Jacqueline Mix

Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients

ObjectiveTo examine functional status versus medical comorbidities as predictors of acute care readmissions in medically complex patients.DesignRetrospective database study.SettingU.S. inpatient rehabilitation facilities.ParticipantsSubjects included 120,957 patients in the Uniform Data System for Medical Rehabilitation admitted to inpatient rehabilitation facilities under the medically complex impairment group code between 2002 and 2011.InterventionsA Basic Model based on gender and functional status was developed using logistic regression to predict the odds of 3-, 7-, and 30-day readmission from inpatient rehabilitation facilities to acute care hospitals. Functional status was measured by the FIM® motor score. The Basic Model was compared to six other predictive models—three Basic Plus Models that added a comorbidity measure to the Basic Model and three Gender-Comorbidity Models that included only gender and a comorbidity measure. The three comorbidity measures used were the Elixhauser index, Deyo-Charlson index, and Medicare comorbidity tier system. The c-statistic was the primary measure of model performance.Main Outcome MeasuresWe investigated 3-, 7-, and 30-day readmission to acute care hospitals from inpatient rehabilitation facilities.ResultsBasic Model c-statistics predicting 3-, 7-, and 30-day readmissions were 0.69, 0.64, and 0.65, respectively. The best-performing Basic Plus Model (Basic+Elixhauser) c-statistics were only 0.02 better than the Basic Model, and the best-performing Gender-Comorbidity Model (Gender+Elixhauser) c-statistics were more than 0.07 worse than the Basic Model.ConclusionsReadmission models based on functional status consistently outperform models based on medical comorbidities. There is opportunity to improve current national readmission risk models to more accurately predict readmissions by incorporating functional data.

Validity and reliability of the FIM instrument in the inpatient burn rehabilitation population.

OBJECTIVE To provide evidence of construct validity for the FIM instrument in the inpatient rehabilitation burn population. DESIGN Confirmatory factor analysis and item response theory were used to assess construct validity. Confirmatory factor analysis was performed on a 2-factor model of the FIM instrument and on a 6-subfactor model. Mokken scale analysis, a nonparametric item response theory, was performed on each of the FIM instruments 2 major factors, motor and cognitive domains. Internal consistency using Cronbach alpha and Molenaar and Sijtsmas statistic was also examined. SETTING Inpatient rehabilitation facilities. PARTICIPANTS Data from the Uniform Data System for Medical Rehabilitation for patients with an impairment code of burn injury from the years 2002 to 2011 were used for this analysis. A total of 7569 subjects were included in the study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Comparative fit index results for the confirmatory factor analyses and adherence to assumptions of the Mokken scale model. RESULTS Confirmatory factor analysis provided a comparative fit index of .862 for the 2-factor model and .941 for the 6-subfactor model. Mokken scale analysis showed scalability coefficients of .681 and .891 for the motor and cognitive domains, respectively. Measures of internal consistency statistic gave values of >.95 for each major domain of the FIM instrument. CONCLUSIONS The FIM instrument has evidence of validity and reliability as an outcome measure for patients with burn injuries in the inpatient rehabilitation setting. The 6-subfactor model provides a better fit than the 2-factor model by confirmatory factor analysis. There is evidence that the motor and cognitive domains each form valid unidimensional metrics based on nonparametric item response theory.

Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population.

Objective Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissions in the inpatient rehabilitation stroke population compared with medical comorbidities using a large, administrative data set. Methods A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed examining stroke patients admitted to inpatient rehabilitation facilities. A Basic Model for predicting acute care readmission risk based on age and functional status was compared with models incorporating functional status and medical comorbidities (Basic-Plus) or models including age and medical comorbidities alone (Age-Comorbidity). C-statistics were compared to evaluate model performance. Findings There were a total of 803,124 patients: 88,187 (11%) patients were transferred back to an acute hospital: 22,247 (2.8%) within 3 days, 43,481 (5.4%) within 7 days, and 85,431 (10.6%) within 30 days. The C-statistics for the Basic Model were 0.701, 0.672, and 0.682 at days 3, 7, and 30 respectively. As compared to the Basic Model, the best-performing Basic-Plus model was the Basic+Elixhauser model with C-statistics differences of +0.011, +0.011, and + 0.012, and the best-performing Age-Comorbidity model was the Age+Elixhauser model with C-statistic differences of -0.124, -0.098, and -0.098 at days 3, 7, and 30 respectively. Conclusions Readmission models for the inpatient rehabilitation stroke population based on functional status and age showed better predictive ability than models based on medical comorbidities.

Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities.

