Emulating 3 Clinical Trials That Compare Stroke Rehabilitation at Inpatient Rehabilitation Facilities With Skilled Nursing Facilities

ObjectiveTo inform the design of a potential future randomized controlled trial (RCT), we emulated 3 trials where patient-level outcomes were compared after stroke rehabilitation at inpatient rehabilitation facilities (IRFs) with skilled nursing facilities (SNFs).DesignTrials were emulated using a 1:1 matched propensity score analysis. The 3 trials differed because facilities from rehabilitation networks with different case volumes were compared. Rehabilitation network case volumes were based on the number of patients with stroke that each hospital discharged to each specific IRF or SNF. Trial 1 included 60,529 patients from all networks, trial 2 included 34,444 patients from networks with medium and large case volumes (ie, ≥5 patients), and trial 3 included 19,161 patients from networks with large case volumes (ie, ≥10 patients). The E values were calculated to estimate the minimum strength that an unmeasured confounder would need to be to nullify the results.SettingA national sample of IRFs and SNFs from across the United States.ParticipantsFee-for-service Medicare patients with acute stroke who received IRF or SNF based rehabilitation.InterventionsNot applicable.Main Outcome MeasuresOne-year successful community discharge (home for >30 consecutive days) and all-cause mortality.ResultsOverall, 29,500, 15,156, and 7450 patients were matched for trials 1, 2, and 3. For 1-year successful community discharge, absolute risk differences for IRF patients were 0.21 (95% CI, 0.20-0.22), 0.17 (95% CI, 0.16-0.19), and 0.12 (95% CI, 0.10-0.14) in trials 1, 2, and 3, respectively. For 1-year all-cause mortality, corresponding risk differences were ?0.11 (95% CI, ?0.12 to ?0.11), ?0.11 (95% CI, ?0.12 to ?0.09), and ?0.08 (95% CI, ?0.10 to ?0.06). The E values indicated that a moderately sized unmeasured confounder, with a relative risk of 1.6-2.0 would nullify differences in successful community discharge.ConclusionsIRF patients had superior outcomes, but differences were attenuated when IRFs and SNFs from larger rehabilitation networks were compared. The vulnerability of the findings to unmeasured confounding supports the need for an RCT.     

Joint Replacement Rehabilitation Outcomes on Discharge From Skilled Nursing Facilities and Inpatient Rehabilitation Facilities

DeJong G, Horn SD, Smout RJ, Tian W, Putman K, Gassaway J. Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities.

Objective

To compare functional outcomes at discharge across postacute settings.

Design

Prospective observational cohort study.

Setting

Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States.

Participants

Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751).

Interventions

None; examination of existing practice patterns.

Main Outcome Measure

FIM discharge motor score.

Results

Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome.

Conclusions

As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes.     

Characterizing Rehabilitation Services for Patients With Knee and Hip Replacement in Skilled Nursing Facilities and Inpatient Rehabilitation Facilities

DeJong G, Hsieh C-H, Gassaway J, Horn SD, Smout RJ, Putman K, James R, Brown M, Newman EM, Foley MP. Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities.

Objective

To characterize rehabilitation services for patients with knee and hip replacement in 3 types of postacute facilities in the U.S.

Design

Multi-site prospective observational cohort study.

Setting

Eight freestanding skilled nursing facilities (SNFs), 1 hospital-based SNF, and 11 inpatient rehabilitation facilities (IRFs).

Participants

Patients (N=2158) with knee or hip replacement.

Interventions

No new interventions.

Main Outcome Measures

Length of stay (LOS), amount and intensity of physical therapy (PT) and occupational therapy (OT), types of therapy activities.

Results

Average LOS was about 15 days for freestanding SNF patients, and 9 to 10 days for hospital-based SNF and IRF patients. Freestanding SNFs and IRFs provide about the same number of hours of PT and OT; the hospital-based SNF provided 27% fewer hours. Freestanding SNFs and the hospital-based SNF provided fewer hours a day than did IRFs. Joint replacement patients across all 3 types of facilities spent, on average, 70% to 75% of their PT time in just 2 activities—exercise and gait and spent 56% to 66% of their OT time in 3 activities—exercise, functional mobility, and dressing lower body.

Conclusions

Both freestanding SNFs and IRFs provided similar amounts of PT with a similar emphasis on exercise and gait activities. IRFs, however, provided more OT than freestanding SNFs. IRFs had shorter LOSs and more intensive therapy services than freestanding SNFs. Study freestanding SNFs exhibited greater variation in LOS and intensity of therapy than IRFs.     

Long-Term Outcomes of Joint Replacement Rehabilitation Patients Discharged From Skilled Nursing and Inpatient Rehabilitation Facilities

DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Hsieh C-H, Gassaway J, Smith P. Long-term outcomes of joint replacement rehabilitation patients discharged from skilled nursing and inpatient rehabilitation facilities.

Objective

To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF).

