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1.
Laura Coots Daras Melvin J. Ingber Anne Deutsch Jennifer Gaudet Hefele Jennifer Perloff 《Archives of physical medicine and rehabilitation》2018,99(6):1060-1066
Objective
To examine whether there are differences in inpatient rehabilitation facilities' (IRFs') all-cause 30-day postdischarge hospital readmission rates vary by organizational characteristics and geographic regions.Design
Observational study.Setting
IRFs.Participants
Medicare fee-for-service beneficiaries discharged from all IRFs nationally in 2013 and 2014 (N = 1166 IRFs).Interventions
Not applicable.Main Outcome Measures
We applied specifications for an existing quality measure adopted by Centers for Medicare & Medicaid Services for public reporting that assesses all-cause unplanned hospital readmission measure for 30 days postdischarge from inpatient rehabilitation. We estimated facility-level observed and risk-standardized readmission rates and then examined variation by several organizational characteristics (facility type, profit status, teaching status, proportion of low-income patients, size) and geographic factors (rural/urban, census division, state).Results
IRFs’ mean risk-standardized hospital readmission rate was 13.00%±0.77%. After controlling for organizational characteristics and practice patterns, we found substantial variation in IRFs' readmission rates: for-profit IRFs had significantly higher readmission rates than did not-for-profit IRFs (P<.001). We also found geographic variation: IRFs in the South Atlantic and South Central census regions had the highest hospital readmission rates than did IRFs in New England that had the lowest rates.Conclusions
Our findings point to variation in quality of care as measured by risk-standardized hospital readmission rates after IRF discharge. Thus, monitoring of readmission outcomes is important to encourage quality improvement in discharge care planning, care transitions, and follow-up. 相似文献2.
Laura Coots Daras Melvin J. Ingber Jessica Carichner Daniel Barch Anne Deutsch Laura M. Smith Alan Levitt Joel Andress 《Archives of physical medicine and rehabilitation》2018,99(6):1049-1059
Objective
To examine facility-level rates of all-cause, unplanned hospital readmissions for 30 days after discharge from inpatient rehabilitation facilities (IRFs).Design
Observational design.Setting
Inpatient rehabilitation facilities.Participants
Medicare fee-for-service beneficiaries (N=567,850 patient-stays).Interventions
Not applicable.Main Outcome Measures
The outcome is all-cause, unplanned hospital readmission rates for IRFs. We adapted previous risk-adjustment and statistical approaches used for acute care hospitals to develop a hierarchical logistic regression model that estimates a risk-standardized readmission rate for each IRF. The IRF risk-adjustment model takes into account patient demographic characteristics, hospital diagnoses and procedure codes, function at IRF admission, comorbidities, and prior hospital utilization. We presented national distributions of observed and risk-standardized readmission rates and estimated confidence intervals to make statistical comparisons relative to the national mean. We also analyzed the number of days from IRF discharge until hospital readmission.Results
The national observed hospital readmission rate by 30 days postdischarge from IRFs was 13.1%. The mean unadjusted readmission rate for IRFs was 12.4%±3.5%, and the mean risk-standardized readmission rate was 13.1%±0.8%. The C-statistic for our risk-adjustment model was .70. Nearly three-quarters of IRFs (73.4%) had readmission rates that were significantly different from the mean. The mean number of days to readmission was 13.0±8.6 days and varied by rehabilitation diagnosis.Conclusions
Our results demonstrate the ability to assess 30-day, all-cause hospital readmission rates postdischarge from IRFs and the ability to discriminate between IRFs with higher- and lower-than-average hospital readmission rates. 相似文献3.
