Impact of Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury

Qu H, Shewchuk RM, Chen Y, Deutsch A. Impact of Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury.

Objective

To examine the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on inpatient rehabilitation outcomes for patients with traumatic spinal cord injury (SCI).

Design

Retrospective study.

Setting

Twelve SCI Model Systems.

Participants

A sample of Medicare (n=296) and non-Medicare (n=3110) patients was selected from the National SCI Statistical Center Database from 1996 to 2006.

Interventions

Not applicable.

Main Outcome Measures

Motor FIM score change and length of stay (LOS).

Results

LOS decreased by about 5.8 days a year (P<.001) for Medicare patients and about 1.3 days a year (P=.031) for non-Medicare patients after PPS implementation. However, for both groups, FIM score gains were not significantly different in the pre-PPS and PPS periods.

Conclusions

Although significant decreases in LOS were observed for Medicare patients after IRF PPS implementation, Medicare patients' improvements in motor function did not decrease. Non-Medicare patients with SCI also experienced shortened stays after Medicare IRF PPS implementation, but had equivalent FIM score gains compared with their counterparts who received inpatient rehabilitation care before PPS implementation. IRF PPS implementation was associated with shorter stays, but was not associated with lower functional improvement.     

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.     

The effect of the introduction of a case-mix-based funding model of rehabilitation for severe stroke: an Australian experience

OBJECTIVE: To compare resource use of, and outcomes for, rehabilitation for severe stroke before and after the implementation of the Casemix and Rehabilitation Funding Tree case-mix-based funding model. DESIGN: Prospective, observational cohort study. SETTING: Eight inpatient rehabilitation centers in Australia. PARTICIPANTS: Consecutive sample of 609 patients with severe stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation length of stay (LOS), discharge destination, and FIM instrument motor score at discharge. RESULTS: The average rehabilitation LOS changed significantly between the preimplementation year and the implementation year (Mann-Whitney U, P=.001). There were no significant differences in discharge destination. FIM motor score at discharge showed significant reduction in improvement (Mann-Whitney U, P=.001) between the preimplementation year and the implementation year. There were no significant correlations between LOS in rehabilitation and gain in function for either the preimplementation year (Spearman rho, P=.07) or the implementation year (P=.15). CONCLUSIONS: The change in funding model was associated with a decrease in inpatient costs and with an associated increase in disability at discharge. Our results suggest that the rate of improvement in severe stroke is variable; also, they support the use of funding models for stroke rehabilitation that allow flexibility in resource allocation.     

Unilateral spatial neglect: relation to rehabilitation outcomes in patients with right hemisphere stroke

OBJECTIVE: To examine the relation between left unilateral spatial neglect (USN) and rehabilitation outcomes in patients with right hemisphere stroke. DESIGN: A retrospective analysis of a database of right hemisphere stroke patients. SETTING: Acute inpatient rehabilitation hospital. PARTICIPANTS: Patients (N=175) with a diagnosis of right hemisphere stroke who had undergone a neuropsychologic screening including assessment of USN and depressive symptoms at time of admission to an inpatient rehabilitation program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional status was evaluated with the FIM instrument at admission and discharge. The relationship between USN, depressive symptoms, cognitive functioning, length of stay (LOS), and rate of progress in rehabilitation was examined via univariate (correlational) and multivariate (Cox regression) analyses. RESULTS: Patients with USN had longer LOS and progressed more slowly compared with those without USN. When matched against patients with equally poor functional status at admission, USN patients still had longer admissions and progressed more slowly. CONCLUSIONS: USN is a unique predictor of rehabilitation outcomes in patients with right hemisphere stroke. Identification of those specific functional skill areas most affected by USN may make possible the development of targeted interventions aimed at these key areas.     

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.     

