Functional outcomes of cancer patients in an acute inpatient setting at King Fahad Medical City

[Purpose] Cancer survivors have functional impairments that adversely affect patients’ quality of life (QoL). Acute rehabilitation helps to reduce disability and improves QoL in cancer survivors. This study investigated the potential improvement in mobility levels and QoL of cancer patients during acute inpatient physical therapy (PT) from admission to discharge. [Participants and Methods] This was a cross-sectional study conducted at King Fahad Medical City, Riyadh. Acute inpatient cancer survivors (n=99) were assessed at their admission and discharge. The primary outcome measure was the AM-PAC “6-Clicks” Basic Mobility, Functional Assessment of Cancer Therapy-General (FACT-G7) and the Karnofsky Performance Scale (KPS). [Results] Overall, 82.8% of cancer patients were discharged home. There were significant improvements in all the three outcome measures for all the patients from admission to discharge. Patients who were discharged home exhibited significantly better improvement in all the scales. Factors that predicted discharge mobility and quality of life were discharge destination, number of PT sessions, and baseline admission scores. [Conclusion] The study found that acute inpatient cancer rehabilitation helps to improve mobility and QoL. Rehabilitation programs available in Saudi Arabia are limited, and it is important to integrate the cancer rehabilitation model into the oncology services.     

Functional outcomes and quality of life in patients with brain tumors: a preliminary report.

OBJECTIVES: To determine the relationship between functional outcome and quality of life (QOL) in patients with brain tumors receiving inpatient rehabilitation, and to assess the sensitivity of 4 assessment tools in measuring changes in that population. DESIGN: Prospective study using longitudinal data collected from consecutively admitted patients. SETTING: Acute inpatient rehabilitation unit. PARTICIPANTS: Ten patients with primary brain tumors admitted to an acute inpatient rehabilitation unit. INTERVENTIONS: Patients participated in an inpatient interdisciplinary rehabilitation program that used the following disciplines: occupational therapy, rehabilitation therapy, recreational therapy, speech therapy, physical therapy, rehabilitation nursing and case management. MAIN OUTCOME MEASURES: The FIM instrument, Disability Rating Scale (DRS), Karnofsky Performance Status Scale (KPS), Functional Assessment of Cancer Therapy-Brain (FACT-BR). RESULTS: Improvement in total functional outcome was indicated by all 3 functional measures (FIM: F = 46.84, p < .05; DRS: F = 19.25, p < .05; KPS: F = 10.11, p < .05). Significant improvements were found between admission and discharge scores for the FIM and DRS. The KPS revealed significant improvement between admission and 3-month follow-up scores. All admission and discharge functional scales (FIM, DRS, KPS) correlated significantly with each other. No significant change was noted in the FACT-BR between admission and discharge scores, but FACT-BR scores did improve at 1- and 3-months postdischarge relative to admission. The FIM, KPS, and DRS did not show significant correlation with the FACT-BR. Ninety percent of patients were initially discharged to a home environment. CONCLUSION: Although patients make functional gains during and after inpatient rehabilitation, gains in QOL are not significant until 1 month postdischarge. QOL does not appear to correlate well with functional outcomes. Further, the KPS is less sensitive than the FIM and DRS in detecting change in functional status.     

Predicting survival with the Palliative Performance Scale in a minority-serving hospice and palliative care program

Palliative Performance Scale (PPS) scores have shown potential for prognosticating survival in Caucasian samples, but have not been studied for prognostic value in cancer patients from minority groups. Using data obtained from a retrospective chart audit of 492 cancer patients admitted over an 18-month period to a minority-serving home-based hospice and palliative care program, we examined the relationship between PPS scores and length of survival (survival days). Patients with PPS scores of 10% to 30% had fewer survival days than those with scores of 40% and those with scores of 50% to 100% (median=6, 19, and 34 days, respectively; F=25.02, P<0.001). A PPS score of 40% serves as a reliable inclusion criterion for a study requiring two weeks for completion, whereas 50% to 100% is required for a three-week study. Findings from a predominantly minority sample are similar to those from predominantly Caucasian samples.     

