Day hospital service in rehabilitation medicine: an evaluation

The purpose of this study was to evaluate Day Hospital care in rehabilitation medicine as an alternative to intensive inpatient care. The study design called for two groups of randomly selected patients who met all admission criteria for intensive inpatient rehabilitation, who had Medicare or Medicaid insurance coverage, and who had a responsible other person living in the home. Those in the Day Hospital group were sent home after a short period of family training and then were taken to the hospital for treatment five days a week. The control group remained in the hospital on the rehabilitation service as inpatients and received the routine care provided to all other inpatients on that service. Data on utilization of health services, both during and after rehabilitation, cost of services, medical, functional, psychologic and social outcomes were collected for all study participants and analyzed. Findings showed no essential difference between the two groups in physical or functional outcome; however at full capacity with the research costs removed, the Day Hospital method proved the more cost effective.     

Comparison of subacute rehabilitative care with outpatient primary medical care

Purpose: Prior rehabilitation outcome studies have had many weaknesses, but they gradually observe a lack of long-term benefits from inpatient care alone. The goal of this study was to measure the additive effect of outpatient, subacute rehabilitation (compared with usual outpatient primary medical care) for adults diagnosed with a disabling disorder in four major diagnostic groups (nervous, circulatory, musculoskeletal and injury). Method: A randomized clinical trial was conducted to determine the effects of outpatient, subacute rehabilitative care on: (1) physical function; (2) health; (3) well being; (4) family function; and (5) social support. Patients hospitalized for the first time with a disabling condition (n 180) were provided inpatient rehabilitation and then were randomly assigned to either outpatient, subacute rehabilitation at home (n 90) or to usual outpatient follow-up (n 90) in which only primary care medical services were provided. To compare the two groups, univariate analyses of covariance were conducted for the outcome variables. Results: The major finding of this study was that of no significant effect of the intervention on any outcome variable. Conclusions: Based on current study results, we conclude that any long term additive benefit of outpatient, subacute rehabilitation may not be detectable across disability categories and may require closer evaluation in studies with a more homogeneous population than in the current study. Providing complex follow-up case management services to all clients is apparently not beneficial and might better be provided using selection criteria based on need. Future studies should determine if services are more effective when provided to those with the most unmet rehabilitative needs. Further outpatient, subacute care rehabilitation studies should address the specific needs of the patients and be adapted individually to those needs.     

Comparison of subacute rehabilitative care with outpatient primary medical care

Purpose: Prior rehabilitation outcome studies have had many weaknesses, but they gradually observe a lack of long-term benefits from inpatient care alone. The goal of this study was to measure the additive effect of outpatient, subacute rehabilitation (compared with usual outpatient primary medical care) for adults diagnosed with a disabling disorder in four major diagnostic groups (nervous, circulatory, musculoskeletal and injury). Method: A randomized clinical trial was conducted to determine the effects of outpatient, subacute rehabilitative care on: (1) physical function; (2) health; (3) well being; (4) family function; and (5) social support. Patients hospitalized for the first time with a disabling condition (n 180) were provided inpatient rehabilitation and then were randomly assigned to either outpatient, subacute rehabilitation at home (n 90) or to usual outpatient follow-up (n 90) in which only primary care medical services were provided. To compare the two groups, univariate analyses of covariance were conducted for the outcome variables. Results: The major finding of this study was that of no significant effect of the intervention on any outcome variable. Conclusions: Based on current study results, we conclude that any long term additive benefit of outpatient, subacute rehabilitation may not be detectable across disability categories and may require closer evaluation in studies with a more homogeneous population than in the current study. Providing complex follow-up case management services to all clients is apparently not beneficial and might better be provided using selection criteria based on need. Future studies should determine if services are more effective when provided to those with the most unmet rehabilitative needs. Further outpatient, subacute care rehabilitation studies should address the specific needs of the patients and be adapted individually to those needs.     

Care needs and functional status of older acute care patients

A growing number of older adults are admitted to hospitals, and information is needed on how age-related functional decline affects nursing care needs of this population. This study compared the functional status at admission and total nursing care needs of three age groups of older inpatients. A 12-month retrospective audit was performed on the records of 225 patients in a private metropolitan hospital. The three groups of patients were matched on diagnosis. Findings revealed that older patients were significantly more dependent, had greater total nursing care needs, and were less likely to be discharged to home, indicating that in addition to medical diagnoses, age-related differences of older patients' functional status at admission and inpatient nursing care needs should be factored into staff workloads and funding of nursing care. The finding that significantly fewer of the older patients returned home must be considered when reviewing health care policy and services.     