Outcomes in total knee arthroplasty patients after inpatient rehabilitation: influence of age and gender

OBJECTIVES: To examine age and gender effects on outcomes after inpatient rehabilitation in primary total knee arthroplasty (TKA) and revision TKA patients. DESIGN: This retrospective, comparative study was conducted in a 50-bed, university-affiliated rehabilitation hospital. Patients included primary TKA patients (n = 286) and revision TKA patients (n = 138) placed into one of three age brackets: <60 yrs, 60-70 yrs, or >70 yrs. Measurements included length of stay (LOS), FIM scores, hospital charges, and discharge disposition location. RESULTS: FIM scores improved from admission to discharge in both primary and revision patients (P = 0.015). LOS was shorter in primary than revision patients (8.3 vs. 10.4 days, P = 0.001), and the LOS was longest in patients >70 yrs compared with those <60 or 60-70 yrs (10.6 vs. 8.7 and 8.8 days, respectively; P = 0.004). FIM efficiency was greater in primary than in revision TKA patients (3.68 vs. 2.77 points/day, P = 0.001), and greater for men than women in each age bracket regardless of TKA type (3.68 vs. 2.78 points/day, P = 0.001). Total hospital charges were lower for men than women for both TKA types ($9,656 +/- 823 vs. $11,544 +/- 1,359; P = 0.015), and were highest in patients >70 yrs of age (P = 0.015). CONCLUSIONS: Primary and revision TKA patients make improvements in functional independence during inpatient rehabilitation. Although FIM gains were similar among age and gender groupings, FIM efficiency is lowest in women. Despite similar daily hospital costs among the groups, slower progress with functional gains (decreased FIM efficiency) increases the LOS and total hospital charges, especially in older women.     

Rehabilitation of postcardiac surgery stroke patients. Progress,outcomes, and comparisons with other stroke patients

OBJECTIVE: To examine the demographics, progress, and functional outcomes of all postcardiac surgery stroke patients admitted to the rehabilitation unit of an acute, tertiary general hospital over a 5-yr period and to compare this cohort with an age-matched control group of other stroke patients admitted during the same period. DESIGN: A retrospective chart review of 47 postcardiac surgery stroke and a matched control group of other stroke patients admitted to the rehabilitation unit. RESULTS: The mean age of the postcardiac surgery stroke patients was 70.80 +/- 8.37 yr, with 60% of patients being male. Their average length of stay on the rehabilitation unit was 15.64 +/- 11.96 days. Mean admit FIM total score was 65.64 +/- 16.33, with a discharge FIM total score of 86.77 +/- 18.93. Mean admit FIM motor score was 41.47 +/- 9.45, with a discharge FIM motor of 60.74 +/- 13.20. The other stroke group had significantly greater admit FIM total (P = 0.03), admit motor (P = 0.001), and discharge motor (P = 0.025) scores. FIM efficiency and motor and cognitive gains were comparable between the two groups. Length of stay on the rehabilitation unit was approximately 2 days less (P = 0.224) for the other stroke cohort. Ultimately, 39 (83%) of the postcardiac surgery stroke patients were discharged to the community compared with 45 (96%) of the other stroke patients (P = 0.19). CONCLUSIONS: The majority of postcardiac surgery stroke patients successfully completed a comprehensive inpatient rehabilitation program. They had lower admit FIM total scores and admit and discharge FIM motor scores than the other stroke group and were almost as likely to ultimately return to the community.     

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.     

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.     

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.     

Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation

OBJECTIVE: To determine the prevalence of venous thromboembolic disease (VTED) and impact on functional outcome in patients with major lower-extremity (LE) amputation admitted to an inpatient rehabilitation unit. DESIGN: Retrospective medical records review. SETTING: Acute inpatient rehabilitation unit in a tertiary, urban academic medical center. PARTICIPANTS: Fifty consecutive patients admitted to an acute inpatient rehabilitation unit after a major LE amputation. Participants were screened at rehabilitation admission for LE deep vein thrombosis using duplex ultrasonography. INTERVENTIONS: Not applicable.Main outcome measures VTED incidence, FIM instrument, total rehabilitation charges, and length of stay (LOS). RESULTS: Six of 50 patients (12%) had evidence of VTED. The VTED cohort had significantly lower admission and discharge FIM scores than the no-VTED cohort (admission FIM score, 57.2 vs 76.0; discharge FIM score, 66.0 vs 90.1, respectively; P< or =.02). Subjects with VTED had a longer rehabilitation LOS (22.8d vs 13.9d, respectively; P=.02) and higher total rehabilitation charges (28,314 US dollars vs 17,724 US dollars, respectively; P<.05). CONCLUSIONS: In this study, VTED prevalence after LE amputation in a rehabilitation setting was 12%. Subjects with VTED had lower admission and discharge functional status, longer LOS, and higher hospital charges. The utility of screening duplex ultrasound examinations at rehabilitation admission remains unclear.     

Rehabilitation outcomes in patients with brain tumors and acute stroke: comparative study of inpatient rehabilitation

OBJECTIVES: To investigate functional outcomes after hospital rehabilitation of patients surviving craniotomy for primary brain tumor excision compared with post-stroke patients. DESIGN: The database of the Neurological Rehabilitation Department "C" of Loewenstein Rehabilitation Center was used to investigate primary brain tumors and first ischemic and hemorrhagic stroke patients admitted for hospital rehabilitation during an 11-yr period, between January 1993 and August 2004. Particular attention was paid to age and sex distribution, onset-to-admission interval, length of stay, functional status at admission and discharge, functional gain (DeltaFI change) as measured by the FIM instrument. RESULTS: A total of 168 patients with craniotomy for primary brain tumor excision (128 intracranial meningiomas and 40 cerebral gliomas) and 1660 first-stroke patients were admitted to the department for rehabilitation during the study period. Mean patient age was 59.9 yrs in meningioma group, 54.1 yrs in the glioma group, and 60.4 yrs in the stroke group. In the meningioma and stroke groups, male patients were in the majority (62 and 70%); in the glioma group, there was equal sex distribution. On average, patients were admitted to rehabilitation treatment 13 days after meningioma excision, 34 days after glioma operation, and 21.6 days after stroke. Functional variables during inpatient rehabilitation were found to be similar in the all groups. Average FIM rating at admission was 80.07 in the meningioma group, 68.2 in the glioma group, and 70.4 in the stroke group. Average discharge FIM rating was 90.3 for patients with meningiomas, 80.7 for patients with gliomas, and 87.8 for stroke patients. Functional gain was 17.9 for meningioma patients, 17.2 for glioma patients, and 21.8 for stroke patients. Average length of stay was 24 days for the meningioma group, 23 days for the glioma group, and 75.4 days for stroke patients; 88.1% of stroke patients, 91.7% of meningioma patients, and 82.7% of glioma patients were discharged to their homes, and 5.4, 3.4, and 8.6%, respectively, were discharged to nursing homes. CONCLUSIONS: Patients with brain tumors can achieve good functional outcomes with a shorter length of stay.     

Inpatient rehabilitation of patients requiring hemodialysis

OBJECTIVE: To evaluate the outcomes of patients who require hemodialysis and are admitted to an inpatient rehabilitation unit. DESIGN: Retrospective review of the data of all admissions to an inpatient rehabilitation unit in 2001. SETTING: University medical center. PARTICIPANTS: All inpatient rehabilitation admissions in 2001 (N=531), including 497 patients who did not require hemodialysis and 34 who required hemodialysis. INTERVENTION: A comprehensive rehabilitation program including physical therapy and occupational therapy. Speech and language therapy and rehabilitation psychology were provided when necessary. MAIN OUTCOME MEASURES: Length of stay (LOS), change in total score on the FIM instrument, FIM efficiency, and place of discharge. RESULTS: Admission and discharge FIM scores of the patients requiring hemodialysis were virtually identical to those of the other patients admitted to the unit. The average LOS of the hemodialysis patients was 5.4 days longer than that of the other patients, and, therefore, efficiency scores of the dialysis group were less than those of the other patients. The rate of discharge to the community did not differ significantly for the dialysis group. CONCLUSIONS: Patients who require hemodialysis can benefit from rehabilitation services. Their improvement on the FIM instrument is comparable to that of other patients, but their LOS may be longer than that of other patients.     