Hospice family caregivers’ quality of life

Aims and objectives. To study quality of life (QOL) and its important correlates among family caregivers of terminally ill patients receiving in‐home hospice care. Background. Caregiver QOL has been identified as a core outcome variable in studies of dying patients and their families, but few studies have assessed QOL among caregivers of patients with terminal illness, particularly those in hospice care. Design. For this cross‐sectional correlational study, 60 caregivers were recruited from two local in‐home hospice programmes in the Midwestern United States. Methods. Self‐report data were provided by caregivers using the Caregiver Quality of Life Index – Cancer, Spiritual Well‐Being Scale, American Pain Society Patient Outcomes Questionnaire, Eastern Cooperative Oncology Group Performance Status Rating and Medical Outcome Study Social Support Survey to measure their QOL, spirituality, health status and social support. Results. Caregivers’ educational status, physical health status, spirituality and qualitative and quantitative social support, as a set, explained 42% of the variance in their QOL. Caregivers with higher education, better physical health status, greater spirituality and more qualitative and quantitative social support, had a significantly better QOL. Conclusions. QOL for this sample of hospice caregivers was significantly predicted only by physical health status and spirituality, likely because of collinearity among the independent variables. Additional research is needed to explore the factors that sustain or promote caregivers’ QOL over time. Relevance to clinical practice. In the delivery of hospice services, the family caregiver is both a vital member of the health care team and a recipient of care. Health care providers should therefore pay more attention to the health status and spirituality of major caregivers, thus helping them maintain and improve their QOL.     

Characteristics and functional outcomes of elderly rehabilitation patients

Sixty-seven patients admitted to a geriatric rehabilitation unit were assessed from admission to discharge by their primary nurses for functional outcomes and demographic characteristics. The patients had a mean age of 78.1 years and a mean length of stay of 58.6 days. Patients with an admitting diagnosis of a recent leg amputation were discharged more independent in ADL than those admitted following a recent stroke. Sixty-nine percent of the patients were discharged home. Patients sent home were significantly more independent in ADL than those who did not return home. Almost all patients continued to improve in physical ADL and felt they were managing adequately or well in the home setting.     

FIM score, FIM efficiency, and discharge disposition following inpatient stroke rehabilitation.

The Functional Independence Measure (FIM) is a widely accepted scale used to measure the functional abilities of patients undergoing rehabilitation. Scores at the extremes of this scale correlate with discharge disposition, while midrange scores are less well understood. This study evaluated the rate of FIM change with time ("efficiency"), admission and discharge FIM scores, and discharge disposition of 748 patients who underwent stroke inpatient rehabilitation. Patients with low scores at admission or discharge were likely to be discharged to a facility (63% and 78%, respectively), and those with high scores at admission or discharge almost always returned home (88% and 81%, respectively). Those with midrange scores at admission were more likely to return home (62%) than those with similar scores at discharge (33%). Greater FIM efficiency scores were associated with home discharge. Findings provide insight into discharge planning for stroke patients and indicate the need for more detailed evaluation of the midrange group.     

The effect of Medicare's Prospective Payment System on patient satisfaction: an illustration with four rehabilitation hospitals

OBJECTIVE: To examine the impact of Medicare's Prospective Payment System (PPS) on patient satisfaction at four inpatient rehabilitation hospitals. DESIGN: Prospective study using a satisfaction survey to examine the effects of Medicare's PPS for rehabilitation hospitals. Surveys were conducted at four affiliated rehabilitation hospitals in the Midwest. RESULTS: Patient characteristics varied only slightly pre- to post-PPS, and several characteristics were related to overall satisfaction, including motor functional gain, discharge to home, and respondent (patient or proxy). A 12-point increase on a 12-item motor function scale resulted in 1.13 greater odds (95% CI: 1.04, 1.24) of reporting excellent satisfaction. Patient respondents were 1.27 times more likely (95% CI: 1.07, 1.50) than proxies to report excellent satisfaction, and patients discharged home were 1.65 times more likely (95% CI: 1.31, 2.07) to report excellent satisfaction than patients discharged elsewhere. We found an increase in observed satisfaction from 60.3 to 63.4% (P < 0.05) after PPS implementation, despite a decrease in motor FIM gain. CONCLUSIONS: Patient characteristics such as motor FIM gain, discharge status, and respondent type were significantly associated, although only slightly, with patient satisfaction in inpatient rehabilitation. Percentage of excellent satisfaction improved at these four facilities after PPS implementation, despite declines in motor FIM gain. The improvement may be the result of numerous ongoing quality-improvement initiatives directed at improving patient satisfaction at these facilities.     

