Racial disparities in outcomes of inpatient stroke rehabilitation

OBJECTIVE: To determine whether race is associated with outcomes of inpatient stroke rehabilitation. DESIGN: Retrospective cohort study. SETTING: A community-based inpatient rehabilitation facility. PARTICIPANTS: Poststroke patients (N=1002) admitted to a community-based inpatient rehabilitation facility between 1995 and 2001. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional improvement at discharge from the rehabilitation facility, discharge disposition, and functional improvement at 3 months after discharge. Inpatient and follow-up data were collected from the facility's electronic patient database. We used the FIM instrument to assess functional status at admission, discharge, and follow-up. RESULTS: In multivariable models, blacks achieved less functional improvement at discharge (-1.9 FIM points, P=.02) compared with whites and, despite worse FIM scores, were more likely to be discharged to home (adjusted odds ratio=1.7; 95% confidence interval, 1.1-2.5). Although Asian-American patients did not differ from whites in terms of functional improvement at discharge or disposition, they had less improvement at 3 months following discharge (-6.3 FIM points, P=.005). CONCLUSIONS: We identified racial disparities in poststroke outcomes in a community-based inpatient rehabilitation facility. Future research in stroke rehabilitation should explore the consistency of these findings across settings and if they are confirmed, identify explanatory mediators to better inform efforts to eliminate racial disparities.     

A systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation

Abstract

Purpose: This systematic review summarizes the utility of variables available at acute discharge after stroke for predicting functional independence at discharge from inpatient rehabilitation. Methods: A systematic review of four electronic databases (Medline, EMBASE, PsycINFO and CINAHL) was conducted to identify studies reporting multivariable models predicting post-rehabilitation Barthel Index (BI) or Functional Independence Measure (FIM®) scores. In studies meeting inclusion criteria, the frequency with which candidate predictors were found statistically significant was calculated and summarized. Results: A total of 3260 articles were screened, of which 27 were included and 63 multivariable models of discharge BI or FIM® were reported. In all, 126 candidate predictors of BI or FIM® were explored. Variables found to be significant most frequently included admission functional level (BI or FIM®), National Institute of Health Stroke Scale (NIHSS), dysphasia, impulsivity, neglect, previous stroke, and age. Conclusions: Only a selected group of variables have repeatedly proven to be significant predictors of functional ability after post-stroke inpatient rehabilitation.

• Implications for Rehabilitation

• This review identifies, and summarizes, studies that have used a multivariable model to predict Barthel Index (BI) or Functional Independence Measure (FIM®) after post-stroke inpatient rehabilitation.

• Clinicians making decisions about admission to inpatient rehabilitation should consider age and a measure of stroke severity, functional status and progress to date.

• Variables that have been demonstrated to be useful most commonly included age, admission functional level (BI or FIM), National Institute of Health Stroke Scale, dysphasia, impulsivity, neglect, and previous stroke.

     

Caregiver availability for severe stroke results in improved functional ability at discharge from inpatient rehabilitation

Purpose: To evaluate the predictive capacity of caregiver availability on functional ability at time of discharge from inpatient rehabilitation in individuals with severe first-time stroke.

Methods: A retrospective chart review was conducted of severe stroke inpatients admitted to a stroke rehabilitation unit between April 2005 and December 2009. Follow-up telephone interviews were conducted with patients to determine caregiver availability at time of discharge. Hierarchical linear regression analysis was performed to assess the predictive capacity of caregiver availability on functional ability at discharge from an inpatient rehabilitation unit after controlling for covariates.

Results: Data from 180 individuals were included in the analysis. Individuals with a caregiver had significantly higher levels of functional ability at discharge compared to those without (85.8?±?23.6 versus 72.9?±?20.3; p?F (5,174)?=?26.21, p?Conclusions: The presence of a caregiver at time of discharge from inpatient rehabilitation is predictive of significantly higher functional ability at discharge in individuals with severe stroke.

• Implications for rehabilitation

• The availability of a caregiver at time of discharge from inpatient rehabilitation is predictive of improved functional ability at discharge in individuals with severe stroke.

• The presence of an available caregiver positively influences the functional recovery of individuals with severe stroke and may be an important element to successful rehabilitation.

     

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.     