Chih-Ying Li Amol Karmarkar Yu-Li Lin Yong-Fang Kuo Kenneth J. Ottenbacher James E. Graham 《Archives of physical medicine and rehabilitation》2018,99(3):598-602.e2
Objective
To investigate the effects of facility-level factors on 30-day unplanned risk-adjusted hospital readmission after discharge from inpatient rehabilitation facilities (IRFs).Design
Study using 100% Medicare claims data, covering 269,306 discharges from 1094 IRFs between October 2010 and September 2011.Setting
IRFs with at least 30 discharges.Participants
A total number of 1094 IRFs (N=269,306) serving Medicare fee-for-service beneficiaries.Interventions
Not applicable.Main Outcome Measures
Risk-standardized readmission rate (RSRR) for 30-day hospital readmission.Results
Profit status was the only provider-level IRF characteristic significantly associated with unplanned readmissions. For-profit IRFs had a significantly higher RSRR (13.26±0.51) than did nonprofit IRFs (13.15±0.47) (P<.001). After controlling for all other facility characteristics (except for accreditation status because of its collinearity with facility type), for-profit IRFs had a 0.1% point higher RSRR than did nonprofit IRFs, and census region was the only significant region-level characteristic, with the South showing the highest RSRR of all regions (type III test, P=.005 for both).Conclusions
Our findings support the inclusion of profit status on the IRF Compare website (a platform including IRF comparators to indicate quality of services). For-profit IRFs had a higher RSRR than did nonprofit IRFs for Medicare beneficiaries. The South had a higher RSRR than did other regions. The RSRR difference between for-profit and nonprofit IRFs could be due to the combined effects of organizational and regional factors. 相似文献4.
5.
Janet K. Freburger Dongmei Li Erin P. Fraher 《Archives of physical medicine and rehabilitation》2018,99(1):26-34.e5
Objectives
To determine whether receipt of therapy and number and timing of therapy visits decreased hospital readmission risk in stroke survivors discharged home.Design
Retrospective cohort analysis of Medicare claims (2010–2013).Setting
Acute care hospital and community.Participants
Patients hospitalized for stroke who were discharged home and survived the first 30 days (N=23,413; mean age ± SD, 77.6±7.5y).Interventions
Physical and occupational therapist use in the home and/or outpatient setting in the first 30 days after discharge (any use, number of visits, and days to first visit).Main Outcome Measures
Hospital readmission 30 to 60 days after discharge. Covariates included demographic characteristics, proxy variables for functional status, hospitalization characteristics, comorbidities, and prior health care use. Multivariate logistic regression analyses were conducted to examine the relation between therapist use and readmission.Results
During the first 30 days after discharge, 31% of patients saw a therapist in the home, 11% saw a therapist in an outpatient setting, and 59% did not see a therapist. Relative to patients who had no therapist contact, those who saw an outpatient therapist were less likely to be readmitted to the hospital (odds ratio, 0.73; 95% confidence interval, 0.59–0.90). Although the point estimates did not reach statistical significance, there was some suggestion that the greater the number of therapist visits in the home and the sooner the visits started, the lower the risk of hospital readmission.Conclusions
After controlling for observable demographic-, clinical-, and health-related differences, we found that individuals who received outpatient therapy in the first 30 days after discharge home after stroke were less likely to be readmitted to the hospital in the subsequent 30 days, relative to those who received no therapy. 相似文献6.
Background
Understanding risk factors associated with readmission after lower extremity amputation may indicate targets for reducing readmission.Objective
To evaluate factors associated with all-cause 30-day readmission after lower extremity amputation procedures.Design
Retrospective cohort study.Setting
Inpatient.Patients
A total of 2480 patients who had lower extremity amputations between 2008 and 2014 were selected from national electronic medical record database, Cerner Health Facts.Methods
Univariate analysis of demographics, diagnoses, postoperative medications, and laboratory results were examined. Multivariate logistic regression models were used to identify characteristics independently associated with readmission overall and by amputation location—above the knee (AKA) or below the knee (BKA).Main Outcome Measurement
Readmission within 30 days of discharge.Results
More than one half of patients (1403, 57%) underwent BKA and 1077 (43%) underwent AKA. Readmission within 30 days was 22% (24.1% BKA versus 19.4% AKA, P = .005). In multivariable logistic regression, factors associated with 30-day readmission after any amputation included BKA (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.15-1.74, P = .001), hypertension (OR 1.70, 95% CI 1.33-2.16), surgical-site infections (OR 1.44, 95% CI 1.02-2.04), heart failure (OR 1.39, 95% CI 1.10-1.75), discharge to a skilled nursing facility (OR 1.88, 95% CI 1.41-2.51), and emergency/urgent procedures (OR 1.32, 95% CI 1.04-1.67). At readmission, 13.3% of patients with a BKA required an AKA revision, and 21.3% had a diagnosis of surgical-site infection.Conclusions
Risk factors for readmission after any amputation included cardiac comorbidities, associated postoperative medications, and discharge to a skilled nursing facility. The finding that acute arterial embolism or thrombosis and a BKA during the index admission was highly associated with readmission, combined with the high rates of 30-day conversion to an AKA when readmitted, suggests these patients more often develop stump complications or may be undertreated during the initial hospitalization.Level of Evidence
III 相似文献7.