Rehospitalization after initial rehabilitation for acute spinal cord injury: incidence and risk factors

Many acute spinal cord injury (SCI) patients require rehospitalization after discharge from initial rehabilitation. Previous studies of rehospitalization for these patients have been cross-sectional with respect to time since injury (in years), and have not allowed for comparison of patients with equal exposure to the risk of medical complications once they have reentered the community. To examine the incidence, cause, and monetary cost of rehospitalizations during the first year after discharge from initial rehabilitative care (day 365), the medical records of 88 consecutive, acute SCI patients who completed initial rehabilitation at a regional model SCI care system were reviewed. Cases were excluded from the study if the patient was lost to follow-up before day 365. All readmissions to the regional SCI care system during the follow-up period were reviewed for primary diagnosis, length of stay (LOS), and hospital charges incurred. Thirty-four patients (39%) were readmitted at least once by day 365. There was a total of 47 readmissions; mean LOS was 11.9 +/- 2.1 days per admission (+/- 1SE), and mean hospital charge per admission was $9,683. Univariate comparisons between the characteristics of patients who were readmitted vs those who were not indicated that the readmitted group was less educated (11.8 +/- 2.1 years vs 12.9 +/- 0.3 years, p less than 0.05) and had a substantially longer initial rehabilitation LOS (88.9 +/- 6.6 days vs 72.9 +/- 5.1 days, p less than 0.05). Readmissions were less common among patients who were discharged at Frankel class C or D (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Variation by diagnostic and practice pattern groups in the mobility outcomes of inpatient rehabilitation programs for children and youth

BACKGROUND AND PURPOSE: The purpose of this study was to describe variation in functional mobility outcomes among children and youth with different diagnoses and belonging to groups with different practice patterns from an inpatient pediatric rehabilitation hospital setting. SUBJECTS: A sample of 138 individuals between the ages of 1 and 22 years (mean=9.4, SD=5.3) was enrolled. METHODS: Physical therapists administered the "Mobility" domain of the Pediatric Evaluation of Disability Inventory at the time of admission and at the time of discharge. Mobility level (combined admission and discharge scores) and amount of change between and within 4 diagnostic groups (traumatic brain injury, non-traumatic brain injury, orthopedic, and neurological) and 5 neuromuscular and musculoskeletal practice pattern groups were calculated, and post hoc analyses were done for specific contrast comparisons. RESULTS: Mobility scores between admission and discharge for all subgroups were different. Practice pattern groups were useful for identifying variations in level of motor performance. Diagnostic groups best described differences in mobility change during inpatient rehabilitation. DISCUSSION AND CONCLUSION: The use of practice patterns as grouping categories may enhance our understanding of variation in clinical outcomes of children during inpatient rehabilitation.     

Prospective payment and patient acuity levels

The main purpose of the Diagnostic Related Group (DRG) prospective payment system is decreased hospital utilization. Shortened lengths of stay in acute care hospitals may result in increased acuity levels of patients entering rehabilitation facilities. Since there are no reports of this phenomenon in the literature to date, this topic will be reviewed from the experience of one rehabilitation hospital. Data are presented from the nursing patient acuity system for the years 1984–1986. These are then compared to the functional rating scales of patients on admission to determine if the patients are sicker or more functionally disabled. Findings reveal that patients required more nursing care for all rehabilitation diagnostic categories in 1985 than in 1984, but less care was required in 1986 than in 1985 (with the exception of amputee patients). In five out of eight patient categories, patients had better functional abilities on admission in 1986 than in 1985. The department of nursing at this hospital has adjusted to the increased needs of patients by changing the mix of RN staff to LPN and nursing assistant staff and providing more total hours of care.     

Functional outcomes following medical intensive care

This study describes the long-term functional outcomes of a medical and coronary care ICU population. Baseline and 1-yr follow-up data were collected prospectively from all 2213 patients admitted during a 2-yr period. Patients were stratified into three groups based on their preadmission functional status: active (n = 917), sedentary (n = 1017), or severely limited (n = 279). Those with severe functional limitation before admission were twice as likely to undergo major interventions (p less than .005). This group also had a significantly (p less than .001) higher mortality and incurred significantly (p less than .01) higher hospital charges than the other two groups, even though hospital lengths of stay were similar. Finally, cumulative mortality was significantly (p less than .001) greater for the severely limited patients: 33% expired in the ICU, 42% died while still in the hospital, and 63% died after discharge. Most survivors regained their preadmission functional status, with 60% of the previously employed returning to work. However, even for hospital survivors, mortality was high and was related to prior functional status: active 7%, sedentary 20%, severely impaired 37%.     