Outcome of malignant spinal cord compression at a cancer center: implications for palliative care services

One hundred sixty-six patients presented to a cancer center with malignant spinal cord compression (SCC) proven by magnetic resonance imaging (MRI). The majority of patients (92%) were treated with radiotherapy. Changes in functional capability over time were assessed using performance (PS) and neurological status (NS). Over the course of treatment, there was no significant change in PS or NS. The median survival from confirmation of SCC was 82 days (range 1-1349 days). Survival was significantly better for those presenting with good functional status. One hundred thirteen patients (68%) were discharged from hospital; 88 (78%) were discharged home, 11% were sent to another hospital, 4% were transferred to a rehabilitation unit, and 5% went to a hospice. Fifty-three patients (32%) died before discharge. The confirmation that PS and NS have prognostic significance in the functional outcome of patients with SCC may prove helpful in decisions regarding care planning for individual patients with SCC who are discharged from hospital.     

Using the Functional Independence Measure Instrument to Predict Stroke Rehabilitation Outcomes

The purpose of the study described in this article was to identify the factors that have an impact on stroke patients' discharge destination. Two hundred thirty-four stroke patients admitted to a rehabilitation facility over a 2-year period were examined. Functional Independence Measure (FIM?) data were used to examine functional status, demographic characteristics, and the discharge destination of patients admitted to the facility's program. The relationship between patients' FIM scores at discharge and their discharge locations was analyzed using the chi-square statistic. The results showed that a discharge FIM score of 80 or above had a high specificity and sensitivity with patients' discharge to their homes. In addition, outliers were analyzed, and the results showed that family members of only 20% of the patients who were discharged to their homes were working, in contrast to 65% of the family members of patients who were discharged to a skilled nursing facility. The availability of a nonworking family member and the ability of a family to provide supervision and physical assistance were more likely to be factors related to discharge of patients to their homes. Ninety percent of the families of patients discharged to their homes were able to provide supervision and to provide physical assistance. Thus, both functional status and social factors, such as family availability and support, are critical elements in predicting the discharge destination of this patient population.     

Are we selecting the right patients for stroke rehabilitation in nursing homes?

OBJECTIVE: To examine the effect of stroke rehabilitation in the nursing home on community discharge rates and functional status among patients stratified by propensity to receive rehabilitation. DESIGN: Retrospective cohort. SETTING: Medicaid-certified nursing homes (N=945) in Ohio. PARTICIPANTS: Patients with stroke (N=2013) admitted to an Ohio nursing home. INTERVENTION: Rehabilitation therapy services. MAIN OUTCOME MEASURES: The propensity to receive rehabilitation, used to adjust for selection bias, was calculated for each patient by using a logistic regression model. Community discharge and change in functional status, measured by using a crosswalk to the FIM instrument, were determined 3 months after admission. RESULTS: By 3 months after admission, 36.9% of the patients were discharged to the community, 16.6% had died, and 46.5% remained in the nursing home. The overall effect of rehabilitation on community discharge (relative risk [RR]=1.58; 95% confidence interval [CI], 1.33-1.85) was not homogeneous across subgroups stratified by propensity to receive rehabilitation. Patients less likely to receive rehabilitation, as measured by a lower propensity score, had a significant benefit in terms of community discharge (RR=1.65; 95% CI, 1.35-1.97), but those more likely to receive services did not (RR=1.21; 95% CI, 0.87-1.56). Among long-term nursing home residents, rehabilitation services were not associated with improved functional status. CONCLUSIONS: With respect to community discharge, patients who were less likely to receive rehabilitation therapy appear to receive greater benefit from rehabilitation services than those who were more likely to receive rehabilitation. This finding raises concerns about current selection practices for rehabilitation services. Research is needed to identify the patients most likely to benefit, especially in the present fiscally constrained reimbursement environment.     

Development of a care pathway for babies being discharged from a level 3 neonatal intensive care unit to a community setting for end-of-life care

The development of a care pathway for babies being discharged from a level 3 neonatal intensive care unit (NICU) to a community setting for end-of-life care is discussed. The development of the care pathway was a collaborative project between a level 3 NICU, the local children's hospice and the local primary care trust. The development of the care pathway enables parents to decide where they want their babies to be cared for: NICU, hospice or home care. It enables staff to rapidly refer babies and their families to hospice or community care and provides staff with the support they also need during this difficult time.     

