Gender-related differences in acute rehabilitation lengths of stay, charges, and functional outcomes for a matched sample with spinal cord injury: a multicenter investigation

OBJECTIVE: To examine the effects of gender on length of stay (LOS), treatment costs, and outcomes by using a matched sample of patients with spinal cord injury (SCI). DESIGN: A 2 x (15 x 3) mixed, block design was used retrospectively to analyze the impact of gender on subjects matched for age, American Spinal Injury Association (ASIA) motor impairment classification, and level of neurologic injury. SETTING: Twenty medical centers in the federally sponsored Spinal Cord Injury Model Systems project. PARTICIPANTS: One thousand seventy-four adult patients with SCI admitted between 1988 and 1998 were assessed at acute-care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: ASIA motor index and FIM instrument admission, discharge, and efficiency scores; rehabilitation LOS and medical care charges; and discharge disposition. RESULTS: Analysis revealed no gender-related differences in FIM motor scores on admission and discharge. No differences in FIM motor efficiencies or daily change were observed. No significant differences were found for ASIA motor scores on acute-care admission and rehabilitation discharge. No differences in acute rehabilitation LOS and charges were observed. No gender-related differences were seen in the likelihood of discharge to an institutional setting. CONCLUSION: Gender was not a significant factor in functional outcome of SCI patients after acute rehabilitation.     

Potential impact of the new medicare prospective payment system on reimbursement for traumatic brain injury inpatient rehabilitation

OBJECTIVE: To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation. DESIGN: Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria. SETTING: Fourteen urban rehabilitation facilities throughout the United States. PARTICIPANTS: Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes. RESULTS: The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients. CONCLUSIONS: Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.     

A follow-up study of older adults with traumatic brain injury: taking into account decreasing length of stay

OBJECTIVE: To examine age-related differences in rehabilitation outcomes following traumatic brain injury (TBI). DESIGN: Retrospective collaborative study. SETTING: Patients received acute neurotrauma and inpatient rehabilitation services at 1 of the 17 National Institute on Disability and Rehabilitation Research-designated Traumatic Brain Injury Model Systems (TBIMS) centers. PARTICIPANTS: A sample of 273 older patients (> or =55y) admitted for TBI were taken from the TBIMS National Database. Older patients were matched with subjects 44 years of age or younger, based on severity of injury (Glasgow Coma Scale score, length of coma, intracranial pressure elevations). Due to decreasing length of stay (LOS), only patients admitted from 1996 through 2002 were included. INTERVENTION: Inpatient interdisciplinary brain injury rehabilitation. MAIN OUTCOME MEASURES: Acute care LOS, inpatient rehabilitation LOS, admission and discharge FIM instrument and Disability Rating Scale (DRS) scores, FIM and DRS efficiency, acute and rehabilitative charges, and discharge disposition. RESULTS: One-way analyses of variance demonstrated a statistically significant difference between older and younger patients with respect to LOS in rehabilitation but not for acute care. Total rehabilitative charges, and admission and discharge DRS and FIM scores also showed statistically significant differences between groups. Older patients progressed with significantly less efficiency on both the DRS and FIM scales. Significantly more charges were generated per unit for older patients to improve on the DRS scale, but not the FIM scale. Using chi-square analysis, a statistically significant difference in rate of discharge to home was identified between older (80.5%) and younger (94.4%) patients. CONCLUSIONS: Results in this study are similar to those in earlier studies with smaller sample sizes. Major differences observed include significantly slower and more costly progress in inpatient rehabilitation for older patients with TBI, as well as a significantly lower rate of discharge to community for older patients. However, even with decreasing LOS in both settings, community discharge rate is still encouraging for older patients with TBI.     

Neoplastic versus traumatic spinal cord injury: an outcome comparison after inpatient rehabilitation.

