Paulette Niewczyk

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.

Predictors of transfer from rehabilitation to acute care in burn injuries.

BACKGROUND Transfer to acute care from rehabilitation represents an interruption in a patient’s recovery and a potential deficiency in quality of care. The objective of this study was to examine predictors of transfer to acute care in the inpatient burn rehabilitation population. METHODS Data are obtained from Uniform Data System for Medical Rehabilitation from 2002 to 2010 for patients with a primary diagnosis of burn injury. Predictor variables include demographic, medical, and facility data. Descriptive statistics are calculated for acute and nonacute transfer patients. Logistic regression analysis is used to determine significant predictors of acute transfer within the first 3 days. A scoring system is developed to determine the risk of acute transfer. RESULTS There were 78 acute transfers in the first 3 days of a total of 4,572 burn admissions. Functional level at admission, age, and admission classification are significant predictors of transfer to acute care (p < 0.05). Total body surface area burned and medical comorbidities were not significantly associated with acute transfer risk. A 12-point acute transfer risk scoring system was developed, which demonstrates validity. CONCLUSION Efforts to reduce readmissions to acute care should include greater scrutiny of older, lower-functioning patients with burn injury who are evaluated for admission to inpatient rehabilitation. This acute transfer scoring system may be useful to clinicians, health care institutions, and policymakers to help predict those patients at highest risk for early transfer to the acute hospital from rehabilitation. LEVEL OF EVIDENCE Prognostic/diagnostic study, level II.

Outcomes and predictors in burn rehabilitation.

Advances in burn care in recent decades have resulted in a growing population of burn survivors and an increased need for inpatient rehabilitation. Burn survivors who require inpatient rehabilitation typically experience severe and complicated injuries. The purpose of this study is to examine burn rehabilitation outcomes and their predictor variables. Data are obtained from the Uniform Data System for Medical Rehabilitation from 2002 to 2007. Inclusion criterion is primary diagnosis of burn injury. Predictor variables include demographic, medical, and facility data. Outcome measures are length of stay efficiency, FIM® gain, community discharge, and FIM® discharge of at least 78. Linear and logistic regression analyses are used to determine significant predictors of outcomes. There are 2920 patients who meet inclusion criteria. The mean age of the population is 51 years, 33% of the population is female, 73% is Caucasian, and 40% are married. The median TBSA decile is 20 to 29%. The population exhibits a mean FIM® gain of 28 and length of stay efficiency of 2.1. A majority of the population is discharged to the community (76%) and has a FIM® discharge of at least 78 (81%). Significant predictors of outcomes in burn rehabilitation include age, FIM® admission, onset days, employment status, and marital status. Inpatient rehabilitation is critical to community reintegration of burn survivors. Survivors who are young, married, employed, and higher functioning at the time of admission to rehabilitation demonstrate the best outcomes. This research will help assess the rehabilitation potential of burn survivors and inform resource allocation.

Predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients.

Objective This study aimed to determine the predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients. DesignThis was a retrospective study using data from the Uniform Data System for Medical Rehabilitation (UDSMR) between 2008 and 2009. The main outcome variable was discharge location, which included discharge to acute care or discharge to the community after inpatient rehabilitation. The study sample included 223 of the most severely affected stroke patients (Case-Mix Group 0110 of Medicare reimbursement classification), of whom 86 were discharged to acute care from after the inpatient medical rehabilitation setting; 137 similarly classified stroke patients were discharged to the community after inpatient medical rehabilitation. The variables examined were Functional Independence Measure ratings, co-morbid medical conditions, and four groups of stroke-related neurologic deficits (hemiparesis, dysphagia, language deficits, and other stroke-related neurologic deficits). The groups were devised based on International Classification of Diseases, 9th Revision codes. ResultsThere were no significant demographic differences between the two groups—those discharged to the acute care hospital and those discharged to the community. There was a difference in admission Functional Independence Measure ratings, whereby patients discharged to acute care were significantly lower (P < 0.05) on admission motor and cognitive function than were patients discharged to the community. When controlling for 19 groups of co-morbid medical conditions and 4 groups of stroke-related neurologic deficits, there was no significant difference between patients being discharged to an acute care hospital and those discharged to the community. ConclusionsIn the current study, controlling for impairment (stroke), severity of condition, demographic variables, inpatient rehabilitation admission day of the week and discharge day of the week, prehospitalization living setting, prehospitalization living with (alone, family, other), payer (secondary insurance coverage), onset days, co-morbid medical conditions, and classification of stroke-related neurologic deficits, the only variable predictive of discharge to the acute care hospital from an inpatient rehabilitation facility is function at admission, mainly the admission motor Functional Independence Measure rating. If clinicians routinely assess the functional status of patients during the preadmission screening process, it may aid in identifying whether the patient is at an increased risk of being readmitted to the acute care hospital.