Predicting goal achievement during stroke rehabilitation for Medicare beneficiaries

Abstract

Purpose: Few studies have investigated the ability of treatment teams to predict functional improvement and whether an association between predicted goals and discharge function in patients with stroke exists. This study investigated goal prediction during stroke rehabilitation delivered in inpatient rehabilitation facilities (IRF) and the factors associated with goal prediction. Methods: A serial, cross-sectional design analyzing the Medicare IRF Patient Assessment Instrument dataset. The sample included 179?479 admissions for stroke aged over 65 years in 968 IRFs. Generalized estimating equations (GEE) controlled for facility cluster effects were used for analysis of time trends for length of stay (LOS), predicted Functional Independence Measure (FIM) scores, discharge FIM scores and predicted-discharge difference FIM scores (goal FIM scores minus discharge FIM scores). GEE models were employed to determine the correlation between predicted FIM and discharge FIM scores and factors associated with goal achievement. Results: Mean LOS, predicted FIM scores and discharge FIM scores decreased 1.8?d, 2.2 points and 3.6 points, respectively, while predicted-discharge difference FIM scores increased 1.3 points. Discharge goals were not met 78.9% of the time. After controlling for patient characteristics, each predicted FIM point was associated with 0.6 discharge FIM points (p?<?0.0001). Factors associated with not meeting or exceeding goals were: age (odds ratio; OR?=?0.997), African Americans (OR?=?0.905), number of comorbidities (OR?=?0.970), number of complications (OR?=?0.932) and right brain stroke (OR?=?0.869). Factors associated with meeting or exceeding goals were: LOS (OR?=?1.03), admission FIM score (OR?=?1.02) and females (OR?=?1.05). Conclusions: Trends for lower goals and lower discharge function occurred over time. A correlation existed between predicted FIM scores and discharge FIM scores. Patient factors were associated with goal achievement.

• Implications for Rehabilitation

• Using the Functional Independence Measure, rehabilitation teams set lower goals for stroke rehabilitation in inpatient rehabilitation facilities during first 5.5 years of the IRF-PAI dataset.

• Discharge FIM scores also trended lower and fell at faster rate than goal FIM scores.

• Teams’ goal FIM scores averaged nearly 12 points higher than discharge FIM scores, and over 75% of patients did not reach goals for the rehabilitation stay.

• Factors associated with meeting or exceeding goals were: length of stay, admission FIM scores and being a female. Factors associated with not meeting or exceeding goals were: age, number of comorbidities and complications, having a right-brain stroke and being African American.

     

Use of percutaneous endoscopic gastrostomy feeding tubes and functional recovery in stroke rehabilitation: a case-matched controlled study

OBJECTIVE: To compare the morbidity, mortality, and functional recovery of patients who require percutaneous endoscopic gastrostomy (PEG) placement for the management of dysphagia after stroke. DESIGN: Retrospective case-matched controlled study. SETTING: Acute stroke rehabilitation inpatient unit. PARTICIPANTS: Patients (N=193) who were admitted for stroke rehabilitation with a PEG tube in place from January 1, 1993, to December 31, 2002, were matched with 193 case controls without PEG. Patients and controls were within 90 days of stroke onset, and were matched for age, sex, type of stroke, FIM instrument score, duration from onset to stroke unit admission, and year of admission. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of rehabilitation hospital stay, improvement in FIM scores, FIM efficiency score, need for transfer back to acute care hospital, diagnosis for which transfer was required, final discharge destination, and survival status. RESULTS: Significant differences were found between the 2 groups, PEG versus control, respectively, in the following variables: FIM efficiency (.42+/-.57 vs .56+/-.55, P =.016); need for transfer back to acute hospital (58/193 vs 23/193, P =.001); and survival status dead/alive (14/179 vs 3/190, P =.006). Nonsignificant differences were as follows: length of rehabilitation hospital stay (46.9+/-24.8d vs 43.3+/-19.7d, P =.11), improvement in total FIM score from admission to discharge (16.9+/-17.9 vs 21.0+/-15.5, P =.72), and final discharge destination home/institutional care (96/83 vs 101/89, P =.93). Pneumonia was the most frequent reason for transfer to acute care for patients with PEG. CONCLUSIONS: Patients who meet criteria for admission to a stroke rehabilitation unit and who have a PEG in place are at increased risk for medical complications and death. Those who survive, however, show similar functional recovery and rate of home discharge as case-matched controls.     

