Richard D. Wilson

Mortality and Cost of Pneumonia After Stroke for Different Risk Groups

An evidenced-based approach to detecting and treating dysphagia needs to be informed by the costs and risks associated with pneumonia. In this study, the cost of pneumonia during hospitalization after stroke and the effect of pneumonia on mortality were estimated. The effect of pneumonia on mortality and costs for different levels of risk were analyzed as well. The data come from the 2005 and 2006 Nationwide Inpatient Sample. Regression models, including the propensity for pneumonia, were used to estimate the in-hospital mortality-associated pneumonia, as well as the marginal cost of pneumonia on the hospitalization. A stratified analysis based on quintile of propensity for pneumonia was also undertaken. There were 183,976 hospitalizations for stroke in the sample. The adjusted relative risk of death associated with pneumonia was 2.0 (95% confidence interval [CI], 1.9-2.1). The average marginal cost of pneumonia on the hospitalization was

Hospitalizations of adults with spina bifida and congenital spinal cord anomalies.

27,633 (95% CI,

Inpatient Cancer Rehabilitation: A Retrospective Comparison of Transfer Back to Acute Care Between Patients With Neoplasm and Other Rehabilitation Patients

27,078-

Peripheral nerve stimulation compared with usual care for pain relief of hemiplegic shoulder pain: a randomized controlled trial.

27,988). The quintile of hospitalizations with the highest propensity for pneumonia had the highest average marginal cost associated with pneumonia and the lowest adjusted relative risk of death. There was an inverse relationship between adjusted relative risk of death and propensity for pneumonia. The data indicate that pneumonia after stroke is associated with higher mortality and hospitalization costs. Patients with the lowest risk for pneumonia have the highest risk for death associated with pneumonia. Screening is important at all levels of risk.

Central Hypersensitivity in Patients with Subacromial Impingement Syndrome

OBJECTIVE To examine hospital admission records from a large cohort of persons with spina bifida (SB) with a variety of insurers to provide descriptive detail about adult hospital use for persons with SB and associated disorders in terms of primary diagnosis for hospitalization, age, sex, payer source, lengths of stay, and total charges. DESIGN Retrospective secondary data analysis from the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project for 2004 and 2005 of hospitalizations for adults with SB or associated spinal cord anomalies. SETTING Records from U.S. inpatient hospital admissions. PARTICIPANTS Persons with SB age 18 years and older. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Diagnoses associated with hospitalizations and death. RESULTS The most common primary diagnosis for hospitalization was urinary tract infection, followed by complications from devices/grafts/implants and skin wounds. Sepsis accounted for the most deaths. Approximately one third of hospitalizations were for primary diagnoses of potentially preventable conditions. Hospitalizations associated with a primary diagnosis of a potentially preventable condition occurred most often in those less than 51 years of age and in rural or urban nonteaching hospitals. CONCLUSIONS Reducing the number of secondary medical conditions with proactive and preventative approaches to health care could reduce the morbidity, mortality, and cost for health care for this group.

A Cost-Effectiveness Analysis of Screening Methods for Dysphagia After Stroke

OBJECTIVE To determine whether patients with diagnoses of neoplasm undergoing acute rehabilitation differ from other patients in frequency of acute care transfer and type of medical complications. DESIGN Retrospective cohort analysis. SETTING Acute rehabilitation hospital located within an academic medical center. PARTICIPANTS Patients with diagnosis of neoplasm (n=40) and patients without neoplasm (n=253) requiring transfer were identified from a database of 2801 rehabilitation discharges over nearly a 4-year period. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Frequency of unplanned transfer and reasons for the transfer. RESULTS Significant difference occurred in overall rate of transfer between patients with neoplasm (21%) and controls (9.7%; P<.001). When evaluated separately for type of neoplasm (with patients receiving corresponding type of rehabilitation as controls), a significantly higher rate of transfer to acute care was found for brain tumor (25% vs 12%; P=.004) and spinal cord neoplasms (23% vs 10%; P=.009), but statistical significance was not reached for other tumor types (12.5% vs 7.4%; P=.19). Patients with stroke with neoplasm as a comorbidity, analyzed separately, with the other patients with stroke as controls, had significantly higher risk of transfer (22% vs 10%; P=.012). Logistic regression analysis found an odds ratio (OR) of 2.5 for unplanned transfer among patients with diagnosis of neoplasm (OR=2.5 for malignancy; OR=2.4 for benign neoplasm). Patients with neoplasm had infection as the most common reason for transfer (28% of the neoplasm transfers vs 18% of other transfers; P=.01), whereas in the nonneoplasm group, cardiopulmonary factors predominated (12% of patients with tumor vs 31% of patients without tumor transfers; P<.001). CONCLUSIONS In the present sample, patients with neoplasm were more likely to require transfer than patients without neoplasm, although this pattern did not reach statistical significance for noncentral nervous system cases. Overall, patients with neoplasm appear more likely than those without neoplasm to have an infectious cause for unplanned transfer. Increased awareness of this difference may lead to improved medical management on rehabilitation units.

