Margaret G. Stineman

A CASE-MIX CLASSIFICATION SYSTEM FOR MEDICAL REHABILITATION

Dissatisfaction with Medicares current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.

A Prediction Model for Functional Recovery in Stroke

BACKGROUND AND PURPOSE Stroke-related physical disability can diminish quality of daily living, place care burden on families, and increase need for long-term institutionalization. We developed a prognostic index for use in research and with potential for adaptation to clinical practice that establishes the likelihood of an individual achieving a specific stage of functional recovery after stroke rehabilitation. METHODS We constructed the index using logistic regression based on 3760 patient records from 96 rehabilitation facilities in 31 states. The stage, as measured by the Functional Independence Measure, includes achievement of the following: independence in eating, grooming, and dressing the upper body; continence in bowel and bladder; and transfer between a bed and chair with supervision only. RESULTS This stage was achieved by 26.1% of patients functioning below it at rehabilitation admission. Disability onset of less than 60 days was associated with more than a 3-fold increase in the likelihood of achieving the stage (adjusted odds ratio, 3.5; 95% confidence interval, 2.0 to 6.0). Each eight-point increase in an eight-item activities of daily living score, measured at admission to rehabilitation, increased the odds 2.5-fold (95% confidence interval, 2.3 to 2.8). For those living alone or employed before the stroke, the odds of achieving the stage increased by factors of 1.3 and 2.2, respectively. The index showed minimal shrinkage on cross validation. The achievement of this profile of function is important because 95.3% of stroke patients who achieved or exceeded it were discharged home, as opposed to only 66.8% of those who did not achieve it. CONCLUSIONS The index can be used to establish prognoses for individual stroke patients at admission to rehabilitation with regard to achieving this stage. Achievement of the stage is associated with a high likelihood of discharge to home.

Impairment-specific dimensions within the functional independence measure☆☆☆

OBJECTIVE The analyses presented in this article were intended to seek more fine-grained impairment-specific dimensions beyond the motor and cognitive dimensions of the Functional Independence Measure (FIMSM). DESIGN The study used factor analysis within 20 categories of impairment to test the hypotheses that FIM items can be grouped according to functional areas of the body and that these item groupings differ depending on the patients impairment. PATIENTS Data from 93,829 patients discharged in 1992 from 252 free-standing rehabilitation hospitals and units were obtained from the Uniform Data System for Medical Rehabilitation. RESULTS In 18 of 20 impairment categories, factor analyses of patients admission FIM scores showed impairment-specific FIM dimensions. Four impairments had a 3-dimensional factor structure, and 14 had a 4-dimensional structure. The impairment-specific dimensions were always nested within the motor-FIM subscale. Reliability coefficients for subscales based on these dimensions ranged from .74 to .97. The subscales appear to cluster FIM items by the area of body involved, neurological level, or relative energy consumption. CONCLUSION The FIM can be viewed as a multilayered multidimensional measure of human function. The impairment-specific dimensions, at an intermediate layer, provide insight about the causal linkage between the impairment and resultant patterns of disability. Impairment-specific subscales are relevant to those clinical or research applications where the type of disability needs to be more closely related to impairment.

The capabilities of upper extremity instrument: reliability and validity of a measure of functional limitation in tetraplegia☆☆☆★

