Carl V. Granger

Discharge outcome after stroke rehabilitation.

Background and Purpose The purpose of this study was to examine the relations between host characteristics (age and side of body affected) and program variables (lengths of stay in acute care and rehabilitation, levels of functional ability at admission and discharge, and rates of community discharge). Methods A sample of 7,905 patients was drawn from medical rehabilitation facilities enrolled in the Uniform Data System for Medical Rehabilitation who were admitted and discharged for the first time between January 1988 and June 1989. Data were analyzed using either χ2 tests or z normal tests of proportions, and analyses of variance (ANOVA) and/or t tests. Significance was set at p<0.05, and statistically significant F ratios were examined using Student-Newman-Keuls tests. Results The average age of patients was 70.7 years (24% <65 years, 53% 65–79 years, and 23% <79 years). Lengths of stay in acute care and rehabilitation, admission and discharge functional independence ratings, and rates of community discharge were generally inversely related to patient age. Patients with bilateral paresis had lower rates of community discharge than those with unilateral paresis, although this distinction was not evident in the older group. Conclusions Results showed that older age and bilateral paresis are negatively associated with levels of independence at admission and discharge and with rates of community discharge.

Measuring developmental and functional status in children with disabilities

This study compared performance on the Functional Independence Measure for Children (WeeFIM), the Battelle Developmental Inventory Screening Test (BDIST), and the Vineland Adaptive Behavior Scales (VABS) in children with developmental disabilities. The three instruments were administered to 205 children with identified disabilities. All 205 children were tested using the WeeFIM instrument. The BDIST was administered to 101 children and the VABS to the remaining 104 children. Administration was counterbalanced and randomized across all three instruments. A proportional sampling plan was used to select the 205 children, who ranged in age from 11 to 87 months. A variety of medical diagnoses and levels of severity of motor, cognitive, and communication impairments were systematically included in the sample. Correlations (r) among subscales for all three instruments ranged from 0.42 to 0.92. Correlations for total scores ranged from 0.72 to 0.94. Analyses of potential moderator variables found no significant relation between age and severity of disability (r=0.05) or between socioeconomic status (SES) and severity of disability (r=0.21). Correlations with age were strongest for those subscale scores involving gross and fine motor skills. Correlations with SES and subscale scores ranged from 0.03 to 0.18. The three instruments provide important information regarding childhood performance in motor, self‐care, communicative, cognitive, and social skills. The WeeFIM instrument requires less administration time and provides information directly relevant to evaluating functional outcomes for children with disabilities and their families.

Outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs for Medicare beneficiaries with hip fracture.

Objective:We sought to assess whether outcomes and reimbursement differ for Medicare beneficiaries with hip fracture when treated in an inpatient rehabilitation facility (IRF) compared with a skilled nursing facility (SNF) subacute rehabilitation program. Participants:Clinical data were linked with Medicare claims for 29,793 Medicare fee-for-service beneficiaries with a recent hip fracture who completed treatment in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation. Outcome Measures:We measured discharge destination, change in motor FIM™ rating, and Medicare Part A reimbursement. Results:For patients with moderate-to-severe and severe disabilities, case mix groups (CMGs) 704 and 705, the percentage of patients discharged to the community from IRFs was lower than for patients treated in subacute rehabilitation SNFs, after controlling for covariates. Adjusted odds ratios were 0.71 (95% confidence interval 0.55–0.92) for CMG 704 and 0.72 (95% confidence interval 0.63–0.83) for CMG 705. For patients in the 3 other CMGs, no significant differences were detected. Improvement in motor functional status was roughly equivalent for patients treated in IRFs and those treated in the subacute rehabilitation programs across all 5 CMGs, after controlling for covariates. Medicare Part A payments for IRFs were significantly higher than SNF payments across all CMGs. Conclusion:SNF-based subacute rehabilitation was less costly and outcomes were in most, but not all, instances similar or better than IRF-based rehabilitation for Medicare fee-for-service beneficiaries who had a recent hip fracture.

Relation of Disability Costs to Function: Spinal Cord Injury

OBJECTIVE This study evaluated the validity of the Functional Independence Measure (FIM instrument) in predicting (1) the number of minutes of daily assistance provided, (2) the cost of durable goods currently used, and (3) the number of paid helper hours provided daily to persons with spinal cord injury living in the community. DESIGN A cross-sectional study. SUBJECTS One hundred nine persons with spinal cord injury who were a median 6 years postdischarge from initial medical rehabilitation. RESULTS A significant inverse linear relationship was observed between FIM scores and the square root values of the three cost-related measures. The FIM-18 and the FIM motor scores were the best single predictors of the square root of minutes of assistance (paid and/or unpaid) per day, explaining 85% of variance. The FIM motor measure was the best single predictor of square root of cost of durable goods, explaining 29% of variance. The Self-Care, FIM motor, and FIM-18 scores equally predicted square root of hours of paid help per day, explaining 58% of variance. CONCLUSION The findings indicate FIM-related scores predict the amount of assistance needed and certain costs for persons with spinal cord injury disability.