OBJECTIVE: To compare outcomes of patients with neoplastic spinal cord compression (SCC) to outcomes of patients with traumatic spinal cord injury (SCI) after inpatient rehabilitation. DESIGN: A comparison between patients with a diagnosis of neoplastic SCC admitted to an SCI rehabilitation unit and patients with a diagnosis of traumatic SCI admitted to the regional Model Spinal Cord Injury Centers over a 5-year period, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification. SETTING: Tertiary university medical centers. PATIENTS: Twenty-nine patients with neoplastic SCC and 29 patients with SCI of traumatic etiology who met standard rehabilitation admission criteria. MAIN OUTCOME MEASURES: Acute and rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, and discharge rates to home. RESULTS: Patients with neoplastic SCC had a significantly (p < .01) shorter rehabilitation LOS than those with traumatic SCI (25.17 vs 57.46 days). No statistical significance was found in acute care LOS. Motor FIM scores on admission were higher in the neoplastic group, but discharge FIM scores and FIM change were significantly lower. Both groups had similar FIM efficiencies and community discharges. CONCLUSIONS: Patients with neoplastic SCC can achieve rates of functional gain comparable to those of their counterparts with traumatic SCI. While patients with traumatic SCI achieve greater functional improvement, patients with neoplastic SCC have a shorter rehabilitation LOS and can achieve comparable success with discharge to the community.     

Severe penetrating head injury: a study of outcomes

OBJECTIVE: To determine and describe the demographics and functional outcomes of persons who require inpatient rehabilitation for severe penetrating head injury resulting from a gunshot wound to the head. DESIGN: Data were collected prospectively from the time of admission to acute care through discharge from inpatient rehabilitation. SETTING: Two sites: an urban, level I, acute care, trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. PARTICIPANTS: Twenty-seven persons with severe penetrating head injury. MAIN OUTCOME MEASURES: The FIM instrument, the Disability Rating Scale (DRS), and the length of stay (LOS). RESULTS: Demographic data showed our population to be similar to other groups of persons at high risk for violent injury. Eighty-five percent of the subjects were men with a mean age of 34 years. The majority were African American (93%), reflective of our general patient population. Average acute care LOS was 31 days and average rehabilitation LOS was 44 days. Average FIM gain was 40.2 and, on average, DRS scores improved 7.6 points from rehabilitation admission to discharge. All study participants made enough progress to be discharged to private residences. CONCLUSION: Although the mortality rate is high among patients with penetrating head injury, those who survive to receive inpatient rehabilitation can achieve functional improvement.     

Incidence,risk factors,and outcomes of fecal incontinence after acute brain injury: findings from the Traumatic Brain Injury Model Systems national database

OBJECTIVE: To investigate the incidence, risk factors, and outcome in patients with fecal incontinence after acute brain injury. DESIGN: A retrospective study of the incidence of and risk factors contributing to fecal incontinence, and outcomes at admission to and discharge from inpatient rehabilitation and at 1-year follow-up. SETTING: Medical centers in the federally sponsored Traumatic Brain Injury Model Systems (TBIMS). PARTICIPANTS: A total of 1,013 consecutively enrolled rehabilitation inpatients from 17 TBIMS centers who were admitted to acute care within 24 hours of traumatic brain injury and seen at 1-year postinjury between 1990 and 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Incidence of fecal incontinence, length of coma, length of posttraumatic amnesia (PTA), admission Glasgow Coma Scale (GCS) score, length of stay (LOS), FIM instrument scores, disposition at discharge and follow-up, and incidences of pelvic fracture, frontal contusion, and urinary tract infection (UTI). RESULTS: The incidence of fecal incontinence was 68% at admission to inpatient rehabilitation, 12.4% at rehabilitation discharge, and 5.2% at 1-year follow-up. Analysis of variance and chi-square analyses revealed statistically significant associations between the incidence of fecal incontinence at rehabilitation admission and admission GCS score, length of coma and PTA, LOS, and incidence of UTI and frontal contusion. Fecal incontinence at rehabilitation discharge was significantly associated with several variables, including age, discharge disposition, admission GCS score, length of coma, PTA, LOS, FIM scores, and incidence of pelvic fracture and frontal contusion. Significant associations were also found between fecal incontinence at 1-year follow-up and age, discharge and current 1-year disposition, admission GCS score, length of coma, LOS, FIM scores, and incidence of UTI (P<.05). Although logistic regression analyses were significant (P<.001), and predicted continence with 100% accuracy, demographics, injury characteristics, medical complications, and functional outcomes did not predict incontinence at discharge and at 1-year follow-up. CONCLUSIONS: Fecal incontinence is a significant problem after brain injury. Certain factors may increase its likelihood. Further studies evaluating mechanisms of fecal incontinence and treatment or control interventions would be useful.     

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.     