Outcome of patients who refused out-of-hospital medical assistance

Activation of the emergency medical services (EMS) system does not always result in transport of a patient to the hospital. This study assessed the outcomes of patients who refused medical assistance in the field, to determine if refusal of medical assistance (RMA) is associated with poor outcomes. Four high-volume suburban volunteer ambulance corps participated in the study. Consecutive patients who refused medical assistance were prospectively enrolled. Medical and identifying data were collected for each patient. Telephone follow-up was conducted to determine the patient's condition and if the patient sought further care after RMA. Primary endpoints were whether the patient sought further care, was admitted to a hospital, or died subsequent to RMA. Follow-up was successfully obtained for 199 of 321 patients enrolled (62%). Of these 199 patients, 95 (48%) sought further medical care within 1 week for the same complaint, with 13 being admitted to the hospital. Six of the 13 admitted patients had chief complaints of a cardiac or respiratory nature. One patient died during hospital admission. Even if none of the patients lost to follow-up had sought further care, a substantial number of patients who refuse out-of-hospital medical assistance seek further care. Some of these patients require hospital admission, especially those with cardiac or respiratory complaints. Efforts to minimize RMA should be especially focused on patients with such complaints.     

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.     

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.     

Rehabilitation needs of an inpatient medical oncology unit

OBJECTIVE: To identify prospectively functional impairments and rehabilitation needs in an acute care medical oncology unit. DESIGN: Prospective cohort study. SETTING: Inpatient medical oncology unit at a Veterans Affairs hospital. PARTICIPANTS: Fifty-five patients admitted over a 6-month period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM instrument, functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. RESULTS: On admission, the mean FIM total score was 105 out of 126, the FIM motor score was 72 out of 91, and the FIM cognitive score was 34 out of 35. The functionally based physical examination did not generally correlate with scores obtained on the FIM. Forty-eight (87%) patients had rehabilitation needs on admission. Forty-six (84%) patients had rehabilitation needs on discharge. Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients; mobility impairment in 32 (58%) patients; a significant decrease in range of motion in 23 (42%) patients; deficits in activities of daily living in 12 (22%) patients; a need for recreational therapy in 7 (13%) patients; potential for benefit from patient education in 30 (55%) patients; and a need for modalities, edema control, or wound care in fever than 5% of patients. The most commonly requested recreational activity was reading. CONCLUSIONS: Patients admitted to inpatient medical oncology units have many unmet, remediable rehabilitation needs that may not be recognized by nonrehabilitation physicians and other clinical staff. These findings suggest that assessment of medical oncology patients may be enhanced by consultation with rehabilitation medicine specialists.     

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.     

Predicting inpatient rehabilitation length of stay

Using standardized forms and predefined criteria, information was collected on all 1,238 patients admitted to the inpatient rehabilitation facility at our university hospital between August 1, 1980 and December 30, 1986. Data from 96% of these patients were used retrospectively to create a mathematic model, based on multiple linear regression, that predicts the patient's total rehabilitation length of stay (LOS). The model requires only information about the patient's admitting diagnosis, referral source, admission functional status, and date of admission. The model compared favorably with prospective estimates of LOS made independently by attending physicians at admission to rehabilitation. We conclude that such models could be used to facilitate management of rehabilitation units, forecast patient census, schedule unit personnel, set interim goals for LOS, and facilitate discharge planning. The delivery of rehabilitation services, like the delivery of other medical services, can be defined in part by objective, measurable patient characteristics.     

Stroke rehabilitation outcome: the Turkish experience

The objectives of this study were to examine the demographic and clinical characteristics of stroke patients admitted for inpatient rehabilitation, to study the occurrence of medical problems/complications, and to document functional outcome and possible factors influencing outcome. The mean age of this cohort (30 females, 53 males) was 58+/-12 years and the mean length of hospital stay was 45.7+/-23 days. The most common medical comorbidity was hypertension (65%), followed by heart disease (42%) and diabetes mellitus (22%). The length of hospital stay was related to the number of medical comorbidities (r=0.24, P<0.05). Almost all patients experienced several medical problems during rehabilitation stay (average 7.1 events/patient). Shoulder dysfunction (80.7%), symptomatic blood pressure fluctuations (72.3%) and psychosocial problems (57.8%) were among the most common problems. There was a statistically significant improvement in total Functional Independence Measure scores from admission to discharge (56.5 vs. 74.6), with a mean gain of 18.1. Functional Independence Measure gain was significantly correlated with onset to admission time (r=-0.21, P<0.05), length of hospital stay (r=0.50, P<0.001) and the number of previous strokes (r=-0.23, P<0.05), but not with age, onset to admission interval, comorbidities and the presence of medical problems. Discharge total Functional Independence Measure scores were significantly correlated only with the admission total Functional Independence Measure scores (r=0.72, P<0.001) and onset-admission interval (r=-0.23, P<0.05). Significant functional improvements were documented in this cohort of stroke patients after an interdisciplinary rehabilitation approach. Discharge functional status was best correlated with admission functional status. Medical problems/complications were common among patients undergoing stroke rehabilitation. In our patients, functional outcomes were not significantly influenced by the occurrence of medical problems.     

