced Budget Amendment of 1997. DESIGN: Retrospective cohort. SETTING: A total of 945 Medicaid-certified nursing homes in Ohio. PARTICIPANTS: A total of 11,150 patients admitted for the first time to a nursing home from 1994 to 1996. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community discharge and survival rates among patients who did or did not receive rehabilitation services, using multivariable techniques to adjust for patients' propensity to receive rehabilitation and for other potential confounders. In secondary analyses, we also examined dose-response effects and analyzed the effects of rehabilitation when patients were divided into 5 diagnostic groups (stroke, hip fracture, congestive heart failure, chronic lung disease, other). RESULTS: Rehabilitation was provided to 58% of the patients and was associated with higher community discharge rates (relative risk=1.48; 95% confidence interval [CI], 1.40-1.57) and a lower hazard of death (hazard ratio=.81; 95% CI,.75-.88). Dose-response effects were observed for both outcomes (P<.001) among patients receiving rehabilitation. Rehabilitation was associated with improved community discharge rates in each of the 5 diagnostic groups. CONCLUSIONS: New reimbursement policies that discourage the provision of rehabilitation services may have adverse effects on patients, their families, and societal costs of care.     

Understanding cancer patients’ experience and outcomes: development and pilot study of the Cancer Care Outcomes Research and Surveillance patient survey

Goals of work The National Cancer Institute’s Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is conducting a population-based study of newly diagnosed patients with lung and colorectal cancer to describe the experience of persons living with cancer and to understand which barriers present the most significant obstacles to their receipt of appropriate care. The keystone to this effort is the baseline patient survey administered approximately 4 months after diagnosis.Patients and methods We developed a survey to obtain information from patients newly diagnosed with lung and colorectal cancer about their personal characteristics, decision making, experience of care, and outcomes. We conducted a pilot study to evaluate the feasibility of a lengthy and clinically detailed interview in a convenience sample of patients within 8 months of diagnosis (n=71).Main results The median length of the interviews was 75 min for patients with lung cancer (range 43–130) and 82 min for patients with colorectal cancer (range 46–119). Most patients had received some form of treatment for their cancer: 66.1% had undergone surgery, 28.2% had received radiation therapy, and 54.9% were treated with chemotherapy. In addition, 26.7% reported their overall health was less than 70 on a 0–100 scale, demonstrating that patients with substantial health impairment were able to complete the survey.Conclusions A clinically detailed survey of newly diagnosed lung and colorectal cancer patients is feasible. A modified version of this survey is being fielded by the CanCORS Consortium and should provide much needed population-based data regarding patients’ experiences across the continuum of cancer care and their outcomes.     

Predictors of Functional Outcomes After Simple Decompression for Ulnar Neuropathy at the Elbow: A Multicenter Study by the SUN Study Group

Objective

To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE).

Design

Prospective cohort followed for 1 year.

Setting

Clinics.

Participants

Patients diagnosed with UNE (N=55).

Intervention

All subjects had simple decompression surgery.

Main Outcome Measures

The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow.

Results

Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9–23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9–24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, −0.38; 95% CI, −.67 to −.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, −.40; 95% CI, −.79 to −.01).

Conclusions

Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.     

Development of an applied cognition scale to measure rehabilitation outcomes

OBJECTIVE: To examine the structure and content coverage of an item pool of new items based on the Activity categories from the International Classification of Functioning, Disability and Health and items from existing instruments to measure the applied cognition dimension of function. DESIGN: Prospective study. SETTING: Four postacute care rehabilitation settings (inpatient, transitional care, home care, outpatient) in an urban-suburban area of northeast United States. PARTICIPANTS: Convenience sample of 477 patients (mean age, 62.7 y) receiving rehabilitation services for neurologic, orthopedic, or complex medical conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were administered applied cognition items from the new Activity Measure for Post-Acute Care, the Medical Outcomes Study 8-Item Short-Form Health Survey, and an additional setting-specific measure: the FIM instrument (inpatient rehabilitation); the Minimum Data Set (skilled nursing facility); the Minimum Data Set-Post Acute Care (postacute settings); or the Outcome Assessment and Information Set (home care). Rasch (partial-credit model) analyses were conducted to examine item fit, item coverage, scale unidimensionality, and category difficulty estimates. RESULTS: The majority of items (46/59) could be located along a single continuum. Relatively few people were performing at the lower end of the difficulty scale, and about 25% were at ceiling. CONCLUSIONS: The proposed definition of applied cognition dimension provides a useful guide for item development to measure this dimension. Further work is needed to determine how best to measure function in this domain for people at the upper and lower ends of the continuum.     

The role of transport intervals in outcomes for critically ill patients who are transferred to referral centers

Purpose

The aim of this study was to determine the association between transport intervals (including time from call to arrival of transport team at the sending hospital, time spent by the transport team in the sending hospital, and transport time between the sending and receiving hospital) and intensive care unit (ICU) and hospital length of stay and hospital mortality at the receiving hospital.

