Samuel J. Markello

The uniform data system for medical rehabilitation: report of patients with stroke discharged from comprehensive medical programs in 2000-2007.

Granger CV, Markello SJ, Graham JE, Deutsch A, Ottenbacher KJ: The Uniform Data System for Medical Rehabilitation: report of patients with stroke discharged from Comprehensive Medical Programs in 2000-2007. Objective:To provide benchmarking information for a large national sample of patients receiving inpatient rehabilitation after a stroke. Design:Analysis of secondary data from 893 medical rehabilitation facilities located in the United States and contributing information to the Uniform Data System for Medical Rehabilitation from 2000 to 2007. Results: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, event onset date, rehabilitation impairment group, International Classification of Diseases-9 codes for the admitting diagnosis, and comorbidities), and functional status information (FIM® instrument [“FIM”] ratings at admission and discharge, FIM efficiency, and FIM gain). Descriptive statistics revealed that the length of stay decreased from a mean of 19.6 (±12.8) days to 16.5 (±9.8) days during the 8-yr study period. FIM instrument admission and discharge ratings also decreased. Mean admission ratings decreased from 62.5 (±20.1) to 55.1 (±19.3), and mean discharge ratings decreased from 86.4 (±23.6) to 79.8 (±24.0). FIM change remained relatively stable; the mean for the entire sample was 23.9 (±14.8). The percent of persons discharged to the community ranged from 75.8% in 2000 to 69.3% in 2007. All results are likely affected by changes in the definition for program interruption and procedures for FIM data collection. Conclusion:Uniform Data System for Medical Rehabilitation data from persons with stroke receiving rehabilitation from 2000 to 2007 indicate patients are showing improvement in functional independence during their rehabilitation stay, and a large percentage are discharged to community settings.

The Uniform Data System for Medical Rehabilitation Report of Patients with Traumatic Brain Injury Discharged from Rehabilitation Programs in 2000 – 2007

Granger CV, Markello SJ, Graham JE, Deutsch A, Reistetter TA, Ottenbacher KJ: The Uniform Data System for Medical Rehabilitation: Report of patients with traumatic brain injury discharged from rehabilitation programs in 2000–2007. Objective:To provide benchmarking information for a large national sample of patients receiving inpatient rehabilitation after traumatic brain injury. Design:Secondary data analysis 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. Variables analyzed included demographic information (age, sex, marital status, race or ethnicity, prehospital living setting, and discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, Internation Classification of Diseases–9th revision codes for admitting diagnosis, and co-morbidities), and functional status information (FIM instrument [FIM] ratings at admission and discharge, FIM efficiency, FIM gain). Results:Descriptive statistics from 101,188 patients showed length of stay decreasing from a mean of 22.7 (±20.5) days to 16.6 (±14.8) days during the 8-yr study period. FIM total admission and discharge ratings also decreased. Mean admission ratings decreased from 58.6 (±24.7) to 54.8 (±21.2). Mean discharge ratings decreased from 92.4 (±24.2) to 85.0 (±24.0). Accordingly, mean functional independence measure change decreased from 33.8 (±20.5) to 30.2 (±18.4). The percentage of patients discharged to the community settings ranged from 81.3% in 2000 to 74.1% in 2007. All results are likely influenced by various policy changes affecting classification or documentation processes or both. Conclusions:National rehabilitation data from persons with traumatic brain injury in 2000–2007 indicate that patients are spending less time in an inpatient care setting than in the previous years and are experiencing improvements in functional independence during their stay. In addition, a majority of patients are discharged to community settings after inpatient rehabilitation.

Diabetes Comorbidity and Age Influence Rehabilitation Outcomes After Hip Fracture

OBJECTIVE To examine the influence of diabetes on length of stay (LOS), functional status, and discharge setting in individuals with hip fracture. RESEARCH DESIGN AND METHODS This work included secondary analyses of 79,526 individuals from 915 rehabilitation facilities in the U.S. Patients were classified into three groups using the Centers for Medicare and Medicaid Services comorbidity structure: individuals without diabetes (77.0%), individuals with non-tier diabetes (18.3%), and individuals with tier diabetes (4.7%). RESULTS Mean age was 79.4 years (SD 9.6), and mean LOS was 13.3 days (SD 5.3). Tier diabetes was associated with longer LOS, lower functional status ratings, and reduced odds of discharge home when compared with individuals with no diabetes and non-tier diabetes. Statistically significant interactions (P < 0.05) were found between age and diabetes classification for LOS, functional status, and discharge setting. CONCLUSIONS The impact of diabetes on recovery after hip fracture is moderated by age.

Utility of Functional Status for Classifying Community Versus Institutional Discharges After Inpatient Rehabilitation for Stroke

OBJECTIVE To evaluate the ability of patient functional status to differentiate between community and institutional discharges after rehabilitation for stroke. DESIGN Retrospective cross-sectional design. SETTING Inpatient rehabilitation facilities contributing to the Uniform Data System for Medical Rehabilitation. PARTICIPANTS Patients (N=157,066) receiving inpatient rehabilitation for stroke from 2006 and 2007. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Discharge FIM rating and discharge setting (community vs institutional). RESULTS Approximately 71% of the sample was discharged to the community. Receiver operating characteristic curve analyses revealed that FIM total performed as well as or better than FIM motor and FIM cognition subscales in differentiating discharge settings. Area under the curve for FIM total was .85, indicating very good ability to identify persons discharged to the community. A FIM total rating of 78 was identified as the optimal cut point for distinguishing between positive (community) and negative (institution) tests. This cut point yielded balanced sensitivity and specificity (both=.77). CONCLUSIONS Discharge planning is complex, involving many factors. Identifying a functional threshold for classifying discharge settings can provide important information to assist in this process. Additional research is needed to determine if the risks and benefits of classification errors justify shifting the cut point to weight either sensitivity or specificity of FIM ratings.