The relationship between therapy intensity and rehabilitative outcomes after traumatic brain injury: a multicenter analysis

OBJECTIVES: To identify factors relating to the intensity of rehabilitation services received and to ascertain the relation between injury outcomes, demographics, types of therapy, and the intensity of rehabilitation services provided. DESIGN: A multicenter, prospective, nonrandomized study with inpatient rehabilitation data collected between 1989 and 1996. SETTING: Three medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, and inpatient rehabilitation. PARTICIPANTS: A total of 491 consecutively enrolled patients with a mean age +/- standard deviation of 34.3+/-15.88 years recruited from 3 medical centers. To be included in the study, patients must have been at least 16 years of age, have presented to the emergency department within 24 hours of injury, and have received acute care and inpatient rehabilitation. INTERVENTIONS: Patients received comprehensive medical care along with a combination of rehabilitative therapies, including physical, occupational, psychologic, and speech therapy. MAIN OUTCOME MEASURES: Therapy intensity; levels of functional independence, cognitive function, functional gain, and treatment efficiency, as indicated by the FIM instrument; rehabilitation length of stay (LOS); and charges. RESULTS: Age predicted the intensity of both psychologic (P<.001) and total therapy (P<.01) services. Acute care LOS was also a significant predictor of psychologic services (P<.01). Only admission motor FIM was relevant in predicting speech services intensity (P<.01). Therapy intensity was predictive of motor functioning at discharge (P<.001). However, therapy intensity did not predict cognitive gain (P<.05). CONCLUSIONS: This study is among the first multicenter efforts to examine the potential benefits of individual therapy services. Findings support assertions that increased therapy intensity, particularly physical and psychologic therapies, enhances functional outcomes.     

Efficacy of the rehabilitation of elderly primary health care patients after short-stay hospital treatment.

The purpose of this study was to evaluate the impact of a primary home care intervention program on patient outcomes after selected patients were discharged from a short-stay hospital. Random assignment of 249 frail, elderly patients was made to a group provided with physician-led primary home care, and home assistance service on a 24-hour basis, or to a control group given standard care. At randomization, patients were considerably disabled, had a mean age of 80.5 years, and had a high likelihood of long-stay hospital care. Medical and functional data were essentially the same at baseline for both groups. At 6-months follow-up, significant improvement in instrumental activities of daily living (P = 0.04) and outdoor walking (P = 0.03), and medical condition was found in the primary care intervention group compared with the controls and less utilization of long-stay hospital facilities was displayed in the team patients (P < 0.001) than in the controls. A selection of elderly, dependent patients can be cared for in their homes after short-stay hospital discharge and benefit from this primary home care intervention program in terms of improved medical and functional outcomes and less long-stay hospitalization.     

Recovery from stroke: differences between subtypes

The objective of this study was to compare the differences in patterns of recovery and incidence of medical complications in hemorrhagic and ischemic stroke patients admitted for rehabilitation, using a retrospective case series design. It was set in three tertiary care facilities in London, Ontario, Canada. Eight-hundred-and-nineteen consecutive patients, admitted from 1997 to 2001 for rehabilitation following cerebrovascular event, were reviewed. The main outcome measures were: age, length of hospital stay, time to admission, medical complications, ambulation status and functional independence measure scores on both admission and discharge. The results showed that 110 patients had strokes that were hemorrhagic, while 709 were ischemic. The hemorrhagic stroke patients were younger (66 vs. 70 years, P=0.001) and were admitted later post stroke onset (30 vs. 18 days, P<0.0001). They had a higher incidence of pneumonia (6.4 vs. 2.7%, P=0.04), pulmonary emboli (3.6 vs. 0.07%, P=0.006) and wheelchair ambulation on admission (53 vs. 41%, P=0.026). There was no significant difference in incidence of seizures or wheelchair ambulation on discharge, length of rehabilitation stay or Functional Independence Measure scores on both admission and discharge. In conclusion, hemorrhagic stroke patients took longer than ischemic stroke patients to enter into rehabilitation, and were more inclined to experience ambulatory impairments and develop medical complications.