Risks of acute hospital transfer and mortality during stroke rehabilitation.

OBJECTIVE To identify demographic, medical, and functional factors associated with transfer of stroke patients to acute hospital services and/or mortality during stroke rehabilitation. DESIGN Two case-control studies in which logistic regression was used to control for clinical traits associated with differences in likelihood. SETTING A total of 542 US inpatient and rehabilitation units. PARTICIPANTS A total of 64,471 patients discharged during 1995. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Transfer to an acute hospital service and death. RESULTS There were 5847 (9.1%) acute hospital transfers and 320 (0.5%) deaths. Greater disability at admission was associated with higher odds of both acute hospitalization and mortality. Cardiopulmonary arrest, chest pain, gastrointestinal problems, bleeding disorders, hypercoagulable states, and acute renal difficulties increased the relative odds of acute hospitalization from 3.1 (95% confidence interval [CI], 2.3-4.2) to 12.7 (95% CI, 9.2-17.6). The likelihood of mortality for patients 85 years of age or older was more than 2-fold (2.5; 95% CI, 1.7-3.6) that of patients 65 years of age or younger for blacks, it was nearly 2-fold (1.7; 95% CI, 1.3-2.3) compared with whites, after adjusting for clinical differences. CONCLUSION Higher likelihoods of mortality among older patients versus younger, black patients versus white, and patients with more rather than less disability at admission suggest the need for greater vigilance in monitoring medical status.

Predicting the achievement of 6 grades of physical independence from data routinely collected at admission to rehabilitation.

OBJECTIVE To develop prognostic indexes with which to establish the likelihood of individuals achieving specific grades of physical independence by the conclusion of inpatient rehabilitation. DESIGN Logistic regression with prospective validation. SETTING Five hundred sixty inpatient rehabilitation facilities. PARTICIPANTS Records of 218,290 adults discharged in 1995 were used to establish the grades and the indexes predicting those grades. There were 259,806 1997 discharges included in the validation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Six physical independence grades reflecting the most likely profiles of performance across the 13 motor FIM items. RESULTS After severity adjustment, patients 65 years of age or younger, compared with those 84 years of age or older, had odds ratios of reaching higher grades ranging from 1.5 (95% confidence interval [CI], 1.4-1.7) to 7.5 (95% CI, 4.3-13.1). Admission to rehabilitation within 2 weeks of disability was associated with more favorable prognoses. Areas under the receiver operating characteristic curve ranged from.80 to.94 for the indexes, with minimal shrinkage on prospective validation. CONCLUSION The models have sufficient reliability to establish from admission information the likelihood that a patient will achieve a specific grade of physical independence by the time of discharge from rehabilitation. The capacity to quantify prognosis has clinical, policy, and research applications.

Satisfaction With Medical Rehabilitation in Patients With Orthopedic Impairment

OBJECTIVE To examine patient satisfaction after orthopedic impairment at 80 to 180 days after inpatient rehabilitation. DESIGN Retrospective design examining records from facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDSmr). SETTING Information submitted to UDSmr from 1997 to 1998 by 177 hospital and rehabilitation facilities from 40 states. PARTICIPANTS The sample (N=7781) was 72.63% female and 88.60% non-Hispanic white, with a mean age +/- standard deviation of 73.07+/-11.81 years, and average length of stay (LOS) of 13.84+/-10.48 days. INTERVENTION Usual rehabilitation care. Main outcome measures Level of satisfaction 80 to 180 days after discharge as well as motor, cognitive, and subscale ratings for the FIM trade mark instrument. Predictor variables included gender, age, English language, marital status, discharge setting, LOS, rehospitalization, FIM gain, and primary payer. RESULTS A logistic regression model was used to predict patient satisfaction at follow-up. Five statistically significant (P<.05) variables were found and correctly classified 94.9% of the patients. Discharge motor FIM rating, rehospitalization, age, patients primary language, and discharge setting were associated with increased satisfaction. Discharge motor FIM ratings were significantly associated with increased satisfaction in patients with joint replacements and lower-extremity fractures. CONCLUSION unctional and demographic variables were identified as predictors of satisfaction in patients with orthopedic impairments.

