Barbara E. Bates

Management of Adult Stroke Rehabilitation Care A Clinical Practice Guideline

Stroke is a leading cause of disability in the United States.1 The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that 15 000 veterans are hospitalized for stroke each year (VA HSR&D, 1997). Forty percent of stroke patients are left with moderate functional impairments and 15% to 30% with severe disability.2 Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. Improved functional outcomes for patients also contribute to patient satisfaction and reduce potential costly long-term care expenditures. There are only 45 rehabilitation bed units (RBUs) in the VA today. Many veterans who have a stroke and are admitted to a VA Medical Center will find themselves in a facility that does not offer comprehensive, integrated, multidisciplinary care. In a VA rehabilitation field survey published in December 2000, more than half of the respondents reported that the “rehabilitative care of stroke patients was incomplete, fragmented, and not well coordinated” at sites lacking a RBU (VA Stroke Medical Rehabilitation Questionnaire Results, 2000). In Department of Defense (DoD) medical treatment facilities, approximately 20 000 active-duty personnel and dependents were seen in 2002 for stroke and stroke-related diagnoses according to ICD-9 coding.3 Comprehensive treatment for stroke patients in DoD medical facilities is given primarily at medical centers. Smaller DoD community hospitals may have limited resources to see both inpatients and outpatients, relying more on the TRICARE network for ongoing stroke rehabilitation services. A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke.4–6 The VA/DoD Stroke Rehabilitation Working Group only focused on the post–acute stroke rehabilitation care. Duncan and colleagues7 found that greater adherence to post-acute stroke rehabilitation guidelines was associated with improved patient outcomes and concluded “compliance …

The Effectiveness of Inpatient Rehabilitation in the Acute Postoperative Phase of Care After Transtibial or Transfemoral Amputation: Study of an Integrated Health Care Delivery System

OBJECTIVE To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. DESIGN An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. SETTING Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. PARTICIPANTS A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. RESULTS After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. CONCLUSIONS The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system.

Background.Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system. Objective.The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences. Design.This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system. Subjects.The study included 55,438 stroke patients. Measures.Study measures were LOS, functional status at discharge, and community discharge. Results.The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P <0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P <0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P <0.05); and community discharge rates were lower in 12 FRGs (P <0.05). Conclusions.While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients’ home environments may be among the most important unmeasured determinants of VA differences.

Assessing and Using Comorbidity Measures in Elderly Veterans with Lower Extremity Amputations

Background: Understanding comorbidity prevalence and the effects of comorbidities in older veterans with lower extremity amputations may aid in assessing patient outcomes, resource use, and facility-level quality of care. Objectives: To determine the degree to which adding outpatient to inpatient administrative data sources yields higher comorbidity prevalence estimates and improved explanatory power of models predicting 1-year mortality and to compare the Charlson/Deyo and Elixhauser comorbidity measures. Methods: A retrospective cohort study applying frequencies, cross-tabulations, and logistic regression models was conducted, including data from 2,375 veterans with lower extremity amputations. Comorbidity prevalence according to the Charlson/Deyo and Elixhauser measures, 1-year mortality rates, and standardized mortality ratios (SMRs) were analyzed. Results: Comorbidity prevalence estimates increased sharply for both the Charlson/Deyo and Elixhauser measures with the addition of data from multiple settings. The Elixhauser compared to the Charlson/Deyo generally yielded higher estimates but did not improve explanatory power for mortality. Modeling expected versus actual deaths produced varying SMRs across geographic regions but was not dependent on which measure or data sources were used. Conclusions: Merging outpatient with inpatient data may reduce the under coding of comorbidities but does not enhance mortality prediction. Compared to the Charlson/Deyo, the Elixhauser has a more complete coding scheme for comorbid conditions, such as diabetes mellitus and peripheral vascular disease, important to addressing lower extremity amputation etiology.

Prognostic Differences for Functional Recovery After Major Lower Limb Amputation: Effects of the Timing and Type of Inpatient Rehabilitation Services in the Veterans Health Administration

To compare the recovery of mobility and self‐care functions among veteran amputees according to the timing and type of rehabilitation services received.