ObjectiveThe aim of this study was to examine the impact of pressure ulcers on inpatient rehabilitation facility (IRF) outcomes. DesignThis is a retrospective analysis of the IRF data in the United States from the Uniform Data System for Medical Rehabilitation between 2009 and 2011. The study sample included 2902 pairs of pressure ulcer and pressure ulcer–free patients upon IRF admission, matching on age at admission, sex, impairment groups, and comorbidity tier measures. The study outcomes were cognition and motor functional gains measured by the Functional Independence Measure instrument, IRF length of stay, and discharge to the community. ResultsThe mean pressure ulcer prevalence upon IRF admission was 5.23%. After controlling for other covariates under study, the pressure ulcer group had a lower motor gain (20.12 vs. 21.58, P < 0.0001), had a longer length of stay (16.5 vs. 15.5, P < 0.0001), and were less likely to be discharged to the community after IRF stay (odds ratio, 0.72; 95% confidence interval, 0.62–0.84) than the patients without a pressure ulcer. ConclusionsThe presence of a pressure ulcer among the patients seen in United States IRFs had no impact on cognition functional gain but was associated with a minor lower motor gain, a longer IRF length of stay, and lower odds of being discharged to the community.

Time to rehabilitation in the burn population: incidence of zero onset days in the UDSMR national dataset.

A preliminary investigation of the burn rehabilitation population found a large variability of zero onset day frequency between facilities. Onset days is defined as the time from injury to inpatient rehabilitation admission; this variable has not been investigated in burn patients previously. This study explored if this finding was a facility-based phenomena or characteristic of burn inpatient rehabilitation patients. This study was a secondary analysis of Uniform Data System for Medical Rehabilitation (UDSmr®) data from 2002 to 2007 examining inpatient rehabilitation characteristics among patients with burn injuries. Exclusion criteria were age less than 18 years and discharge against medical advice. Comparisons of demographic, medical and functional data were made between facilities with a high frequency of zero onset days versus facilities with a low frequency of zero onset days. A total of 4738 patients from 455 inpatient rehabilitation facilities were included. Twenty-three percent of the population exhibited zero onset days (n = 1103). Sixteen facilities contained zero onset patients; two facilities accounted for 97% of the zero onset subgroup. Facilities with a high frequency of zero onset day patients demonstrated significant differences in demographic, medical, and functional variables compared to the remainder of the study population. There were significantly more zero onset day admissions among burn patients (23%) than other diagnostic groups (0.5– 3.6%) in the Uniform Data System for Medical Rehabilitation database, but the majority (97%) came from two inpatient rehabilitation facilities. It is unexpected for patients with significant burn injury to be admitted to a rehabilitation facility on the day of injury. Future studies investigating burn rehabilitation outcomes using the Uniform Data System for Medical Rehabilitation database should exclude facilities with a high percentage of zero onset days, which are not representative of the burn inpatient rehabilitation population.

Length of Stay at Inpatient Rehabilitation Facility and Stroke Patient Outcomes

Purpose: To examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes. Design: A secondary data analysis of the Uniform Data System for Medical Rehabilitation database. Methods: Stroke patients discharged from IRFs in the United States between 2009 and 2011 were identified and divided into mild (n = 639), moderate (n = 2,065), and severely (n = 2,077) impaired groups. Study outcomes included cognition and motor functional gains measured by the Functional Independence Measure (FIM) instrument and discharge to the community. Findings: The average LOS was 8.9, 13.9, and 22.2 days for mild, moderate, and severely impaired stroke patients, respectively. After controlling for FIM admission and other important covariates, a longer LOS was associated with a modest increase in cognition gain (&bgr; = 0.038, p = .0045) for the moderately impaired patients, and a modest increase in cognition (&bgr; = 0.13, p < .0001) and motor gains (&bgr; = 0.25, p < .0001) as well as a tendency for discharge to the community (OR = 1.01, 95% CI = 1.00–1.02) among the severely impaired patients. However, a longer LOS showed a negative association with functional gains among the mildly impaired patients as well as discharge to community for both mild and moderately impaired patients. Conclusion: The association of IRF LOS and patient outcomes varied by stroke impairment severity, positively for more severely impaired patients and negatively for mildly impaired patients. Clinical Relevance: The study provides evidence for the care of stroke patients at the IRF setting.

Using Functional Status in the Acute Hospital to Predict Discharge Destination for Stroke Patients.