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.     

Effect of rehabilitation site on functional recovery after hip fracture

OBJECTIVE: To evaluate whether FIM instrument motor outcomes differ between hip fracture survivors undergoing rehabilitation in inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs). DESIGN: Inception cohort with follow-up to 12 weeks after hospital discharge. SETTING: University-affiliated tertiary care hospital, IRFs, and SNFs. PARTICIPANTS: All hip fracture patients prospectively admitted between March 1, 2002, and June 30, 2003, were eligible if they were 60 years or older and had surgical stabilization of the fracture. INTERVENTIONS: Posthip fracture rehabilitation delivered at either IRFs or SNFs. MAIN OUTCOME MEASURE: FIM motor score obtained postoperatively and at 2 and 12 weeks posthospital discharge. RESULTS: IRF patients stayed an average of 12.8 days, whereas SNF patients averaged 36.2 days. Rehabilitation participation scores were obtained during therapy sessions and did not differ between groups. A repeated-measures analysis of covariance found a significant group by time interaction (F 2,68 =23.75, P <.001), which indicates that patients in an IRF had significantly higher FIM motor scores than those in an SNF across time. Logistic regression showed that IRF subjects were more likely to reach 95% of their prefracture FIM motor by week 12 than were SNF patients. A significantly higher percentage of IRF patients were discharged home after rehabilitation compared with SNF patients. CONCLUSIONS: IRF patients had superior 12-week functional outcomes, as measured by the FIM motor score, compared with those treated in an SNF. The improved outcomes occurred during a significantly shorter rehabilitation length of stay and remained even when statistically controlling for baseline differences between groups. These data suggest that hip fracture survivors should not be excluded from receiving inpatient rehabilitation services. Randomized clinical trials are needed to understand more fully differences between rehabilitation treatment settings.     

Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury

Weeks DL, Greer CL, Bray BS, Schwartz CR, White JR Jr. Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury.

Objective

To study whether outcomes in patients who have undergone inpatient rehabilitation for stroke, traumatic brain injury (TBI), or traumatic spinal cord injury (TSCI) differ based on antidepressant medication (ADM) use.

Design

Retrospective cohort study of 867 electronic medical records of patients receiving inpatient rehabilitation for stroke, TBI, or TSCI. Four cohorts were formed within each rehabilitation condition: patients with no history of ADM use and no indication of history of depression; patients with no history of ADM use but with a secondary diagnostic code for a depressive illness; patients with a history of ADM use prior to and during inpatient rehabilitation; and patients who began ADM therapy in inpatient rehabilitation.

Setting

Freestanding inpatient rehabilitation facility (IRF).

Participants

Patients diagnosed with stroke (n=625), TBI (n=175), and TSCI (n=67).

Interventions

Not applicable.

Main Outcome Measures

FIM, rehabilitation length of stay (LOS), deviation between actual LOS and expected LOS, and functional gain per day.