Analysis of FIM instrument scores for patients admitted to an inpatient cardiac rehabilitation program

OBJECTIVE: To evaluate in an inpatient cardiac rehabilitation program (a phase IB) whether length of stay (LOS), discharge to home, and improvement in physical function differed between patients with lower and higher degrees of functional independence on admission. DESIGN: A retrospective study. SETTING: A public acute long-term care hospital. PATIENTS: All cardiac rehabilitation patients (N = 143) admitted to the hospital from January 1998 through June 1999. Patients were divided into a higher- and a lower-functioning group by using the admission FIM instrument scores above and below the midpoint of 72. Comparisons in LOS, discharge disposition, and functional gains between these 2 groups were then performed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM scores, FIM change, FIM gains per week, LOS, and discharge disposition. RESULTS: Total FIM scores at discharge were significantly higher than those on admission (25%, P <.0001). The median value of total FIM gains per week was 7.78 with a stay of 17 days and a home discharge rate of 76%. The higher-functioning group (n = 106) differed from the lower group (n = 37) with shorter stay (15 vs 23d, P <.0001), greater FIM gains per week (8.6 vs 4.8, P =.002), and greater likelihood of discharge to home or community (84% vs 54%, P <.001). The average incremental FIM change in each group was the same. In multivariate analysis, both admission (P =.001) and discharge (P <.001) FIM scores were the best predictors of patients' discharge disposition to home. CONCLUSIONS: Admission FIM scores are important predictors for the clinical course and discharge outcomes of cardiac rehabilitation patients, with those with higher admission FIM scores having a shorter LOS and greater likelihood of discharge to home. The admission FIM scores can help to establish realistic goals.     

A preliminary examination of the CMS eligibility criteria in total-joint arthroplasty

OBJECTIVE: To analyze inpatient rehabilitation outcomes in total-knee arthroplasty (TKA) and total-hip arthroplasty (THA) patients using the 2004 Medicare 75% rule criteria. DESIGN: This retrospective study compared outcomes in unilateral TKA (UTKA), bilateral TKA (BTKA), and THA after interdisciplinary inpatient rehabilitation (n = 867). Patients were separated into three comparison pairs: 1) UTKA or BTKA, 2) age <85 yrs or > or =85 yrs, and 3) body mass index (BMI) <50 or > or =50 kg/m. Length of stay (LOS), functional independence measure (FIM) scores (total, motor, and cognitive), hospital charges, FIM efficiency, and discharge disposition were analyzed. RESULTS: BTKA improved total FIM score more than UTKA (43 vs. 38%; P = 0.039). TKA with BMI > or =50 kg/m had similar admission and discharge FIM motor scores compared with BMI <50 kg/m (P > 0.05). TKA patients > or =85 yrs had lower admission FIM scores, longer LOS (11.3 vs. 9.4 days), and 22% higher total charges than TKA patients younger than 85 yrs (P = 0.042). THA patients > or =85 yrs had 6-10% lower total FIM, FIM motor, and FIM cognition scores and were discharged to home less frequently than younger patients (P < 0.05). Total and daily charges were 21-162% higher in THA patients with BMIs > or =50 kg/m than in THA patients with BMIs <50 kg/m (P < 0.045). CONCLUSION: All patients made functional gains during rehabilitation. However, the most costly and lengthy rehabilitation occurred in TKA patients > or =85 yrs and THA patients with BMI > or =50 kg/m.     

FIM量表在外伤性颅脑损伤患者康复疗效评价中的应用

目的 :运用功能独立性评价量表 (FIM )评价外伤性颅脑损伤 (TBI)患者的康复治疗疗效 ,比较闭合性颅脑损伤 (CBI)和开放性颅脑损伤 (OBI)患者的临床特点和康复治疗的效果。方法 :79例TBI患者中 ,5 7例为CBI、2 2例为OBI。运用FIM量表评价两组患者康复治疗前后的功能情况 ,统计患者的入院天数 ,计算FIM效率。结果 :CBI和OBI患者入院时的FIM总评分分别为 81.5 1和 73.0 9;出院时FIM总评分分别为 115 .0 4和 117.77,两组平均增加 4 1%和 5 3%。两组患者康复治疗前后FIM各项评分自身相比有非常显著差异 (P <0 .0 0 1) ,但两组之间相比无显著差异。两组患者的FIM效率分别为 1.99分 /天和 1.71分 /天。结论 :康复治疗可有效改善TBI(无论是CBI还是OBI)患者的功能情况。康复治疗应强调早期和综合性治疗     