Design

Postdischarge follow-up interview study at 7.5 months after admission.

Setting

Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs.

Participants

Patients (N=856): 561 with knee replacement and 295 with hip replacement.

Interventions

None.

Main Outcome Measures

FIM and Short-Form 12-Item Health Survey (SF-12).

Results

Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12–related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes.

Conclusions

At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes.     

Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries Discharged Home After a Stroke: Findings From the COMPASS Trial

ObjectivesTo examine the effect of a comprehensive transitional care model on the use of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke.DesignCluster randomized pragmatic trialSettingForty-one acute care hospitals in North Carolina.Participants2262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (SD) age of 74.9 (10.2) years and a mean ± SD National Institutes of Health stroke scale score of 2.3 (3.7).InterventionComprehensive transitional care model (COMPASS-TC), which consisted of a 2-day follow-up phone call from the postacute care coordinator and 14-day in-person visit with the postacute care coordinator and advanced practice provider.Main Outcome MeasuresTime to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission.ResultsOnly 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (hazard ratio, 1.20, with a range of 0.95-1.52) compared to usual care. This estimate was robust to additional covariate adjustment (hazard ratio, 1.23) (0.93-1.64). Both clinical and non-clinical factors (ie, insurance, geography) were predictors of SNF/IRF use.ConclusionsCOMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.     

Use of Rehabilitation and Other Health Care Services by Patients With Joint Replacement After Discharge From Skilled Nursing and Inpatient Rehabilitation Facilities

DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Smith P, Gassaway J, DaVanzo JE. Use of rehabilitation and other health care services by patients with joint replacement after discharge from skilled nursing and inpatient rehabilitation facilities.

Objective

To compare use of rehabilitation and other health services among patients with knee and hip replacement after discharge from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF).

Design

Follow-up interview study at 7.5 months after discharge.

Setting

Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs from across the United States.

Participants

Patients (N=856): patients with knee replacement (n=561) and patients with hip replacement (n=295).

Interventions

No interventions.

Main Outcome Measures

Number of home and outpatient therapy visits, physician visits, emergency room visits, rehospitalizations, and medical complications.

Results

After discharge from postacute care, the vast majority of patients received home rehabilitation, outpatient rehabilitation, or both. Patients with knee replacement received an average of 19 home and/or outpatient rehabilitation visits; patients with hip replacement received almost 15 visits. There were no statistically significant differences in rates of emergency room use and rehospitalization except that patients with hip replacement discharged from IRFs had higher rates of rehospitalization than those discharged from freestanding SNFs (15.8% vs 3.1%). Multivariate analyses did not find any SNF/IRF effects.

Conclusions

Patients with joint replacement from both SNFs and IRFs receive considerable amounts of follow-up rehabilitation care. Study uncovered no setting effects related to rehospitalization or medical complications. Looking only at care rendered in the initial postacute setting provides an incomplete picture of all care received and how it may affect follow-up outcomes.     

Change in Self-Care Quality Measure for Inpatient Rehabilitation Facilities: Exclusion Criteria and Risk-Adjustment Model

ObjectiveTo describe the exclusion criteria and risk-adjustment model developed for the quality measure Change in Self-Care. The exclusion criteria and risk adjustment model are used to calculate Change in Self-Care scores, allowing scores to be compared across inpatient rehabilitation facilities (IRFs).DesignThis national cohort study examined admission demographic and clinical factors associated with IRF patients’ self-care change scores using standardized self-care data for Medicare patients discharged in calendar year 2017.SettingA total of 1129 IRFs in the United States.ParticipantsA total of 493,209 (N=493,209) Medicare Fee-for-Service and Medicare Advantage IRF patient staysInterventionsNot applicable.Main Outcome MeasuresSelf-care change scores using admission and discharge standardized assessment data elements from the Inpatient Rehabilitation Facility–Patient Assessment Instrument.ResultsApproximately 53% of patients were female, and 67% were between 65 and 84 years old. The final risk-adjustment model contained 93 clinically relevant risk adjusters and explained 23.1% of variance in self-care change scores. Risk adjusters that had the greatest effect on change scores and included IRF primary diagnosis group (ie, binary risk adjusters representing 13 diagnoses), prior self-care functioning, and age older than 90 years. When split by deciles of expected scores, the ratio of the average expected and observed change scores was within 2% of 1.0 across 8 groups and within 8% at the extremes, showing good predictive accuracy.ConclusionsThe risk adjustment model quantifies the relationship between IRF patients’ demographic and clinical characteristics and their self-care score changes. The exclusion criteria and model are used to risk-adjust the IRF Change in Self-Care quality measure.     

Profile of Patients at Admission into an Inpatient Stroke Rehabilitation Programme: Cardiorespiratory Fitness and Functional Characteristics

Purpose:

The purposes of this study were to characterize the cardiorespiratory capacity of individuals on admission to inpatient rehabilitation following stroke and to examine the relationship between measures of cardiorespiratory capacity and standard indices of neurological deficit and functional status.