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

ObjectiveThis study sought to establish the efficacy of single-lead, 3-wk peripheral nerve stimulation (PNS) therapy for pain reduction in stroke survivors with chronic hemiplegic shoulder pain. DesignThis study is a single-site, pilot, randomized controlled trial of adults with chronic shoulder pain after stroke. Participants were randomized to receive a 3-wk treatment of single-lead PNS or usual care. The primary outcome was the worst pain in the last week (Brief Pain Inventory, Short Form, question 3) measured at baseline and weeks 1, 4, 12, and 16. The secondary outcomes included pain interference (Brief Pain Inventory, Short Form, question 9), pain measured by the ShoulderQ Visual Graphic Rating Scales, and health-related quality-of-life (Short-Form 36 version 2). ResultsTwenty-five participants were recruited, 13 to PNS and 12 to usual care. There was a significantly greater reduction in pain for the PNS group compared with the controls, with significant differences at 6 and 12 wks after treatment. Both PNS and usual care were associated with significant improvements in pain interference and physical health-related quality-of-life. ConclusionsShort-term PNS is a safe and efficacious treatment of shoulder pain. Pain reduction is greater compared with usual care and is maintained for at least 12 wks after treatment.

Single‐Lead Percutaneous Peripheral Nerve Stimulation for the Treatment of Hemiplegic Shoulder Pain: A Case Series

OBJECTIVE To investigate the presence of primary and secondary hyperalgesia among subjects with chronic subacromial impingement syndrome (SIS) compared with pain-free controls. DESIGN Cross-sectional design. SETTING Outpatient rehabilitation clinic, urban, academic medical center. PARTICIPANTS Volunteer sample (N=62) (31 with SIS, 31 controls). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Pressure-pain thresholds (PPTs) were measured at the middle deltoid of the affected/dominant arm (primary or secondary hyperalgesia) and the middle deltoid and tibialis anterior of the unaffected/nondominant side (secondary hyperalgesia) in SIS and healthy controls, respectively. Differences in PPTs were analyzed by Wilcoxon rank sum test and with linear regression analysis controlling for sex, a known confounder of PPTs. RESULTS After adjusting for sex, subjects with SIS had significantly lower PPTs than did controls at all locations. Controls had a 1.4 kg/cm(2) (95% confidence interval [CI], 1.2-1.5) higher PPT at their affected shoulder than did those with SIS, a 0.7 kg/cm(2) (95% CI, 0.5-0.9) higher PPT at their nonaffected shoulder, and a 1.1 kg/cm(2) (95% CI, 1.1-1.2) higher PPT at their contralateral tibialis anterior. Observers were not blinded to patient groupings but were blinded to the level of applied pressure. CONCLUSIONS This study provides further evidence that patients with SIS have significantly lower PPTs than do controls in both local and distal areas from their affected arm consistent with primary and secondary hyperalgesia, respectively. Data suggest the presence of central sensitization among subjects with chronic SIS.

Central Hypersensitivity in Chronic Hemiplegic Shoulder Pain

To provide a cost‐effectiveness analysis of dysphagia screening in the acute poststroke period with use of a videofluoroscopic swallowing study, a clinical bedside swallowing evaluation, or a combined approach.

Targeted Preventive Care May Be Needed for Adults with Congenital Spine Anomalies

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.