Association of hemoglobin levels, acute hemoglobin decrease, age, and co-morbidities with rehabilitation outcomes after total knee replacement

OBJECTIVE: A study was undertaken to assess the association of preoperative and postoperative hemoglobin levels with rehabilitation outcomes, age, and selected co-morbidities DESIGN: Charts of 49 patients admitted to rehabilitation after total knee arthroplasty due to degenerative joint disease were reviewed. Outcome measures included rehabilitation admission and discharge motor FIMtrade mark scores, motor FIM gain, and rehabilitation length of stay. RESULTS: Patients with higher preoperative hemoglobin levels had higher rehabilitation admission motor FIM scores (r=0.38, P<0.01) and lower motor FIM gains (r=-0.45, P<0.001). Patients who had higher hemoglobin levels at rehabilitation admission had higher admission motor FIM scores and shorter length of stay. Patients with diabetes had lower preoperative hemoglobin levels. Patients with hypertension had longer length of stay. Older patients had lower admission and discharge motor FIM scores and longer length of stay. CONCLUSIONS: Patients admitted to rehabilitation after total knee replacement have the potential to improve motor function, regardless of their preoperative and rehabilitation admission hemoglobin levels and the decrease in hemoglobin levels. However, those admitted to rehabilitation with lower hemoglobin levels, those with lower admission motor FIM scores, those who are older, and those who have hypertension may expect longer hospital stays to reach their functional goals.     

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.     

Significance of poor patient participation in physical and occupational therapy for functional outcome and length of stay

OBJECTIVES: To determine the frequency of poor patient participation during inpatient physical (PT) and occupational therapy (OT) sessions and to examine the influence of poor participation on functional outcome and length of stay (LOS). DESIGN: Prospective observational study. SETTING: University-based, freestanding acute rehabilitation hospital. PARTICIPANTS: Two hundred forty-two inpatients, primarily elderly (age range, 20-96y), with a variety of impairment diagnoses (eg, stroke), who were admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Pittsburgh Rehabilitation Participation Scale, the 13 motor items from the FIM instrument (FIM motor), LOS, and discharge disposition. RESULTS: We categorized the sample into 3 groups: "good" participators were those for whom all inpatient PT and OT sessions were rated 4 or greater (n=139), "occasional poor" participators were those with less than 25% of scores rated below 4 (n=53), and "frequent poor" participators were those with 25% or more of scores rated below 4 (n=50). Change in FIM motor scores during the inpatient rehabilitation stay was significantly better for good and occasional poor participators, compared with frequent poor participators (mean FIM improvement: 23.2, 22.8, and 17.6, respectively; repeated-measures analysis of variance group by time interaction, P <.002). LOS was significantly longer for occasional poor participators, compared with good and frequent poor participators controlling for admission FIM differences (adjusted means: 13.9d, 11.0d, and 10.9d, respectively; analysis of covariance, P <.001). CONCLUSIONS: Poor participation in therapy is common during inpatient rehabilitation and has important clinical implications, in terms of lower improvement in FIM scores and longer LOS. These results suggest that poor inpatient rehabilitation participation and its antecedents deserve further attention.     

The impact of the inpatient rehabilitation facility prospective payment system on stroke program outcomes

OBJECTIVE: To examine the impact of the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS) on outcomes in a stroke rehabilitation program. DESIGN: An analysis was performed on a database including 945 stroke patients admitted to an inpatient stroke rehabilitation program 5 yrs before implementation of the IRF PPS and 3.5 yrs after implementation. Patients were classified with regard to stroke location (left vs. right), level of cognitive impairment, presence/absence of unilateral neglect, and level of depressive symptomatology. Functional status was evaluated at time of admission and discharge by functional independence measure (FIM). Other outcome measures included length of stay (LOS) and discharge destination. The impact of IRF PPS on LOS, progress in rehabilitation, and discharge destination was examined via univariate analyses of covariance and logistic regression. RESULTS: Patients admitted after implementation of the IRF PPS had shorter LOS but made less progress, had lower functional levels at discharge, and had higher rates of institutional discharge. CONCLUSIONS: Although associated with decreased LOS, implementation of the IRF PPS was associated with decreased functional gains, lower discharge FIM levels, and higher rates of institutional discharge. Cost savings associated with the PPS must be considered in light of these untoward outcomes.     

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.