Racial disparities in outcomes following PEA and asystole in-hospital cardiac arrests

AimTo define the racial differences present after PEA and asystolic IHCA and explore factors that could contribute to this disparity.MethodsWe analyzed PEA and asystolic IHCA in the Get-With-The-Guidelines-Resuscitation database. Multilevel conditional fixed effects logistic regression models were used to estimate the relationship between race and survival to discharge and return of spontaneous circulation (ROSC), sequentially controlling for hospital, patient demographics, comorbidities, arrest characteristic, process measures, and interventions in place at time of arrest.ResultsAmong the 561 hospitals, there were 76,835 patients who experienced IHCA with an initial rhythm of PEA or asystole (74.8% white, 25.2% black). Unadjusted ROSC rate was 55.1% for white patients and 54.1% for black patients (unadjusted OR: 0.94 [95% CI, 0.90–0.98], p = 0.016). Survival to discharge was 12.8% for white patients and 10.4% for black patients (unadjusted OR: 0.83 [95% CI, 0.78–0.87], p < 0.001). After adjusting for temporal trends, patient characteristics, hospital, and arrest characteristics, there remained a difference in survival to discharge (OR: 0.85 [95% CI, 0.79–0.92]) and rate of ROSC (OR: 0.88 [95% CI, 0.84–0.92]). Black patients had a worse mental status at discharge after survival. Rates of DNAR placed after survival from were lower in black patients with a rate of 38.3% compared to 44.5% in white patients (p < 0.001).ConclusionBlack patients are less likely to experience ROSC and survival to discharge after PEA or asystole IHCA. Individual patient characteristics, event characteristics, and hospital characteristics don’t fully explain this disparity. It is possible that disease burden and end-of-life preferences contribute to the racial disparity.     

Measuring patient-reported outcomes after discharge from inpatient rehabilitation settings.

OBJECTIVE: To examine the sensitivity of the Short Form Activity Measure for Post-Acute Care (AM-PAC) in comparison to the Functional Independence Measure (FIM) across a 12-month period after discharge from rehabilitation hospital. DESIGN: Prospective longitudinal study. Patients were recruited while receiving inpatient services from facilities in the north-east USA and interviewed 1, 6 and 12 months thereafter. PATIENTS: Convenience sample of 516 patients at baseline (65% retention at the final follow-up) receiving rehabilitation services for neurological, lower extremity orthopedic, or complex medical conditions. Mean age 68.3 years; 47% male. MAIN OUTCOME MEASURES: AM-PAC Physical and Movement, Personal Care and Instrumental, and Applied Cognitive Activity scales; FIM Motor and Cognitive scales. RESULTS: All 3 AM-PAC scales were sensitive to both positive and negative change across the follow-up period. Standardized response means for the AM-PAC were consistently larger than for the FIM across patient and severity groups. A greater percentage of patients showed positive change that exceeded the minimal detectable change on the AM-PAC than on the FIM both 6- and 12-month follow-ups. CONCLUSION: The short-form AM-PAC scales are more sensitive measures of change in functional activity performance over time in the general population of persons who receive inpatient rehabilitation services compared to the FIM. Thus, the AM-PAC offers a short, comprehensive, and sensitive measure of positive and/or negative change in patients' ability to perform important activities of daily life.     

Fear of falling among stroke survivors after discharge from inpatient rehabilitation

The objectives of this study were to assess the incidence of falls and fall consequences among patients who were discharged from inpatient stroke rehabilitation and to investigate the proportion of those who experienced a fear of falling following a fall. This was a follow-up postal questionnaire study of patients who were admitted to the rehabilitation ward in a local hospital (Japan) for stroke rehabilitation. Seventy-three patients who met inclusion criteria were sent questionnaires and 49 (67%) responded to the questionnaire. Thirty-three patients had at least one fall after discharge from the hospital and of these, four patients experienced fractures resulting from their falls. Twenty-nine patients developed a fear of falling. As falls are common in stroke survivors, more attention should be paid to falls after stroke during inpatient rehabilitation to prevent physical and emotional consequences of falls.     

A narrative review of the impact of medical comorbidities on stroke rehabilitation outcomes

Purpose: Medical comorbidities in stroke patients influence acute mortality, but may also affect participation of survivors in rehabilitation. There is limited research investigating the impact of comorbidities on stroke rehabilitation outcomes. The review will explore the literature on the impact of comorbidities on stroke rehabilitation outcome.

Materials and methods: The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome.

Results: Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes.

Conclusions: There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes.

• Implications for rehabilitation

• Benefit of rehabilitation after stroke in improving functional outcome is well-established.

• Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation.

• The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.

     

Nurse staffing and patient outcomes in inpatient rehabilitation settings.