8.
9.
Paola Forti Fabiola Maioli Elisabetta Magni Letizia Ragazzoni Roberto Piperno Marco Zoli Maura Coveri Gaetano Procaccianti 《Archives of physical medicine and rehabilitation》2018,99(3):477-483
Objective
To investigate whether oldest-old age (≥85y) is an independent predictor of exclusion from stroke rehabilitation.Design
Retrospective cohort study.Setting
Stroke unit (SU) of a tertiary hospital.Participants
Elderly patients (N=1055; aged 65–74y, n=230; aged 75–84y, n=432; aged ≥85y, n=393) who, between 2009 and 2012, were admitted to the SU with acute stroke and evaluated by a multiprofessional team for access to rehabilitation. The study excluded patients for whom rehabilitation was unnecessary or inappropriate.Interventions
Not applicable.Main Outcome Measures
Access to an early mobilization (EM) protocol during SU stay and subsequent access to postacute rehabilitation after SU discharge. Analyses were adjusted for prestroke and stroke-related characteristics.Results
32.2% of patients were excluded from EM. Multivariable-adjusted odds ratios (ORs) of EM exclusion were 1.30 (95% confidence interval [CI], .76–2.21) for ages 75 to 84 years and 2.07 (95% CI, 1.19–3.59) for ages ≥85 years compared with ages 65 to 74 years. Of 656 patients admitted to EM and who, at SU discharge, had not yet fully recovered their prestroke functional status, 18.4% were excluded from postacute rehabilitation. For patients able to walk unassisted at SU discharge, the probability of exclusion did not change across age groups. For patients unable to walk unassisted at SU discharge, ORs of exclusion from postacute rehabilitation were 3.74 (95% CI, 1.26–11.13) for ages 75 to 84 years and 9.15 (95% CI, 3.05–27.46) for ages ≥85 years compared with ages 65 to 74 years.Conclusions
Oldest-old age is an independent predictor of exclusion from stroke rehabilitation. 相似文献10.
Cameron J.B. Cunningham Heather C. Finlayson William R. Henderson Russell J. O’Connor Andrew Travlos 《PM & R》2018,10(5):494-500
Background
Critical illness polyneuromyopathy (CIPNM) increasingly is recognized as a source of disability in patients requiring intensive care unit (ICU) admission. The prevalence and impact of CIPNM on patients in the rehabilitation setting has not been established.Objectives
To determine the proportion of at-risk rehabilitation inpatients with evidence of CIPNM and the functional sequelae of this disorder.Design
Prospective observational study.Setting
Tertiary academic rehabilitation hospital.Patients
Rehabilitation inpatients with a history of ICU admission for at least 72 hours.Methods
Electrodiagnostic studies were performed to evaluate for axonal neuropathy and/or myopathy in at least one upper and one lower limb.Main Outcome Measurements
The primary outcome was prevalence of CIPNM. Secondary outcomes included Functional Independence Measure (FIM) scores, rehabilitation length of stay (RLOS), and discharge disposition.Results
A total of 33 participants were enrolled; 70% had evidence of CIPNM. Admission FIM score, discharge FIM, FIM gain, and FIM efficiency were 64.1, 89.9, 25.5, and 0.31 in those with CIPNM versus 78.4, 94.6, 16.1, and 0.33 in those without CIPNM, respectively. Average RLOS was 123 days versus 76 days and discharge to home was 57% versus 90% in the CIPNM and non-CIPNM groups, respectively.Conclusions
CIPNM is very common in rehabilitation inpatients with a history of ICU admission. It was associated with a lower functional status at rehabilitation admission, but functional improvement was at a similar rate to those without CIPNM. Longer RLOS stay may be required to achieve the same functional level.Level of Evidence
III 相似文献11.