Results

In each impairment condition, patients initiating ADM therapy in inpatient rehabilitation had longer LOS than patients in the same impairment condition on ADM at IRF admission, and had significantly longer LOS than patients with no history of ADM use and no diagnosis of depression (P<.05). LOS for patients initiating ADM therapy as inpatients even exceeded LOS for patients without ADM history, but who had a diagnosis for a depressive disorder. Deviation in LOS was significantly larger in the stroke and TBI groups initiating ADM in IRF than their counterparts with no history of ADM use, illustrating that the group initiating ADM therapy in rehabilitation significantly exceeded expected LOS. Increased LOS did not translate into functional gains, and in fact, functional gain per day was lower in the group initiating ADM therapy in IRF.

Conclusions

Explanations for unexpectedly long LOS in patients initiating ADM in inpatient rehabilitation focus on the potential for ADM to inhibit therapy-driven remodeling of the nervous system when initiated close in time to nervous system injury, or the possibility that untreated sequelae (eg, depressive symptoms or fatigue) were limiting progress in therapy, which triggered ADM treatment.     

Clinical characteristics and rehabilitation outcomes of patients with posterior cerebral artery stroke

OBJECTIVES: To describe the demographics, clinical profile, and functional outcomes in posterior cerebral artery (PCA) stroke and to identify factors associated with functional change during rehabilitation and discharge disposition. DESIGN: Retrospective study of patients with PCA stroke admitted to a rehabilitation hospital over an 8-year period. SETTING: Free-standing urban rehabilitation hospital in the United States. PARTICIPANTS: Eighty-nine consecutive patients with PCA stroke (48 men, 41 women; mean age, 71.5y) met inclusion criteria. INTERVENTION: Inpatient multidisciplinary comprehensive rehabilitation program. MAIN OUTCOME MEASURES: Demographic, clinical, and discharge disposition information were collected. Functional status was measured using the FIM instrument, recorded at admission and discharge. The main outcome measures were the discharge total FIM score, the change in total FIM score (DeltaFIM), and the discharge disposition. Multiple and logistic regression analyses were performed to identify factors associated with the main outcome measures. RESULTS: The most common impairments were motor paresis (65%), followed by visual field defects (54%) and confusion or agitation (43%). The mean discharge total FIM score +/- standard deviation was 88.3+/-28.2. The mean DeltaFIM was 23.3+/-16.4. Fifty-five (62%) patients were discharged home. On multiple regression analysis, higher admission total FIM score, longer length of stay (LOS), and a rehabilitation stay free of interruptions were associated with higher discharge total FIM score and greater DeltaFIM. Absence of diabetes mellitus and younger age were also associated with higher discharge total FIM scores, and male sex had greater DeltaFIM. On logistic regression analysis, younger patients, higher discharge FIM scores, presence of a caregiver, and the nonnecessity for 24-hour support were associated with a discharge to home. CONCLUSIONS: Motor, visual, and cognitive impairments are common in PCA stroke, and good functional gains are achievable after comprehensive rehabilitation. Higher admission FIM scores, longer LOS, and younger and male patients were associated with better functional outcomes. Most patients were discharged home, particularly those with caregivers and those for whom 24-hour support was not required. Further research should aim at the development of functional outcome measures of greater breadth and sensitivity to visual and cognitive deficits and should compare PCA stroke outcomes with outcomes of strokes in other vascular territories.     

Changes in Functional Independence Measure Ratings Associated with a Safe Patient Handling and Movement Program

Safe patient handling and movement (SPHM) programs are effective in reducing healthcare worker injuries. However, the perception among rehabilitation personnel that SPHM equipment promotes patient dependence and adversely affects functional outcomes is one barrier to implementing successful programs. This barrier is particularly evident in acute inpatient rehabilitation facilities, where functional independence is the primary goal. The purpose of this retrospective cohort study was to evaluate this perception. Functional Independence Measure (FIM) ratings were collected from 94 patients with a diagnosis of stroke. Forty‐seven patients were admitted 1 year prior to implementation of the SPHM program (Group 1), and 47 were admitted to the facility over a period of 1 year (Group 2) 18 months after program implementation. Group 2 obtained equal or better discharge mobility FIM ratings than Group 1, who received care without the SPHM equipment. This study suggests that SPHM programs do not impede functional outcomes in stroke patients.