OBJECTIVE To evaluate the reliability and validity of the Capabilities of Upper Extremity (CUE) instrument, designed to measure upper extremity functional limitations in individuals with tetraplegia. Functional limitations are actions such as reaching or grasping and are a link between the domains of impairment and disability. DESIGN Survey of people with chronic spinal cord injury. SETTING Regional spinal cord injury center. SUBJECTS One hundred fifty-four individuals (140 male) with tetraplegia at least 1 year after injury and followed by the center. Mean age was 36.7 years (SD=11.1). Sixty-eight percent were motor complete. METHODS The 32-item CUE was administered by telephone interview twice about 2 weeks apart. The motor portion of the Functional Independence Measure (FIM) was collected during the first interview. Upper extremity motor scores and motor levels were obtained from the most recent assessment in the outpatient chart. The instrument was evaluated for internal consistency, reliability, and validity. Exploratory factor analysis was performed to examine scale structure. RESULTS Homogeneity of the scale was excellent. Cronbachs alpha was .96, and item-total correlations ranged from .49 to .78. Test-retest reliability was high (ICC=.94). All but three items had desired levels of agreement (K > .60). Analysis of variance indicated that the CUE distinguished between motor levels of tetraplegia more than one level apart. The CUE was correlated highly with both motor scores and FIM. Regression analysis indicated that the CUE was better than upper extremity motor scores for predicting FIM scores. The model containing the CUE explained 73% of the variance in FIM and was not enhanced by the addition of motor scores. Factor analysis suggested four potential subscales: arm function (bilateral), right hand function, left hand function, and reaching down. CONCLUSION The CUE exhibits good homogeneity, reliability, and validity; further work is needed to determine its sensitivity to change in function.

All-Cause 1-, 5-, and 10-Year Mortality in Elderly People According to Activities of Daily Living Stage

To examine the independent association between five stages of activities of daily living (ADLs) and mortality after accounting for known diagnostic and sociodemographic risk factors.

Outcome, efficiency, and time-trend pattern analyses for stroke rehabilitation.

We present a series of pattern analysis techniques using inpatient medical rehabilitation as an example setting, stroke as a model diagnosis, and various versions of the Functional Independence Measure-Function Related Groups as a case mix adjuster. The pattern analytic approach uses severity-adjusted benchmarks to distinguish among groups of patients whose outcomes and resource use patterns are lower, typical, or higher than established ranges at set points in treatment. Changing outcome and resource use patterns were illustrated for 1990, 1992, and 1995 discharges (n=34,734). These pattern analytic approaches are applicable to any postacute care rehabilitation setting, assuming the availability of an appropriate case mix adjuster and a reliable patient information system. These techniques provide clinicians with tools to help maintain quality in this era of managed care.

Functional gain and length of stay for major rehabilitation impairment categories. Patterns revealed by function related groups.

This study evaluates the relationship of functional severity to patterns of functional gain and length of stay (LOS) for patients discharged from medical rehabilitation. It further compares differences in patterns between summed and Rasch transformed subscales of the Functional Independence Measure (FIM). Two different schemes of the FIM-Function Related Groups (FIM-FRGs) are used to define groups of patients who present with similar degrees of functional severity. The first scheme was developed using summed admission motor and cognitive FIM subscores (FIM-FRGs). The second scheme was developed by transforming these same motor and cognitive FIM subscores into logits (Logit FIM-FRGs), thus making FIM scores more equal-interval. The study included 32,494 patients who were discharged from 123 facilities that submitted data to the Uniform Data System for Medical Rehabilitation (UDSMR) and involved the separate evaluation of 18 different rehabilitation impairment categories. Motor FIM gain was calculated for each FRG in both schemes as the patients discharge motor FIM score minus the admission motor FIM score. There were four patterns of motor FIM gain and two patterns of LOS across rehabilitation impairment. The most common pattern in both schemes was linear trend, for which median gains and LOS were highest for patients in the most disabled FRGs and lowest for patients in the least disabled FRGs. Gain patterns differed across impairment and across the two schemes. The motor FIM gain distributions provide clinicians with a range of typical functional outcomes for patients admitted to medical rehabilitation. This descriptive approach provides clinicians and administrators with a simple way to compare the motor FIM gain and LOS patterns of patients teated in local facilities with broad-based norms. This sample includes about one-quarter of rehabilitation facilities nationwide, thus representing population standards for facilities participating in the UDSMR. Suggestions are made on how to use these norms most appropriately for both facility and patient comparison.

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.

Activity of Daily Living Staging, Chronic Health Conditions, and Perceived Lack of Home Accessibility Features for Elderly People Living in the Community

OBJECTIVE: To examine the cross‐sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community‐dwelling adults aged 70 and older.

Clinical Factors Associated with Prescription of a Prosthetic Limb in Elderly Veterans

OBJECTIVES: To determine how advanced age influences prosthetic prescription.