ObjectiveThe aim of this study was to determine whether functional status, as measured by the AcuteFIM instrument, can be used to predict discharge destination of stroke patients from the acute hospital setting. DesignA retrospective cohort study was carried out in an urban academic medical center. Data were collected on 481 new-onset stroke patients 18 yrs or older in an acute hospital between January 1 and September 30, 2013. Functional Independence Measure (FIM) instrument data were linked to a subset of 54 patients who received additional services at an inpatient rehabilitation facility. A receiver operator characteristic curve was constructed to validate the predictive ability of the AcuteFIM instrument and to determine the optimal cutoff score associated with discharge to a community setting. ResultsAll AcuteFIM items in stroke patients at admission demonstrated strong interitem correlation coefficients (all above 0.6) and high internal consistency (Cronbach &agr; = 0.94). The AcuteFIM total score was positively associated with discharge to the community from the acute hospital (odds ratio, 1.06; 95% confidence interval, 1.05–1.07). Receiver operator characteristic curve analysis generated a c statistic of 0.89 (95% confidence interval, 0.87–0.92), indicating that the AcuteFIM instrument is predictive of patient discharge to the community setting. ConclusionThis study suggests that the AcuteFIM instrument is a reliable tool that can be used to predict discharge destination from the acute hospital among stroke patients.

Inpatient rehabilitation experience of children with burn injuries: a 10-yr review of the Uniform Data System for Medical Rehabilitation

ObjectiveThis study aimed to describe the pediatric burn inpatient rehabilitation population and short-term functional outcomes using the Uniform Data System for Medical Rehabilitation. DesignThis is a secondary analysis of data from the Uniform Data System for Medical Rehabilitation database between 2002 and 2011 included children younger than 18 yrs at time of admission to inpatient rehabilitation with primary diagnosis of burn injury. Demographic, medical, and functional data were evaluated. Function was assessed with the Functional Independence Measure or the WeeFIM. ResultsA total of 509 children were included, of whom 124 were evaluated with Functional Independence Measure and 385 with WeeFIM. The mean age of the population was 8.6 yrs and most were boys (72%). The mean length of stay for the population was 35 days. Functional status improved significantly from admission to discharge; most gains were in the motor subscore. Most patients were discharged home (95%). Of those discharged home, most (96%) went home with family. ConclusionsChildren receiving multidisciplinary inpatient rehabilitation make significant functional improvements in total functional scores and in both motor and cognitive subscores. Most patients are discharged home with family. This study advances understanding of pediatric burn post–acute care outcomes.

Early inpatient rehabilitation admission and stroke patient outcomes.

ObjectiveThe aim of this study was to examine the associations of onset days, time from stroke onset to inpatient rehabilitation facility (IRF) admission, and patient outcomes (FIM gain, discharge destination, and IRF length of stay), using nationally representative data. DesignA secondary data analysis was conducted on a random sample of stroke patients discharged from IRFs in the United States between 2009 and 2011, including mildly (n = 649), moderately (n = 2185), and severely (n = 2390) impaired patients. ResultsThe study sample had a median of onset days of 5.5, with an interquartile range of 4–9. With the use of 15–365 days as reference, the severely impaired patients had a higher cognition gain (P < 0.01) and were more likely to be discharged to the community (odds ratio, 1.45; 95% confidence interval, 1.12–1.87) when admitted within 7 days, a greater motor gain when admitted within 14 days (P < 0.01), and a lower risk for acute hospital transfer when admitted 3–7 days (odds ratio, 0.62; 95% confidence interval, 0.43–0.90). The moderately impaired patients had a greater motor gain when admitted within 7 days (P < 0.01). Early IRF admission was also associated with a shorter length of stay. ConclusionsEarlier IRF admission was beneficial among severely and moderately impaired patients. IRF admission within 7 days is recommended for stroke patients who achieved medical stability.

Assessing the ability of comorbidity indexes to capture comorbid disease in the inpatient rehabilitation burn injury population

Objective Burn patients exhibit comorbidities that influence outcomes. This study examines whether existing comorbidity measures capture comorbidities in the burn inpatient rehabilitation population. Design Data were obtained from the Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury. International Classification of Diseases, 9th Revision, codes were used to assess three comorbidity measures (Charlson Comorbidity Index, Elixhauser Comorbidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers). The number of subjects and unique comorbidity codes (>1% of frequency) captured by each comorbidity measure was calculated. Results The study included 5347 patients with a median total body surface area burn decile of 20%–29%, mean age of 51.6 yrs, and mean number of comorbidities of 7.6. There were 2809 unique International Classification of Diseases, 9th Revision, comorbidity codes. The Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Centers for Medicare and Medicaid Services Comorbidity Tiers did not capture 67%, 27%, and 58% of the subjects, respectively. There were 107 unique comorbidities that occurred with a frequency of greater than 1%. Of these, 67% were not captured in all three comorbidity measures. Conclusions Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the burn rehabilitation population. Future work is needed to assess the need for comorbidity indexes specific to the inpatient rehabilitation setting.