In rehabilitation nursing, the patient classification systems or acuity models and nurse-staffing ratios are not supported by empirical evidence. Moreover there are no studies published characterizing nursing hours per patient day, proportion of RN staff and impact of agency nurses in inpatient rehabilitation settings. The purpose of this prospective observational study was to describe rehabilitation nurse staffing patterns, to validate the impact of rehabilitation nursing on patient outcomes, and to test whether existing patient measures on severity and outcomes in rehabilitation could be used as a proxy for burden of care to predict rehabilitation nurse staffing ceilings and daily nurse staffing requirements. A total of 54 rehabilitation facilities in the United States, stratified by geography, were randomly selected to participate in the study.     

综合康复对重症脑卒中患者残疾功能改善的作用

目的：探讨综合康复对重症脑卒中患者残疾功能改善的作用。方法：选择重症脑卒中患者80例分为康复组50例和对照组30例。康复组患者入院后生命体征稳定48h起即给予早期综合康复，病情好转或出院后恢复期继续给予社区或家庭综合康复与指导；对照组仅给予简单康复与指导。两组分别于1周内、1，3，6，12个月时用GCS、NIHSS、FMA、ADL进行阶段量化评分，所得数据采用SPSS10．0软件统计。结果：两组间GCS在1个月时差异有统计学意义（P〈0．05）、3个月时NIHSS、FMA差异有统计学意义（P〈0．01），6个月时ADL差异有统计学意义（P〈0．05），12个月时ADL差异有统计学意义（P〈0．05）。结论：综合康复对重症脑卒中患者残疾功能改善有着重要作用。     

Length of stay benchmarks for inpatient rehabilitation after stroke

Purpose: In Canada, no standardized benchmarks for length of stay (LOS) have been established for post-stroke inpatient rehabilitation. This paper describes the development of a severity specific median length of stay benchmarking strategy, assessment of its impact after one year of implementation in a Canadian rehabilitation hospital, and establishment of updated benchmarks that may be useful for comparison with other facilities across Canada. Method: Patient data were retrospectively assessed for all patients admitted to a single post-acute stroke rehabilitation unit in Ontario, Canada between April 2005 and March 2008. Rehabilitation Patient Groups (RPGs) were used to establish stratified median length of stay benchmarks for each group that were incorporated into team rounds beginning in October 2009. Benchmark impact was assessed using mean LOS, FIM^® gain, and discharge destination for each RPG group, collected prospectively for one year, compared against similar information from the previous calendar year. Benchmarks were then adjusted accordingly for future use. Results: Between October 2009 and September 2010, a significant reduction in average LOS was noted compared to the previous year (35.3 vs. 41.2 days; p < 0.05). Reductions in LOS were noted in each RPG group including statistically significant reductions in 4 of the 7 groups. As intended, reductions in LOS were achieved with no significant reduction in mean FIM^® gain or proportion of patients discharged home compared to the previous year. Adjusted benchmarks for LOS ranged from 13 to 48 days depending on the RPG group. Conclusions: After a single year of implementation, severity specific benchmarks helped the rehabilitation team reduce LOS while maintaining the same levels of functional gain and achieving the same rate of discharge to the community.

Implications for Rehabilitation

• Efficient post-stroke rehabilitation can help to improve patient outcomes and reduce the financial burden placed on the healthcare system.

• Yet, unnecessarily long lengths of stay in rehabilitation are not in the best interest of the patient and act to increase the cost of care.

• This study illustrates how a length of stay benchmarking system can help to promote efficiency in post-stroke rehabilitation and reduce the cost of care without negatively impacting patient recovery.

     

脑梗死短期住院患者康复效益研究

目的:应用功能独立性评价量表(FIM)探讨脑梗死短期住院患者康复效益。方法:本研究为随机对照研究。选择65例脑梗死患者,随机分为康复治疗组和对照组,两组药物治疗基本相同。治疗组每天进行以Bobath法为主的康复训练,对照组只进行关节活动度训练和物理因子治疗,两组患者均采用FIM量表进行测量,将两组患者入院、出院值,住院期间获得值,以及康复效益进行配对分析。结果:①两组患者入院、出院时功能独立检查运动分、认知分、总分无显著性差异(P>0.05),康复组、对照组住院期间功能独立检查改变均有显著性差异(P<0.05),两组患者FIM改变值比较仅运动项有显著性差异(P<0.05)。②两组患者住院效率分别为:0.43分/天和0.37分/天,两者相比无显著性差异(P>0.05)。结论:脑梗死短期住院患者进行早期康复治疗只能提高FIM中的“运动项”得分,但在提高患者整体ADL功能上并无积极意义,强调住院时间过短并不利于脑梗死患者康复效益的提高。     

Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases

Freburger JK, Holmes GM, Ku L-JE, Cutchin MP, Heatwole-Shank K, Edwards LJ. Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases.