Materials and Methods

This was a retrospective, stratified cohort study involving all patients 15 years and older who were transferred from one hospital to another of equal or larger size in British Columbia, Canada, and who spent at least 1 day in an ICU or coronary care unit (CCU) at the receiving hospital during 1999 (n = 1930). Data were obtained from 6 administrative databases and linked using generalized software.

Results

After adjustment for age, sex, comorbidity, and diagnostic group, longer time from call to arrival of paramedics at the sending hospital was associated with a shorter length of ICU/CCU stay (rate ratio [RR], 0.91; 95% confidence interval [CI], 0.86-0.97) for survivors and a longer length of hospital (RR, 1.12; 95% CI, 1.05-1.21) and ICU/CCU (RR, 1.14; 95% CI, 1.04-1.25) stay for nonsurvivors in the higher-priority air transport group, and with a slightly shorter length of hospital stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the lower-priority air transport group. Longer time spent by paramedics at the sending hospital was associated with a shorter length of hospital stay (RR, 0.79; 95% CI, 0.65-0.96) for survivors in the higher-priority air transport group. Longer time for transport between the sending and receiving hospitals was associated with a longer length of ICU/CCU stay (RR, 1.69; 95% CI, 1.26-2.27) for survivors in the higher-priority air transport group but a slightly shorter length of ICU/CCU stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the ground transport group. There were no associations between transport times and hospital mortality.

Conclusions

Transport intervals are independently associated with ICU/CCU and hospital lengths of stay at the receiving hospital for critically ill adults transferred to referral centers.     

Time to rehabilitation admission and associated outcomes for patients with traumatic brain injury

OBJECTIVE: To examine the association between time from injury to rehabilitation admission and outcomes for patients with traumatic brain injuries (TBIs). DESIGN: Retrospective chart review. SETTING: One hundred-bed inpatient rehabilitation facility with a 20-bed brain injury unit. PARTICIPANTS: Patients with TBIs discharged from initial inpatient rehabilitation between 2003 and 2004 (N=158). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcomes examined were functional independence at discharge (motor, cognitive, total FIM scores), rehabilitation length of stay (LOS), and rehabilitation cost. RESULTS: Significant linear trends were observed for time to admission and motor FIM scores, total FIM scores, rehabilitation LOS, and cost. All linear regression models contained time to admission as a significant predictor of rehabilitation outcomes. Over half of the variability in outcomes was explained by predictors including time to admission and case-mix group or individual FIM scores with the exception of discharge motor FIM score, for which only 45% of the variability was explained. CONCLUSIONS: Patients who progress to rehabilitation earlier do better functionally and have lower costs and shorter LOSs. Furthermore, the time to rehabilitation admission is easily calculated and could be used by rehabilitation providers in adjunct with admission FIM scores to estimate resource utilization.     

Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data

Background

Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited.

Objectives

This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care.

Design-setting-participants

Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n = 1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n = 260,923) of the year 2003 from all acute hospitals (n = 115).

Methods

Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes.

Results

The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D. = 0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes.

Conclusion

The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.     

Point of entry and functional outcomes after comprehensive day treatment participation

Micklewright JL, Yutsis M, Smigielski JS, Brown AW, Bergquist TF. Point of entry and functional outcomes after comprehensive day treatment participation.

Objectives

To explore the relationship between point of entry into a comprehensive day treatment (CDT) program and outcomes after acquired brain injury (ABI). We hypothesized that participants entering our program 0 to 6 months postinjury would demonstrate greater declines in neurobehavioral sequelae and improvements in residential/vocational independence than those entering >6 to 12 and >12 to 24 months postinjury.

Design

Retrospective examination of admission, discharge, and 1-year follow-up data from a CDT program.

Setting

A large Midwestern academic medical center.

Participants

Adult CDT participants with traumatic brain injuries (TBI) (n=54) or cerebrovascular accidents (CVAs) (n=29).

Interventions

A CDT rehabilitation program.

Main Outcome Measures

Portland Adaptability Inventory/Mayo-Portland Adaptability Inventory (percent change scores between admission and discharge) and the Independent Living and Vocational Independence Scales.

Results

Time since injury was categorically coded into the 3 aforementioned point of entry groups. A 2 (injury type) × 3 (point of entry) between subjects analysis of covariance revealed a significant main effect for the point of entry (P<.001). Post hoc tests indicated that individuals entering the program 0 to 6 months postinjury demonstrated significantly greater treatment gains than those entering 6 to 12 or 12 to 24 months postinjury. Within group chi-square analyses revealed that a significantly higher percentage of the early entry participants were living and working independently at discharge and 1-year follow-up.

Conclusions

Entry into a CDT program (0–6mo postinjury) is associated with significantly greater declines in neurobehavioral sequelae and improvements in residential and vocational independence in participants with TBI or CVA. Sustainable modest treatment gains were also observed in the late entry groups, suggesting that these individuals also benefit significantly from CDT program participation.