Poonam K. Pardasaney Anne Deutsch Jeniffer Iriondo-Perez Melvin J. Ingber Tara McMullen 《Archives of physical medicine and rehabilitation》2018,99(6):1035-1041
Objective
To describe the calculation and psychometric properties of the discharge self-care functional status quality measure implemented in the Centers for Medicare & Medicaid Services' (CMS) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program on October 1, 2016.Design
Medicare fee-for-service (FFS) patients from 38 IRFs that participated in the CMS Post-Acute Care Payment Reform Demonstration were included in this cohort study. Data came from the Continuity Assessment Record and Evaluation Item Set, IRF–Patient Assessment Instrument, and Medicare claims. For each patient, we calculated an expected discharge self-care score, risk-adjusted for demographic and baseline clinical characteristics. The performance score of each IRF equaled the percentage of patient stays where the observed discharge self-care score met or exceeded the expected score. We assessed the measure's discriminatory ability across IRFs and reliability.Setting
IRFs.Participants
Medicare FFS patients aged ≥21 years (N=4769).Interventions
Not applicable.Main Outcome Measures
Facility-level discharge self-care quality measure performance score.Results
A total of 4769 patient stays were included; 57% of stays were in women, and 12.1% were in patients aged <65 years. Stroke was the most common diagnosis (21.8%). The mean±SD performance score was 55.1%±16.6% (range, 25.8%–100%). About 54% of IRFs had scores significantly different from the percentage of stays that met or exceeded the expected discharge self-care score in the overall demonstration sample. The quality measure showed strong reliability, with intraclass correlation coefficients of .91.Conclusions
The discharge self-care quality measure showed strong discriminatory ability and reliability, representing an important initial step in evaluation of IRF self-care outcomes. A wide range in performance scores suggested a gap in quality of care across IRFs. Future work should include testing the measure with nationwide data from all IRFs. 相似文献12.
Suzanne R. O&#x;Brien Ning Zhang 《Archives of physical medicine and rehabilitation》2018,99(1):107-115
Objectives
To determine the association between therapy intensity and discharge outcomes for aged Medicare skilled nursing facilities (SNFs) fee-for-service beneficiaries and to determine the association between therapy intensity and time to community discharge.Design
Retrospective observational design.Setting
SNFs.Participants
Aged Medicare fee-for-service beneficiaries (N=311,338) in 3605 SNFs.Interventions
The total minutes of physical therapy, occupational therapy, and speech therapy per day were divided into intensity groups: high (≥60min); medium-high (45–<60min); medium-low (30–<45min); and low (<30min).Main Outcome Measures
Four discharge outcomes—community, hospitalization, permanent placement, and death—were examined using a multivariate competing hazards model. For those associated with community discharge, a Poisson multivariate model was used to determine whether length of stay differed by intensity.Results
High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95).Conclusions
High intensity therapy was associated with desirable discharge outcomes and may shorten SNF length of stay. Despite growing reimbursements to SNFs for rehabilitation services, there may be desirable benefits to beneficiaries who receive high intensity therapy. 相似文献13.
Alexander J. Bajorek Chloe Slocum Richard Goldstein Jacqueline Mix Paulette Niewczyk Colleen M. Ryan Carla Tierney Hendricks Ross Zafonte Jeffrey C. Schneider 《PM & R》2017,9(1):1-7
Background
A significant proportion of burn injury patients are admitted to inpatient rehabilitation facilities (IRFs). There is increasing interest in the use of functional variables, such as cognition, in predicting IRF outcomes. Cognitive impairment is an important cause of disability in the burn injury population, yet its relationship to IRF outcomes has not been studied.Objective
To assess how cognitive function affects rehabilitation outcomes in the burn injury population.Design
Retrospective study.Setting
Inpatient rehabilitation facilities in the United States.Participants
A total of 5347 adults admitted to an IRF with burn injury between 2002 and 2011.Methods or Interventions
Multivariable regression was used to model rehabilitation outcome measures, using the cognitive domain of the Functional Independence Measure (FIM) instrument as the independent variable and controlling for demographic, medical, and facility covariates.Main Outcome Measurements
FIM total gain, readmission to an acute care setting at any time during inpatient rehabilitation, readmission to an acute care setting in the first 3 days of IRF admission, rate of discharge to the community setting, and length of stay efficiency.Results
Cognitive FIM total at admission was a significant predictor of FIM total gain, length of stay efficiency, and acute readmission at 3 days (P < .05). Cognitive FIM total scores did not have an impact on acute care readmission rate or discharge to the community setting.Conclusions
Cognitive status may be an important predictor of rehabilitation outcomes in the burn injury population. Future work is needed to further examine the impact of specific cognitive interventions on rehabilitation outcomes in this population.Level of Evidence
II 相似文献14.