Objective

To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke.

Design

Cross-sectional analysis of data for 2 years (2005–2006) from the State Inpatient Databases.

Setting

All short-term acute-care hospitals in 4 demographically and geographically diverse states.

Participants

Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic.

Interventions

Not applicable.

Main Outcome Measures

(1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply.

Results

Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location.

Conclusions

Several sociodemographic and geographic disparities in PARC use were identified.     

Goal achievement in the six months after inpatient rehabilitation for stroke

Purpose. The purpose of the project was to identify characteristics associated with successful re-integration into the community post-inpatient rehabilitation after stroke. A key issue was determining re-integration from the person's perspective, taking into account the person's preferred lifestyle choices.

Method. Research design: A prospective exploratory follow up study. Participants: A consecutive sample of 45 participants discharged from IP rehabilitation following stroke and 23 carers associated with the participants. Measures: Goal attainment scaling was utilised to determine successful community integration. Factors that may have contributed to goal achievement were measured prior to discharge and at 6 months post-discharge. Scales used include the Functional Independence Measure, Mini Mental test, the CES-D depression scale and a self-efficacy scale, Strategies Used by People to Promote Health. London Handicap Scale scores and Carer Strain Index were collected at 6 months.

Results. Twenty percent of participants achieved all their goals. Significant correlations were observed between goal achievement score and concurrent measures of physical function, depression and self efficacy at 6 months post-discharge.

Conclusions. Stroke survivors who achieved their goals were less likely to be depressed, showed stronger self efficacy beliefs and more positive perceptions of their participation in everyday and community life.     

早期综合康复对脑卒中患者功能恢复及继发并发症的影响

要目的：探讨早期综合康复对脑卒中患者功能恢复及并发症的影响。方法：将183例脑卒中患者随机分为康复组和对照组．其中康复组90例。在常规药物治疗的基础上采用B0bath法、心理康复和健康教育的方法进行训练；对照组93例仅进行常规药物治疗。对神经功能缺损程度（NIHSS评分）、ADL能力、焦虑、抑郁和并发症进行评估。结果：①治疗4周后两组NIHSS评分明显减少，运动功能、ADL积分均明显增加，焦虑、抑郁得分明显降低，两组的变化均数相比，康复组优于对照组（P〈0．05）。②在并发症方面，康复后两组肩关节半脱位情况差异无显著性意义（P〉0．05）；其余4项两组差异有显著性意义（P〈0．05）；康复组继发并发症明显少于对照组（P〈0．05）。结论：脑卒中患者早期综合康复与对照组相比，在降低其神经功能缺损积分、减少并发症、提高运动功能、ADL积分上效果更好。     

踏车训练中应用循环性功能性电刺激对脑卒中患者下肢运动功能恢复的影响

目的:观察踏车训练中联合应用循环性功能性电刺激对脑卒中患者下肢运动功能恢复的影响。方法:40例脑卒中患者随机数字表法分为观察组和对照组各20例。2组均采用常规康复训练,其中对照组增加下肢踏车训练(RT300踏车训练系统),观察组在踏车训练的基础上增加循环性功能性电刺激(FES)训练。治疗前后分别采用简式Fugl-Meyer评定法(FMA),Berg评定法(BBS),功能性步行分级量表(FAC)进行下肢运动功能评定。结果:治疗8周后,2组FMA、BBS评分及FAC分级均较治疗前明显提高(均P0.05),且观察组高于对照组(P0.05)。结论:在踏车训练中联合应用循环性功能性电刺激能够更好地改善脑卒中患者的下肢运动功能。     

功能性电刺激联合康复训练治疗脑卒中偏瘫

目的:探讨功能性电刺激联合康复训练对脑卒中偏瘫患者的功能活动影响.方法:脑卒中偏瘫患者30例,随机分为电刺激组和对照组各15例,2组均给予常规康复训练,电刺激组另外佩戴步态训练矫正仪进行功能电刺激下步行功能训练.分别在治疗前后测量患者患侧踝背屈肌肌力、10m步行速度,并行“站起-走”计时测试(TUG)及Barthel指数评分.结果:治疗4周后,2组患侧踝背屈肌肌力、10m步行速度、Barthel指数均较治疗前明显增加,且电刺激组更高于对照组(P＜0.01,0.05);2组TUG时间均较治疗前显著减少,且电刺激组更少于对照组(P＜0.01,0.05).结论:功能性电刺激联合常规康复训练能显著地提高脑卒中偏瘫患者踝背屈肌的力量,改善患者的运动功能及日常生活活动能力.