Patrick K. Murray

Trends in the Rehabilitation Therapist Workforce in Underserved Areas: 1980-2000.

CONTEXT There is little information about how increases in the rehabilitation therapist workforce have been distributed over the nation. There is evidence that rural areas continue to face a shortage of trained rehabilitation providers. There has also been little attention to therapist distribution in non-rural settings where health professionals are in short supply. PURPOSE To assess the change in the distribution of rehabilitation therapists in 1980, 1990, and 2000 across counties with different levels of health professional shortages and the difference between metropolitan and non-metropolitan counties. METHODS A trend analysis of cross-sectional data of employment of physical therapists, occupational therapists, and speech-language pathologists from 1980 to 2000 by county, relative to population, was done. The groups were stratified by shortage area, partial shortage area, and non-shortage counties and metropolitan and non-metropolitan counties. FINDINGS There is a maldistribution of rehabilitation therapists in the United States. Although the absolute differences have remained the same or, in most instances, have increased, the relative change was greatest in the shortage areas and non-metropolitan areas. If the trends in the relative changes continue, the absolute differences may begin to narrow. CONCLUSIONS This study provides evidence that there are maldistributions of rehabilitation therapists in traditionally underserved areas. It is unclear if these maldistributions represent a shortage of rehabilitation therapists. Continued monitoring of the rehabilitation therapist workforce and the determination of the optimal supply should be undertaken in the future.

Rapid growth of rehabilitation services in traditional community-based nursing homes

OBJECTIVE To describe the changes in rehabilitation therapy services in nursing homes based in the community during a period of rapid escalation of Medicare payments to nursing homes. SETTING All Medicaid-certified nursing homes in Ohio. SUBJECTS The 52,705 residents newly admitted to nursing homes in 1994 and 1995. DESIGN Retrospective trend analysis of administrative data. MAIN OUTCOME MEASURES For newly admitted residents receiving 90 or more minutes of rehabilitation therapy per week, the trends in percentage and in the amount and type of therapy received were determined for eight quarters. RESULTS Of all newly admitted residents, 50.5% received 90 or more minutes of therapy. When they received such therapy it averaged 412 minutes per week (SD = 259). Those residents who received rehabilitation services increased by 2.2% each quarter (p<.001), and the amount of therapy they received increased by 6.4 minutes each quarter (p<.0001). All three types of rehabilitation therapy-physical, occupational, and speech-increased (p<.015) over the study period. CONCLUSIONS The traditional nursing home is an important site for the provision of rehabilitation therapy services. Rehabilitation specialists should be aware of these trends as they plan for the future of rehabilitation. The effectiveness of this increased provision of therapy service in terms of measurable outcomes needs to be evaluated.

Rehabilitation services after the implementation of the nursing home prospective payment system: differences related to patient and nursing home characteristics.

Background:The prospective payment system (PPS) for nursing homes was designed to curtail the rapid expansion of Medicare costs for skilled nursing care. This study examines the changes that occurred in nursing home patients and rehabilitation services following the PPS. Setting:Free-standing Medicare and/or Medicaid certified nursing homes in Ohio. Primary Outcomes:The percent of new admissions receiving therapy and the amount of rehabilitation therapy provided. Sample:A total of 7006 first admissions in 1994–6 (pre-PPS) and 61,569 first admissions in 2000–1 (post-PPS). Methods:A logistic model predicting likelihood of rehabilitation was developed and validated in pre-PPS admissions and applied to the post-PPS patients. Rehabilitation services were compared in the pre-PPS and post-PPS cohorts overall, stratified by quintile of predicted score, diagnosis group, and by nursing home profit status. Results:Post-PPS patients had less cognitive impairment, more depression, and more family support. The amount of rehabilitation services declined the most in the higher quintiles of predicted likelihood of rehabilitation and among patients with stroke. The percent of patients receiving rehabilitation services increased the most in the lowest quintile and among patients with medical conditions. These changes were greater in for-profit nursing homes. Conclusions:The implementation of the PPS in nursing homes has been associated with a decrease in the amount of rehabilitation services, targeted at those predicted to receive higher amounts and an increased frequency of providing services targeted at those predicted to be less likely to receive them. The outcomes of the changes deserve further study.

Patients With Worse Mental Health Report More Physical Limitations After Adjustment for Physical Performance

Objective: To determine whether mental health scores are associated with self-reported physical limitations after adjustment for physical performance. Patient-reported physical limitations are widely used to assess health status or the impact of disease. However, patients’ mental health may influence their reports of their physical limitations. Methods: Mental health and physical limitations were measured using the SF-36v2 mental health and physical functioning subscales in a cross-sectional study of 1024 participants. Physical performance was measured using tests of strength, endurance, dexterity, and flexibility. Multivariable linear regression was performed to examine the relationship between self-reported mental health and physical limitations adjusting for age, gender, race/ethnicity, education, body mass index, and measured physical performance. Results: The score distributions for mental health and physical functioning were similar to that of the United States population in this age range. In unadjusted analyses, every 10-point decline in mental health scores was associated with a 4.8-point decline in physical functioning scores (95% Confidence Interval (CI) = −4.2 to −5.3; p < .001). After adjusting for covariables including measured physical performance, every 10-point decline in mental health scores was associated with a 3.0-point decline in physical functioning scores (95% CI = −2.5 to −3.6; p < .001). Conclusions: People with poor mental health scores seem to report more physical limitations than would be expected based on physical performance. When comparing self-reported physical limitations between groups, it is important to consider differences in mental health. BMI = body mass index; CI = Confidence Interval; SD = standard deviation; SF-36v2 = SF-36v2 Health Survey.

Hypertension Guideline Adherence Among Nursing Home Patients

BackgroundAdherence to hypertension guidelines in the outpatient setting is low.ObjectiveTo evaluate adherence to JNC VII guidelines in nursing home patients.DesignData were obtained from the 2004 National Nursing Home Survey (NNHS), a nationally representative sample of US nursing homes. Patients with hypertension were identified using ICD-9 codes. Adherence to JNC VII guidelines was defined as the use of a thiazide diuretic in patients without a compelling indication for a different class of antihypertensive medication, such as diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke.ParticipantsThere were 13,507 patients in the 2004 NNHS survey, of whom 7,129 had hypertension.Main ResultsOf these 7,129 hypertensive patients, only 12.6% were on a thiazide. Out of the 7,129 hypertensive patients, 3,113 did not have diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke. Of these 3,113 patients, only 13.9% were on a thiazide. After excluding patients with a potential contraindication to a diuretic, such as hospice care or incontinence, only 18% were prescribed a thiazide. Of the 3,113 patients, 1,148 were on a single class of antihypertensive and more were prescribed a beta blocker, ACE inhibitor, calcium channel blocker, loop diuretic, and ARB than a thiazide diuretic.ConclusionsAdherence to hypertension guidelines among nursing home patients is low. The appropriate use of thiazide diuretics could reduce costs and improve blood pressure control and patient outcomes.