Survival Analysis in Amputees Based on Physical Independence Grade Achievement

BACKGROUND Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. OBJECTIVES To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. DESIGN Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. SETTING Ninety-nine US Department of Veterans Affairs Medical Centers. PATIENTS Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. MAIN OUTCOME MEASURE Cumulative 6-month survival after rehabilitation discharge. RESULTS The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. CONCLUSIONS Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

Possible Incremental Benefits of Specialized Rehabilitation Bed Units Among Veterans After Lower Extremity Amputation

Background:Little is known about the effect of different types of inpatient rehabilitation on outcomes of patients undergoing lower extremity amputation for nontraumatic reasons. Objective:To compare outcomes between patients who received inpatient rehabilitation on specific rehabilitation bed units (specialized) to patients who received rehabilitation on general medical/surgical units (generalized) during the acute postoperative period. Methods:This was an observational study including 1339 veterans who underwent lower extremity amputation between October 1, 2002 and September 30, 2004. Data were compiled from 9 administrative databases from the Veterans Health Administration. Propensity score risk adjustment methodology was used to reduce selection bias in looking at the effect of type of rehabilitation on outcomes (1-year survival, home discharge from the hospital, prescription of a prosthetic limb within 1 year post surgery, and improvement in physical functioning at rehabilitation discharge). Results:After applying propensity score risk adjustment, there was strong evidence that patients who received specialized versus generalized rehabilitation were more likely to be discharged home (risk difference = 0.10), receive a prescription for a prosthetic limb (risk difference = 0.13), and improve physical functioning (gains on average 6.2 points higher). Specialized patients had higher 1-year survival (risk difference = 0.05), but the difference was not statistically significant. The sensitivity analysis demonstrated our findings to be unaffected by a moderately strong amount of unmeasured confounding. Conclusions:Receipt of specialized compared with generalized rehabilitation during the acute postoperative inpatient period was associated with better outcomes. Future studies will need to look at different intensity, timing, and location of rehabilitation services.

One-Year All-Cause Mortality After Stroke: A Prediction Model

By using data from Department of Veterans Affairs (VA) national databases, this article presents and internally validates a 1‐year all‐cause mortality prediction index after hospitalization for acute stroke.

Development and validation of a discharge planning index for achieving home discharge after hospitalization for acute stroke among those who received rehabilitation services.

ObjectiveThe aim of this study was to develop an index for establishing the probability of being discharged home after hospitalization for acute stroke using information about previous living circumstances, comorbidities, hospital course, and the physical grades and cognitive stages of independence achieved. DesignThis is a longitudinal observational population-based study. All 6515 persons treated for acute stroke who received rehabilitation services in 110 Veterans Affairs facilities within a 2-yr period were included. ResultsThere were eight independent predictors of home discharge identified, and points were assigned through logistic regression: married (2 points); location before hospitalization (extended care = 0 points, other hospital = 9 points, home = 11 points); discharge physical grade (grade I, II, or III = 0 points; grade IV or V = 3 points; grade VI or VII = 5 points); discharge cognitive stage (stage I = 0 points; stage II, III, IV, or V = 3 points; stage VI or VII = 5 points); and absence of liver disease (2 points), mechanical ventilation (3 points), nonoral feeding (2 points), and intensive care unit admission (1 point). The points were added for all present factors to calculate scores. The probabilities of home discharge ranged from 65.03% in the least likely (⩽21 points) to 98.24% in the most likely group (≥27 points). ConclusionsThe treatment team might apply prognostic estimates from this index in discharge planning and functional goal setting after initial physical medicine and rehabilitation assessment.

Factors Influencing Decisions to Admit Patients to Veterans Affairs Specialized Rehabilitation Units After Lower-Extremity Amputation

UNLABELLED Bates BE, Kwong PL, Kurichi JE, Bidelspach DE, Reker DM, Maislin G, Xie D, Stineman M. Factors influencing decisions to admit patients to Veterans Affairs specialized rehabilitation units after lower-extremity amputation. OBJECTIVE To understand patient- and facility-level characteristics that influence decisions to admit veterans to a specialized rehabilitation unit (SRU) after a lower-extremity amputation. DESIGN Database study. SETTING All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS Veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 30, 2004. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Admission to an SRU. RESULTS There were a total of 2922 veterans with lower-extremity amputations; 616 patients were admitted to an SRU, whereas 2306 received consultative rehabilitation services only. Patients admitted to an SRU waited longer to have their first rehabilitation assessment after surgery and had middle-range physical and cognitive disabilities. Patients who received consultative rehabilitation services only tended to have greater illness burden. They were more likely to have previous amputation complication, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities. CONCLUSIONS The selection of veterans with new lower-extremity amputations for admission to an SRU appears clinically reasonable and based on the likelihood of successful outcomes.