Pamela M. Smith

Intermodal agreement of follow-up telephone functional assessment using the functional independence measure in patients with stroke

OBJECTIVE To examine the intermodal agreement of Functional Independence Measure (FIM) ratings when obtained by two commonly used approaches: telephone interview and in-person assessment of functional performance. DESIGN A random sample of 40 persons with hemiparesis was tested by two registered nurses trained in FIM definitions and telephone interview techniques. The two assessments occurred within 5 days of each other. The raters were blind to previous assessments. The administration of assessments was alternated to minimize bias and order effects. SETTING All subjects were assessed at home, between 3 and 10 months after discharge from rehabilitation. PATIENTS The criteria for inclusion were: (1) diagnosis of cerebral vascular accident (CVA); (2) completion of a minimum of 2 weeks in an acute rehabilitation program; (3) currently living at home; (4) living within a 30-mile radius of the hospital; and (5) cognitive and verbal skills adequate to complete a telephone interview. From a population of 103 patients, 40 subjects were randomly selected, 18 women and 22 men ranging in age from 37 to 90 years. MAIN OUTCOME MEASURES The intermodal agreement between FIM ratings obtained by telephone interview and in-person assessment was examined using the intraclass correlation (ICC). FIM item scores were analyzed for agreement using the Kappa coefficient. The stability of the responses was determined by computing the coefficient of variation and plotting the data to visually examine the relationship between the two methods of administration. RESULTS Data analysis revealed that there was no statistically significant difference (p > .05) between the two methods of administration for total FIM score. The total FIM ICC was .97. ICC values for FIM subscales ranged from .85 to .98, except for social cognition. Kappa scores for noncognitive items ranged from .49 (bowel movement) to .93 (grooming). The coefficient of variation computed to examine cognitive and communication items with reduced variability indicated good stability across all items. CONCLUSION The results indicated good intermodal agreement for follow-up telephone assessment using the Functional Independence Measure. The findings were limited to persons with effective communication skills.

Comparison of logistic regression and neural networks to predict rehospitalization in patients with stroke

CONTEXT Rehospitalization following inpatient medical rehabilitation has important health and economic implications for patients who have experienced a stroke. OBJECTIVE Compare logistic regression and neural networks in predicting rehospitalization at 3-6-month follow-up for patients with stroke discharged from medical rehabilitation. DESIGN The study was retrospective using information from a national database representative of medical rehabilitation patients across the US. SETTING Information submitted to the Uniform Data System for Medical Rehabilitation from 1997 and 1998 by 167 hospital and rehabilitation facilities from 40 states was examined. PARTICIPANTS 9584 patient records were included in the sample. The mean age was 70.74 years (SD = 12.87). The sample included 51.6% females and was 77.6% non-Hispanic White with an average length of stay of 21.47 days (SD = 15.47). MAIN OUTCOME MEASURES Hospital readmission from 80 to 180 days following discharge. RESULTS Statistically significant variables (P <.05) in the logistic model included sphincter control, self-care ability, age, marital status, ethnicity and length of stay. Area under the ROC curves were 0.68 and 0.74 for logistic regression and neural network analysis, respectively. The Hosmer-Lemeshow goodness-of-fit chi-square was 11.32 (df = 8, P = 0.22) for neural network analysis and 16.33 (df = 8, P = 0.11) for logistic regression. Calibration curves indicated a slightly better fit for the neural network model. CONCLUSION There was no statistically significant or practical advantage in predicting hospital readmission using neural network analysis in comparison to logistic regression for persons who experienced a stroke and received medical rehabilitation during the period of the study.

Reliability of the Positive and Negative Affect Schedule (PANAS) in medical rehabilitation

Objective: To examine the reliability of the Positive and Negative Affect Schedule (PANAS) in patients 90 and 100 days after discharge from inpatient medical rehabilitation. Design: A prospective study. Subjects: A convenience sample of 31 medical rehabilitation patients. Main measures: The PANAS. Results: The average age was 74 years, 80.7% were female and the average length of stay was 13 days. The test-retest intraclass correlation (ICC) values for the positive and negative affect scales (at the 90 and 100 day follow-up assessment) were 0.79 and 0.93, respectively. Conclusions: Our results show that the PANAS has excellent reliability among a sample of patients who received inpatient medical rehabilitation.