Anthony H. Lequerica Christian Lucca Nancy D. Chiaravalloti Irene Ward John D. Corrigan 《Archives of physical medicine and rehabilitation》2018,99(9):1811-1817
Objective
To test the feasibility and validity of an online version of an established interview designed to determine a lifetime history of traumatic brain injury (TBI).Design
Cross-sectional.Setting
General community.Participants
A volunteer sample of individuals (N= 265) from the general population across the United States.Interventions
Not applicable.Main Outcome Measure(s)
Online version of the Ohio State University Traumatic Brain Injury Identification Method, Rivermead Postconcussion Symptoms Questionnaire (RPQ), Patient-Reported Outcomes Measurement Information System Cognitive Concerns Scale.Results
The measure was completed by 89.4% of the sample with most participants completing the measure in <8 minutes. After controlling for age, sex, psychiatric history, drug or alcohol history, and history of developmental disability, worst TBI severity was significantly associated with scores on the RPQ, F(2,230)=4.56, P=.011, and having a TBI within the past 2 years was associated with higher scores on the cognitive factor subscale of the RPQ, F(1,75)=7.7, P=.007.Conclusions
The online administration of the Ohio State University Traumatic Brain Injury Identification Method appears to be feasible in the general population. Preliminary validity was demonstrated for the indices of worst TBI severity and time since most recent TBI. 相似文献15.
Sarah L. Martindale Erica L. Epstein Katherine H. Taber 《Archives of physical medicine and rehabilitation》2018,99(12):2485-2495
Objective
To characterize behavioral and health outcomes in veterans with traumatic brain injury (TBI) acquired in nondeployment and deployment settings.Design
Cross-sectional assessment evaluating TBI acquired during and outside of deployment, mental and behavioral health symptoms, and diagnoses.Setting
Veterans Affairs Medical Centers.Participants
Iraq and Afghanistan veterans who were deployed to a warzone (N=1399).Interventions
Not applicable.Main Outcome Measures
Comprehensive lifetime TBI interview, Structured Clinical Interview for DSM-IV Disorders, Combat Exposure Scale, and behavioral and health measures.Results
There was a main effect of deployment TBI on depressive symptoms, posttraumatic stress symptoms, poor sleep quality, substance use, and pain. Veterans with deployment TBI were also more likely to have a diagnosis of bipolar, major depressive, alcohol use, and posttraumatic stress disorders than those who did not have a deployment TBI.Conclusions
TBIs acquired during deployment are associated with different behavioral and health outcomes than TBI acquired in nondeployment environments. The presence of TBI during deployment is associated with poorer behavioral outcomes, as well as a greater lifetime prevalence of behavioral and health problems in contrast to veterans without deployment TBI. These results indicate that problems may persist chronically after a deployment TBI and should be considered when providing care for veterans. Veterans with deployment TBI may require treatment alterations to improve engagement and outcomes. 相似文献16.