Methods:

We recruited 45 patients within the first 10 days of admission to rehabilitation. We performed measures of aerobic fitness (VO₂peak), functional status (Functional Independence Measure [FIM] and Clinical Outcomes Variable Score [COVS]), and neurological deficit (National Institutes of Health Stroke Scale [NIHSS] and Chedoke-McMaster Stroke Assessment scale [CMSA]).

Results:

Nineteen women and 26 men with a mean (SD) age of 65.2 (14.5) years were admitted to rehabilitation 16.2 (11.9) (minimum 3, maximum 62) days post-stroke. Average VO₂peak was less than half the value expected in age-matched healthy individuals at 11.1 (3.1) ml/kg/min. The associations between VO₂peak and FIM, NIHSS, and COVS were weak (r = 0.25, -0.12, and 0.26 respectively, p = 0.12, 0.46, and 0.10 respectively). There were no differences in VO₂peak in higher-functioning individuals with CMSA leg scores of 5 and 6 compared to lower-functioning individuals with scores of 3 and 4 (p = 0.30).

Conclusion:

Cardiorespiratory capacity is extremely low in individuals during the first 3 months after stroke. Alternative measures of functional or clinical status do not adequately reflect this cardiorespiratory state; thus, routine measurement of cardiorespiratory capacity should be considered, along with a risk-factor profile.     

Change in Mobility Quality Measure for Inpatient Rehabilitation Facilities: Exclusion Criteria and the Risk Adjustment Model

ObjectiveTo describe the exclusion criteria and updated risk adjustment model developed for the Change in Mobility quality measure in the inpatient rehabilitation facility (IRF) quality reporting program. Facility-level quality measures focused on patient outcomes usually require risk adjustment to account for varied admission characteristics of patients across facilities.DesignThis cohort study analyzed admission demographic and clinical factors associated with mobility change scores using the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data for Medicare patients discharged from IRFs in calendar year 2017.SettingA total of 1129 IRFs in the United States.ParticipantsA total of 493,209 (N=493, 209) Medicare fee-for-service and Medicare Advantage IRF patient stays discharged in calendar year 2017.InterventionsNot applicable.Main Outcome MeasuresMobility change scores using admission and discharge standardized assessment data from the IRF-PAI.ResultsApproximately 53% of patients in the study were female, 67% were aged 65-84 years, and nearly 80% were White. In the final risk adjustment model, 105 covariates were included, explaining 20% of variance in mobility change scores. Key risk adjusters included IRF primary diagnosis group, prior indoor ambulation functioning, age older than 90 years, and 14 of the comorbidities. The model showed good calibration across the range of deciles of predicted IRF mobility change scores; the ratio of the average expected to observed change scores ranged from 0.93-1.03, with all but 1 within ±0.03.ConclusionsThe updated risk adjustment model uses IRF patients' demographic and clinical characteristics to predict their mobility change scores. The exclusion criteria and resulting risk model are used to calculate the risk adjusted Change in Mobility quality measure scores, enabling comparisons of Change in Mobility scores across IRFs.     

卒中患者的非沉浸式虚拟现实康复

卒中康复期间的治疗干预通常涉及以任务为导向的方法。虚拟现实(VR)训练可以为这种训练创建适用的练习环境。这项研究评估了非沉浸式VR训练对脑卒中偏瘫患者功能预后的影响。这项随机对照试验纳入了在入选前6个月内发生原发性卒中的36例患者。将受试者随机分为干预组和对照组,干预组使用RAPAEL智能手套接受非沉浸式VR训练。对照组则玩电子游戏作为一种娱乐活动。两组都接受了24次治疗,每次30分钟,每周三天,为期八周。在干预组,将算法应用于游戏类训练中,提出了具有适当难度的最优挑战任务。结果测量包括积木-箱子测试(BBT)、Jebsen手功能测试(JT)、握力评估和Wolf运动功能测试(WMFT)。     

Transitioning from Education to Practice: Associate Degree Program,Senior Clinical at a Skilled Nursing Facility,a Pilot Program

Over the last 4 years, there has been a shift in where associated degree registered nurses (ADNs) are being employed. There has been an increase of ADN graduates employed at skilled nursing facilities on a local, regional, and national level in the United States. Graduate surveys from the last 4 years demonstrate that the number of our graduates working at the skilled/subacute nursing facilities had increased to 33%–37% from 10%–15% and had decreased at the acute care facilities to 18%–21% from 35%–40%. The faculty felt we needed to modify our clinical teaching to enhance the knowledge and preparation of the graduates. A pilot program was developed by the nursing faculty in collaboration with the nursing staff at a skilled/subacute nursing facility to help the graduates transition into these facilities. The pilot program utilized the Massachusetts Board of Higher Education core nursing competencies and the nursing process. The intent of the partnership program was to promote learning in an environment where graduates will seek future employment and provide safe and quality care to the residents.