Satisfaction with medical rehabilitation in patients with cerebrovascular impairment

Ottenbacher KJ, Gonzales VA, Smith PM, Illig SB, Fiedler RC, Granger CV: Satisfaction with medical rehabilitation in patients with cerebrovascular impairment. Am J Phys Med Rehabil 2001;80:876–884. ObjectiveOverall satisfaction has important social and economic implications for patients who have received inpatient medical rehabilitation. We conducted this study to examine the overall satisfaction level at 3- to 6-mo follow-up for inpatients with cerebrovascular impairments discharged from medical rehabilitation. DesignThe study was retrospective using information from a national database representative of medical rehabilitation patients across the United States. Information submitted in 1997 and 1998 to the Uniform Data System for Medical Rehabilitation by 177 hospital and rehabilitation facilities from 40 states was examined. The final sample included 8,900 patient records. The main outcome measure was the level of satisfaction with medical rehabilitation at 80–180 days postdischarge follow-up. ResultsA logistic regression model including ten independent variables was used to predict satisfied vs. dissatisfied at follow-up. Three statistically significant variables were included in the final model and correctly classified 95.1% of the patients. Higher FIM™ instrument discharge scores were associated with increased satisfaction. Further analysis of the FIM instrument subscales indicated that higher ratings in transfers, social cognition, and locomotion were significantly associated with increased satisfaction. ConclusionWe identified several functional variables associated with increased satisfaction after medical rehabilitation in persons with stroke. The ability to objectively assess patient satisfaction is important as consumer-based outcome measures are integrated in accreditation and healthcare evaluation.

Use of Rehabilitation and Other Health Care Services by Patients With Joint Replacement After Discharge From Skilled Nursing and Inpatient Rehabilitation Facilities

OBJECTIVE To compare use of rehabilitation and other health services among patients with knee and hip replacement after discharge from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). DESIGN Follow-up interview study at 7.5 months after discharge. SETTING Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs from across the United States. PARTICIPANTS Patients (N=856): patients with knee replacement (n=561) and patients with hip replacement (n=295). INTERVENTIONS No interventions. MAIN OUTCOME MEASURES Number of home and outpatient therapy visits, physician visits, emergency room visits, rehospitalizations, and medical complications. RESULTS After discharge from postacute care, the vast majority of patients received home rehabilitation, outpatient rehabilitation, or both. Patients with knee replacement received an average of 19 home and/or outpatient rehabilitation visits; patients with hip replacement received almost 15 visits. There were no statistically significant differences in rates of emergency room use and rehospitalization except that patients with hip replacement discharged from IRFs had higher rates of rehospitalization than those discharged from freestanding SNFs (15.8% vs 3.1%). Multivariate analyses did not find any SNF/IRF effects. CONCLUSIONS Patients with joint replacement from both SNFs and IRFs receive considerable amounts of follow-up rehabilitation care. Study uncovered no setting effects related to rehospitalization or medical complications. Looking only at care rendered in the initial postacute setting provides an incomplete picture of all care received and how it may affect follow-up outcomes.

Disparity in health services and outcomes for persons with hip fracture and lower extremity joint replacement.

Objective. Examine disparity in health services and outcomes for adults with a hip fracture or lower extremity joint replacement. Materials and methods. This study examined 28,522 patient records including 12,328 (mean age 76.6 years) with hip fracture and 16,194 (mean age 71.8 years) with joint replacement. Results. Non-Hispanic white and black patients were significantly (P <0.05) more likely to be discharged home alone and responsible for their own care than were Asian or Hispanic patients. Sixty-four percent of Hispanic patients received inpatient rehabilitation after hip fracture and 36% after hip or knee arthroplasty. In contrast, 58% of non-Hispanic white persons, 67% of black persons, and 56% of Asian persons received inpatient medical rehabilitation after hip or knee joint replacement. Conclusion. Disparity in outcomes appeared to be related to family structure and social support.