Background
Depression and traumatic brain injury (TBI) substantially contribute to the U.S. health care burden. Depression is a known risk factor for prolonged recovery after TBI. However, the effect of depression treatment on health care utilization has yet to be studied.Objective
To examine whether an association exists between pharmacologic treatment of depression at the time of mild or concussive TBI and the number of subsequent clinician visits for persistent injury-related symptoms.Design
Retrospective medical record review.Setting
Tertiary care medical center.Participants
A total of 120 patients (mean age 45.6 years) with a history of depression who subsequently experienced a mild or concussive TBI were included.Methods
Individuals were identified with co-occurring diagnoses of depression and mild or concussive TBI by retrospective electronic medical record review. The diagnosis of depression must have preceded the diagnosis of TBI.Main Outcome
The number of clinician visits for postinjury symptoms were counted at 3, 6, and 12 months postinjury.Results
Clinician visits for persistent injury-related symptoms were significantly fewer at all 3 time points for the group treated for depression at time of injury.Conclusions
Depressed individuals who were pharmacologically treated for depression at the time of TBI had significantly fewer clinician visits for persistent postinjury symptoms than those not pharmacologically treated for depression at the time of injury. Routine depression screening in patients with a high risk for TBI may identify a mood disorder that could contribute to persistent symptoms if left untreated, with its effective management potentially reducing health-related costs.Level of Evidence
III 相似文献17.
18.
Jennifer H. Marwitz Adam P. Sima Jeffrey S. Kreutzer Laura E. Dreer Thomas F. Bergquist Ross Zafonte Douglas Johnson-Greene Elizabeth R. Felix 《Archives of physical medicine and rehabilitation》2018,99(2):264-271
Objectives
To evaluate (1) the trajectory of resilience during the first year after a moderate-severe traumatic brain injury (TBI); (2) factors associated with resilience at 3, 6, and 12 months postinjury; and (3) changing relationships over time between resilience and other factors.Design
Longitudinal analysis of an observational cohort.Setting
Five inpatient rehabilitation centers.Participants
Patients with TBI (N=195) enrolled in the resilience module of the TBI Model Systems study with data collected at 3-, 6-, and 12-month follow-up.Interventions
Not applicable.Main Outcome Measure
Connor-Davidson Resilience Scale.Results
Initially, resilience levels appeared to be stable during the first year postinjury. Individual growth curve models were used to examine resilience over time in relation to demographic, psychosocial, and injury characteristics. After adjusting for these characteristics, resilience actually declined over time. Higher levels of resilience were related to nonminority status, absence of preinjury substance abuse, lower anxiety and disability level, and greater life satisfaction.Conclusions
Resilience is a construct that is relevant to understanding brain injury outcomes and has potential value in planning clinical interventions. 相似文献19.
Janet K. Freburger Dongmei Li Anna M. Johnson Erin P. Fraher 《Archives of physical medicine and rehabilitation》2018,99(6):1077-1089.e7
Objective
To identify predictors of therapist use (any use, continuity of care, timing of care) in the acute care hospital and community (home or outpatient) for patients discharged home after stroke.Design
Retrospective cohort analysis of Medicare claims (2010–2013) linked to hospital-level and county-level data.Setting
Acute care hospital and community.Participants
Patients (N=23,413) who survived the first 30 days at home after being discharged from an acute care hospital after stroke.Interventions
Not applicable.Main Outcome Measures
Physical and occupational therapist use in acute care and community settings; continuity of care across the inpatient and home or the inpatient and outpatient settings; and early therapist use in the home or outpatient setting. Multivariate logistic and multinomial logistic regression analyses were conducted to identify hospital-level, county-level, and sociodemographic characteristics associated with therapist use, continuity, and timing, controlling for clinical characteristics.Results
Seventy-eight percent of patients received therapy in the acute care hospital, but only 40.8% received care in the first 30 days after discharge. Hospital nurse staffing was positively associated with inpatient and outpatient therapist use and continuity of care across settings. Primary care provider supply was associated with inpatient and outpatient therapist use, continuity of care, and early therapist care in the home and outpatient setting. Therapist supply was associated with continuity of care and early therapist use in the community. There was consistent evidence of sociodemographic disparities in therapist use.Conclusions
Therapist use after stroke varies in the community and for specific sociodemographic subgroups and may be underused. Inpatient nurse staffing levels and primary care provider supply were the most consistent predictors of therapist use, continuity of care, and early therapist use. 相似文献20.
Andrea R.S. Huebner Amy Cassedy Tanya M. Brown H. Gerry Taylor Terry Stancin Michael W. Kirkwood Shari L. Wade 《PM & R》2018,10(5):462-471