Prediction of Survival Time in Advanced Cancer: A Prognostic Scale for Chinese Patients

This study reports the development of a simple Chinese Prognostic Scale (ChPS) for predicting survival in advanced cancer patients. Data relating to 1,019 advanced cancer patients referred to a palliative home care service were retrospectively analyzed. The records were divided into two sets using stratified random sampling: 80% as a “training set” for developing the scale and 20% as a “testing set” for validating it. Demographic data, symptoms/signs, Karnofsky Performance Status (KPS), quality of life (QOL), and survival time were statistically analyzed to create the scale. In the training set, a total of 10 prognostic factors were determined: weight loss, nausea, dysphagia, dyspnea, edema, cachexia, dehydration, gender, KPS, and QOL. The ChPS score was calculated for each case by summing the partial scores of prognostic factors, ranging from 0 (no altered variables) to 124 (maximal altered variables). The score for a cutoff point of three months' survival was 28 (95% confidence interval: 26.6, 28.9). When scores were more than 28, survival appeared to be usually less than three months. The accuracy rate was 69.4% in the training set and 65.4% in the testing set. In conclusion, it is possible with this prognostic scale to guide physicians in predicting more accurately the likely survival time of Chinese cancer patients, and to help policy makers in establishing appropriate referral for hospice care.     

CHOICES: promoting early access to end-of-life care through home-based transition management

CHOICES is a comprehensive home-based care coordination program designed to bridge the gap between home health and hospice for Medicare + Choice enrollees with advanced chronic illness in San Francisco's East Bay region. Key elements of the program include physician education, enrollment of patients with high disease burden who may not be terminally ill, co-management of care with the primary physician, and an advanced practice clinical team that provides comprehensive in-home assessments, a flexible mix of life-prolonging and palliative care that evolves with disease progression, focused education and advance planning, and caregiver support. During a 42-month demonstration, 208 patients were enrolled in the program. Eighty percent had a non-cancer diagnosis; 40% were people of color. After an 8-month follow-up, 44% of the study cohort had died in the program or after transfer to hospice, 51% had been discharged, and 5% remained active. Median length of stay for decedents was 260 days. Preliminary evidence supports the program's feasibility and acceptability to patients, families, physicians, and agency partners. However, the uncertain future of Medicare + Choice and of managed care may jeopardize the program's sustainability. Policymakers and taxpayers will need to determine how to care for the growing number of chronically ill elderly who wish to remain at home as illness advances. The care needs of these patients and their families may overwhelm a health system organized around hospital treatment of acute illness.     

Identification of Functional Limitations and Discharge Destination in Patients With COVID-19

ObjectivesThe objectives of this study were to identify functional limitations in patients with coronavirus 2019 (COVID-19) admitted to acute care hospitals; to evaluate functional limitations by demographic, medical, and encounter characteristics; and to examine functional limitations in relation to discharge destination.Designand Setting:This is a cross-sectional, retrospective study of adult patients with COVID-19 who were discharged from 2 different types of hospitals (academic medical center and a community hospital) within 1 health care system from January 1 to April 30, 2020.ParticipantsPatients were identified from the Cedars-Sinai COVID-19 data registry who had a new-onset positive test for severe acute respiratory syndrome coronavirus 2. A total of 273 patients were identified, which included 230 patients who were discharged alive and 43 patients who died and were excluded from the study sample.InterventionsNot applicable.Main Outcome MeasuresFunctional limitations in patients with COVID-19 in acute care hospitals and the predictors for discharge disposition.ResultsA total of 230 records were analyzed including demographic, encounter, medical, and functional variables. In a propensity score–matched cohort based on age and comorbidity, 88.2% had functional physical health deficits, 72.5% had functional mental health deficits, and 17.6% experienced sensory deficits. In the matched cohort, individuals discharged to an institution experienced greater physical (62.7% vs 25.5%, P<.001) and mental health (49.0% vs 23.5%, P=.006) deficits than patients discharged home. Marital status (odds ratio, 3.17; P=.011) and physical function deficits (odds ratio, 3.63; P=.025) were associated with an increase odds ratio of discharge to an institution.ConclusionsThis research highlights that functional status is a strong predictor for discharge destination to an institution for patients with COVID-19. Patients who were older, in the acute care hospital longer, and with comorbidities were more likely to be discharged to an institution. Rehabilitation is a significant aspect of the health care system for these vulnerable patients. The challenges of adjusting the role of rehabilitation providers and systems during the pandemic needs further exploration. Moreover, additional research is needed to look more closely at the many facets and timing of functional status needs, to shed light in use of interdisciplinary rehabilitation services, and to guide providers and health care systems in facilitating optimal recovery and patient outcomes.     