The uniform data system for medical rehabilitation: Report of patients with traumatic spinal cord injury discharged from rehabilitation programs in 2002-2010

Objective This study aimed to provide benchmarking information from a large national sample of patients receiving inpatient rehabilitation after a traumatic spinal cord injury. Design This was an analysis of secondary data from 891 inpatient medical rehabilitation facilities in the United States that contributed traumatic spinal cord injury data to the Uniform Data System for Medical Rehabilitation from January 2002 to December 2010. Variables analyzed included demographic information (age, sex, marital status, race/ethnicity, prehospital living setting, discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, International Classification of Diseases 9 codes for admitting diagnosis, co-morbidities), and functional status (Functional Independence Measure [FIM] instrument ratings at admission and discharge, FIM efficiency, FIM gain). Results The final sample included 47,153 patients with traumatic spinal cord injury. Overall, the mean length of stay was 26.2 ± 23.2 days: yearly means ranged from 29.7 ± 25.4 in 2002 to 22.9 ± 18.9 in 2009. FIM total admission and discharge ratings also declined during the 8-yr study period; admission decreased from 60.5 ± 17.4 to 55.9 ± 16.3; discharge decreased from 86.1 ± 23.8 to 82.4 ± 23.4. Rehabilitation efficiency (FIM gain per day) remained relatively stable over time (1.6 ± 1.7 points per day). The percentage of all patients discharged to the community ranged from 75.8% to 71.5% per year. Wheelchair users stayed in rehabilitation longer than did persons who could walk (34.6 ± 217.4 vs. 17.4 ± 14.1 days) and also experienced less functional improvement (21.6 ± 15.8 vs. 29.6 ± 16.3 FIM points). Conclusions National data from persons with traumatic spinal cord injury in 2002–2010 indicate that lengths of stay declined, but efficiency in functional independence was stable to slightly increased. More than 70% of patients were consistently discharged to community settings after inpatient rehabilitation.

The Uniform Data System for Medical Rehabilitation: report of patients with hip fracture discharged from comprehensive medical programs in 2000-2007.

Objective: The aim of this study was to provide benchmarking information for a large national sample of patients receiving inpatient rehabilitation because of a hip fracture. Design: A secondary data analysis of records from 893 medical rehabilitation facilities located in the United States that contributed information to the Uniform Data System for Medical Rehabilitation from January 2000 through December 2007 was performed. Variables analyzed included demographic information (age, sex, marital status, race/ethnicity, prehospital living setting, and discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, International Classification of Diseases, Ninth Revision, codes for admitting diagnosis, comorbidities), and Functional Status Information (FIM instrument ratings at admission and discharge, FIM efficiency, and FIM gain). Results: Descriptive statistics from 303,594 patients showed length of stay decreasing from a mean (SD) of 14.5 (7.9) days to 13.3 (5.5) days over the 8-yr study period. FIM total admission and discharge ratings also decreased. Mean admission ratings decreased from 72.5 (14.5) to 59.9 (15.7). Mean discharge ratings decreased from 95.8 (18.1) to 86.0 (19.8). FIM change per day remained relatively stable; mean for the entire sample was 2.1 (1.6). The percentage of persons discharged to the community also decreased across the study period, ranging from 77.8% in 2000 to 70.0% in 2007. All results are likely influenced by various policy changes affecting classification and/or documentation processes. Conclusions: National rehabilitation data from persons with hip fracture in 2000-2007 indicate that patients are spending less time in inpatient rehabilitation care than in previous years and are experiencing improvements in functional independence during their stay. In addition, most patients are discharged to the community after inpatient rehabilitation.

The Uniform Data System for Medical Rehabilitation: report of follow-up information on patients discharged from inpatient rehabilitation programs in 2002-2010.

ObjectiveThe aim of this study was to present yearly aggregated summaries of rehabilitation outcomes at admission, discharge, and follow-up from a national sample of patients receiving inpatient medical rehabilitation for stroke, traumatic brain injury, lower extremity fracture, lower extremity joint replacement, traumatic spinal cord injury, or debility. DesignThis is an analysis of secondary data from more than 300 inpatient rehabilitation facilities in the United States that contributed inpatient and follow-up data to the Uniform Data System for Medical Rehabilitation during the period January 2002 through December 2010. Aggregate variables reported include demographic information, social situation, and functional status (Functional Independence Measure instrument ratings at admission, discharge, and follow-up). Follow-up data were obtained 80–180 days after discharge through telephone interviews by trained clinical staff. ResultsThe final sample included 287,104 patients with follow-up information. The median time to follow-up was 95 days. Overall, more than 90% of the patients within each impairment group were living in the community at follow-up. Follow-up Functional Independence Measure total ratings were stable to slightly increased over time. Change scores (discharge to follow-up) increased in all six groups. The mean Functional Independence Measure gains from discharge to follow-up, as a percentage of mean gains from admission to discharge, varied by impairment category: 46% for spinal cord injury to 71% for lower extremity fracture. Locomotion yielded the lowest ratings at all three assessments within each of the six impairment groups. ConclusionsThe follow-up data from the national sample of patients discharged from inpatient rehabilitation indicate that gains in mean functional independence scores from both admission to discharge and discharge to follow-up gradually increased from 2002 to 2010. At follow-up, more than nine of ten patients in all six groups are living in the community.

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.

The Impact of Comorbidities and Complications on Burn Injury Inpatient Rehabilitation Outcomes

To examine the impact of comorbidities and complications on burn inpatient rehabilitation facilities (IRF) outcomes.

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.