Hospital readmission of persons with hip fracture following medical rehabilitation

A significant percentage of older adults hospitalized and treated for hip fracture are readmitted to a hospital within six months. We analyzed information from a national database, the Uniform Data System for Medical Rehabilitation. Records for 8,236 patients (1994-98) who received inpatient medical rehabilitation following treatment for hip fracture were examined. Mean age was 76.51 years (S.D. = 12.48) with 71% female and 79% non-Hispanic White. The primary outcome measure was incidence of hospital readmission 0-180 days post-discharge. The hospital readmission rate was 16.7%. A Cox regression model predicting rehospitalization included the following variables (p < 0.05): basic daily living skills, age, length of stay, ethnicity, and gender. There was a statistically significant difference in the percent of male versus female patients rehospitalized for Hispanic subjects but not for non-Hispanic white or African American subjects. The greatest variability occurred among male patients. A total of 18.1% of non-Hispanic White males and 16.8% of African American males were rehospitalized. In contrast, only 10.1% of Hispanic males were rehospitalized. Basic daily living skills, length of hospital stay, age, ethnicity and gender were variables associated with hospital readmission following medical rehabilitation in persons with hip fracture. These variables should be considered in developing intervention programs to reduce the risk of hospital readmission.

Perceived pain and satisfaction with medical rehabilitation after hospital discharge

Objective: To examine the association between pain and satisfaction with medical rehabilitation in patients with hip or knee replacement approximately 90 days after discharge from inpatient medical rehabilitation. Design: A cross-sectional design. Participants: The sample included 2507 patients with hip or knee replacement using information from the IT Health Track medical outcome database. Main outcome measure: Satisfaction with medical rehabilitation. Results: The average age was 70.2 years, 66.5% were female, and 88.5% were non-Hispanic white. Pain scores were significantly and inversely associated with satisfaction with medical rehabilitation after adjustment for possible confounding factors. In patients with hip replacement each one-point increase in pain score was associated with a 10% decreased odds ratio (OR) of being satisfied with medical rehabilitation (OR 0.90, 95% confidence interval (CI) 0.84, 0.96). In patients with knee replacement, each one-point increase in pain score was associated with a 9% decreased odds ratio (OR 0.91, 95% CI 0.87, 0.96) of being satisfied with medical rehabilitation. Conclusion: Our data indicate that postoperative pain from hip or knee replacement is associated with reduced satisfaction with medical rehabilitation. Better postoperative pain control may improve a patients level of satisfaction.

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.

Effect of functional gain on satisfaction with medical rehabilitation after stroke.

Tooth LR, Ottenbacher KJ, Smith PM, Illig SB, Linn RT, Gonzales VA, Granger CV: Effect of functional gain on satisfaction with medical rehabilitation after stroke. Am J Phys Med Rehabil 2003;82:692–699. Objective To examine the association between gain in motor and cognitive functional status with patient satisfaction 3–6 mo after rehabilitation discharge. Design Patient satisfaction and changes in functional status were examined in 18,375 patients with stroke who received inpatient medical rehabilitation. Information was obtained from 144 hospitals and rehabilitation facilities contributing records to the Uniform Data System for Medical Rehabilitation and the National Follow-up Services. Results Data analysis revealed significant (P < 0.05) differences in satisfaction responses based on whether information was collected from patient self-report or from a family member proxy, and the two subsets were analyzed separately. Logistic regression revealed the following significant predictors of satisfaction for data collected from stroke patients: cognitive and motor gain, rehospitalization, who the patient was living with at follow-up, age, and follow-up therapy. In the patient-reported data subset, compared with patients who showed improved cognitive or motor functional status, those with no change, respectively, had a 31% and 33% reduced risk of dissatisfaction. In addition, rehospitalized patients had a higher risk of dissatisfaction. For the proxy reported data subset, significant influences on satisfaction were health maintenance, rehospitalization, stroke type, ethnicity, cognitive FIM™ gain, length of stay, and follow-up therapy. Conclusions Ratings of satisfaction with rehabilitation services were affected by change in functional status and whether the information was collected from patient rating or proxy response.