Utilization of inpatient rehabilitation services among traumatically injured children discharged from pediatric trauma centers

This paper investigates factors that predict whether or not children treated at pediatric trauma centers are discharged to inpatient rehabilitation. Variables pertaining to functional impairments, injury severity and institutional factors explained over 45% of the variance in discharge disposition. It appears that a good deal of rationality pervades the decision as to whether patients are discharged to home or to rehabilitation. The extent of functional impairments and the severity of injury are closely related to these discharge decisions, as one would expect in a well-functioning discharge planning system. However, there are indications that discharge decisions are also affected by factors that ideally should be external to the decision process. Chief among these is whether or not the trauma center has an onsite rehabilitation unit. Patients treated at trauma centers that have onsite rehabilitation units are significantly more likely to be discharged to rehabilitation than patients treated at trauma centers without onsite rehabilitation.     

Cognitive Dependence in Physically Independent Patients at Discharge From Acute Traumatic Brain Injury Rehabilitation

ObjectiveTo determine the incidence of cognitive dependence in adults who are physically independent at discharge from acute traumatic brain injury (TBI) rehabilitation.DesignAnalysis of historical clinical and demographic data obtained from inpatient stay.SettingInpatient rehabilitation unit in a large, metropolitan university hospital.ParticipantsAdult inpatients with moderate to severe TBI (N=226) who were physically independent at discharge from acute rehabilitation.InterventionsNot applicable.Main Outcome MeasuresFIM Motor and Cognitive subscales, discharge destination, and care plan.ResultsApproximately 69% (n=155) of the physically independent inpatients were cognitively dependent at discharge from acute rehabilitation, with the highest proportions of dependence found in the domains of problem solving and memory. Most (82.6%; n=128) of these physically independent, yet cognitively dependent, patients were discharged home. Of those discharged home, 82% (n=105) were discharged to the care of family members, and 11% (n=15) were discharged home alone. Patients from racial and ethnic minority backgrounds were significantly more likely than White patients to be discharged while cognitively dependent.ConclusionsThe majority of physically independent patients with TBI were cognitively dependent at the time of discharge from acute inpatient rehabilitation. Further research is needed to understand the effect of cognitive dependence on caregiver stress and strain and the disproportionate burden on racial and ethnic minority patients and families. Given the potential functional and safety limitations imposed by cognitive deficits, health care policy and practice should facilitate delivery of cognitive rehabilitation services in acute TBI rehabilitation.     

A cost-effectiveness analysis of home care and community-based nursing homes for stroke patients and their families

A prospective study designed for 336 hospitalized patients with stroke and their families, who were followed from the discharge day to the third month after being discharged, was carried out in order to compare the costs and effectiveness of home care with the community-based nursing homes for stroke patients with different physical function disabilities in terms of ADL scores and their families. The ADL scores of the patients with severe physical function disability did not improve with or without long-term care; however, the patients with moderate physical function disability were significantly improved at the end of the third month, even without interventions from long-term care. The family costs of the patients in nursing homes were substantially lower than the costs for the patients who stayed at home, and the relationship of the family costs of the patients cared for in their own homes was proportional to the patients'physical function status. The labour input from family caregiving accounted for at least 60% of the total family costs of the patients who stayed at home, and the paid for long-term care services accounted for at least 60% of total family costs when the patients stayed in nursing homes. The multiple linear regression demonstrated that the degree of caregiving from families was a predictor of the amount of the costs families incurred for patients with severe physical function disability; as a result the ADL scored on discharge significantly influenced the average total family costs for the patients cared for in their own homes.     

Outcomes of inpatient rehabilitation for older adults with debility

OBJECTIVE: To determine the functional outcomes and discharge setting of older patients receiving inpatient rehabilitation for debility (ICD-9-CM, 799.3). DESIGN: Retrospective cohort study of 63,171 individuals >or= 65 yrs old with a primary (23%) or comorbid (77%) debility diagnosis from the Uniform Data System for Medical Rehabilitation (UDSMR) database for 2002-2003. RESULTS: Patients with a primary diagnosis of debility (PDD) had a lower mean rehabilitation efficiency score (functional change per day) as compared with the rest of the subjects (1.7 vs. 1.9, P<0.001), including those with a Centers for Medicare & Medicaid Services (CMS) 75% rule primary diagnosis (1.8, P<0.001). The PDD group was less likely to be discharged home (68% vs. 73%, P<0.001) and more likely to be discharged to a hospital (13% vs. 11%, P<0.001). CONCLUSIONS: From a clinical perspective, the functional recovery of older patients with debility is essentially the same, regardless of whether this is a primary or comorbid diagnosis. Their functional improvement is also comparable with that reported for other CMS 75% rule diagnoses, although the debility patients are less likely to be discharged home. More than 10% of these patients were discharged to acute hospital settings. Further research is warranted to identify the most appropriate rehabilitation setting for patients with debility.