Prediction of follow-up living setting in patients with lower limb joint replacement.

Ottenbacher KJ, Smith PM, Illig SB, Fiedler RC, Gonzales VA, Granger CV: Prediction of follow-up living setting in patients with lower limb joint replacement. Am J Phys Med Rehabil 2002;81:471–477. Objective The living setting to which older adults are discharged from medical rehabilitation has important social and economic implications. This study was undertaken to develop statistical models to predict living setting after medical rehabilitation in persons with lower limb joint replacement. Design Information submitted from 1994 through 1998 to the Uniform Data System for Medical Rehabilitation was examined. Hip replacement was experienced by 42% of the patients, 51% experienced a knee replacement, and 7% received some combination or other lower limb procedure. Results Persons with hip replacements were slightly older than persons with knee replacements and had a longer length of stay. Logistic regression was used to develop a predictive model based on 60% of the cases. The model included five statistically significant predictor variables. Conclusion Cognitive and basic motor function associated with activities of daily living, age, length of stay, and marital status were important variables in predicting if older adults would be living at home 80–180 days after rehabilitation for lower limb joint replacement.

A Comparative Evaluation of Inpatient Rehabilitation for Older Adults With Debility, Hip Fracture, and Myopathy

OBJECTIVE To compare the functional outcomes and discharge location of older adults admitted to inpatient rehabilitation for debility, hip fracture, and myopathy. DESIGN Retrospective cohort study from 2002 to 2003 with information from the Uniform Data System for Medical Rehabilitation (UDSMR). SETTING United States inpatient rehabilitation facilities subscribing to the UDSMR. PARTICIPANTS Patients 65 years or older (N=84.701) with primary diagnoses of debility (n=14,835), hip fracture (n=68,915), and myopathy (n=951). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Change in functional status, including efficiency (change in functional status divided by length of stay in days) and discharge setting. RESULTS The efficiency of the patients with debility (1.7+/-2.1) was significantly lower than that of the patients with hip fracture (1.9+/-1.6; P<.001), but not different from the patients with myopathy (1.6+/-1.4; P=.3). Significantly more patients with debility (68%) were discharged home than the hip fracture and myopathy groups (66% and 65%, respectively; P<.001). CONCLUSIONS Although statistical differences exist, the functional recovery and rate of discharge home of older adult patients admitted to inpatient rehabilitation with a primary debility diagnosis are essentially the same clinically as those of patients with a diagnosis of either hip fracture or myopathy. Given these findings, and given that hip fracture and myopathy are approved medical conditions according to the Centers for Medicare and Medicaid Services 75% rule, the medical condition debility warrants consideration for inclusion as a qualifying medical diagnosis under this rule. However, further research is needed to develop relatively objective criteria for the debility diagnosis, and to identify those patients with debility who are most likely to benefit from inpatient rehabilitation.

Functional outcome after stroke in patients with rheumatoid arthritis and systemic lupus erythematosus

OBJECTIVE To compare outcomes following stroke rehabilitation among patients with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) versus patients with neither RA nor SLE (non-RA/SLE). METHODS We conducted a retrospective analysis using a national database of patients with stroke admitted to inpatient rehabilitation between 1994 and 2001. Primary outcomes were discharge disposition and functional status, rated by the Functional Independence Measure (FIM) Instrument, at discharge and at followup. The independent variable was RA or SLE. Covariates were age, sex, race/ethnicity, admission FIM ratings, additional comorbidities (none, 1-3, and >3), type of stroke, and length of stay. RESULTS We studied 47,853 patients with stroke, 368 with RA, and 119 with SLE. Discharge dispositions were similar for patients with RA and non-RA/SLE (81% discharged home). At discharge, the average FIM rating for patients with RA was 85.8, compared with 87.8 for non-RA/SLE patients. At followup, the average FIM rating for patients with RA was 95.9, compared with 99.6 for non-RA/SLE patients. RA was associated with lower FIM ratings at discharge and followup in multivariate analyses. SLE was associated with younger age (17.5 years). However, patients with SLE had similar discharge dispositions and FIM ratings to non-RA/SLE patients. CONCLUSION RA was associated with lower functional status ratings at discharge and followup. Outpatient therapy for patients with RA may reduce long-term assistance. Patients with SLE were younger, but had similar functional outcomes to patients without RA/SLE, suggesting early morbidity from stroke among patients with SLE.