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 patients with lower limb joint replacement discharged from rehabilitation programs in 2000-2007

Granger CV, Markello SJ, Graham JE, Deutsch A, Reistetter TA, Ottenbacher KJ: The uniform data system for medical rehabilitation: Report of patients with lower limb joint replacement discharged from rehabilitation programs in 2000–2007. Objective:To provide benchmarking information from a large national sample of patients receiving inpatient rehabilitation after lower limb joint replacement. Design:Secondary data analysis 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. 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, 9th revision codes for admitting diagnosis, comorbidities), and functional status information (FIM instrument [“FIM”] ratings at admission and discharge, FIM efficiency, FIM gain). Results:Descriptive statistics from 705,345 patients showed an overall mean length of stay of 8.9 (±4.7) days. FIM total admission and discharge ratings declined during the 8-yr study period. Mean admission ratings decreased from 83.5 (±11.3) to 73.2 (±12.9). Mean discharge ratings decreased from 108.4 (±11.0) to 101.7 (±12.9). Conversely, mean FIM change increased from 24.9 (±9.2) to 28.6 (±12.2). The percent of persons discharged to the community decreased from 94.5% to 91.9%. All results are likely to be influenced by various policy changes affecting classification or documentation processes or both. Conclusions:National rehabilitation data from persons with lower limb joint replacement in 2000–2007 indicate that inpatient rehabilitation lengths of stay have remained relatively stable and that patients are experiencing improvements in functional independence during their stay. In addition, more than 9 of 10 patients are discharged to community settings after inpatient rehabilitation.

Poster 475 Predicting Readmissions to Acute Care Hospitals From Inpatient Rehabilitation Facilities in Medicare Fee-for-Service Stroke Patients

Disclosures: E. Abdeshahian, none. Setting: Inpatient acute rehabilitation unit. Participants: A 28-year-old African American man. Interventions: A patient with a medical history of hypertension, long-standing human immunodeficiency virus (HIV), as well as HIV-related nephropathy was admitted to acute rehabilitation unit after an acute thrombotic CVA. Initially, he presented with blurry vision, right facial weakness, headache, and inability to ambulate secondary to weakness and loss of balance. Investigation with magnetic resonance imaging and/or magnetic resonance angiography showed infarction in the pons and right cerebellar area as well as a thrombus in the basilar artery at the level of the AICA. The patient then underwent a successful mechanical thrombectomy and lysis by an interventional neurologist. Revascularization was successful, and he was then admitted to the acute rehabilitation unit for functional deficit in gait in which he improved to regain most of his muscle strength and balance. Main Outcome Measures: It has been reported that HIV and AIDS are linked to hypercoagulable states. Furthermore, basilar artery occlusion is associated with a high incidence of morbidity and mortality. Patients who survive the incident are left severely debilitated. Individuals who undergo mechanical thrombectomy supplemented with pharmacologic lysis show significantly greater amount of improvement while participating in multidisciplinary rehabilitation. Results: The patient showed significant improvement in his Functional Independence Measures score and ability to ambulate within the first 48-72 hours after admission. Within 7 days, he successfully completed his restorative therapy and was discharged home as a modified independent in all activities of daily living and ambulation. Conclusions: It is evident that early diagnosis and prompt intervention resulted in rapid recovery of neurologic dysfunction and subsequently early discharge from acute rehabilitation unit.

Poster 476 Significance of Stroke-related Neurologic Deficits in Determining Discharge Back to an Acute Care Hospital in Stroke Patients After Medical Inpatient Rehabilitation: A Predictor Model

Disclosures: D. M. Chung, none. Objective: To determine the significance of stroke-related neurologic deficits in predicting discharge back to acute care in stroke patients after medical inpatient rehabilitation. Design: A retrospective study that used data from the Uniform Data System for Medical Rehabilitation between 2008 and 2009. Setting: Data from the Uniform Data System for Medical Rehabilitation between 2008 and 2009 that encompasses more than 800 national rehabilitation facilities. Participants: 86 of the most severely affected stroke patients (Case-Mixed Group 0110 of Medicare reimbursement classification) who were rehospitalized to acute care for more than 2 days after inpatient medical rehabilitation and 137 of similarly classified stroke patients who were discharged to the community after inpatient medical rehabilitation. Interventions: Not applicable. Main Outcome Measures: Discharge outcome defined as rehospitalized for more than 2 days after inpatient rehabilitation or discharged to the community. Demographic and Functional Independence Measure (FIM) ratings were comparable between the 2 groups. Results: When controlled for total length of stay, total FIM gain, total admission FIM, and 19 groups of comorbidities, patients with stroke-related neurologic deficits, other than hemiparesis, dysphagia, and language deficits, had significantly increased odds of being discharged to an acute care hospital rather than the community, odds ratio, 3.71 (95% confidence interval [CI], 1.2-11.4). For individuals who had a total admission FIM rating below 30 and other stroke-related neurologic deficits, the odds of rehospitalization increased to 7.29 (95% CI, 1.1-5.67). The odds of rehospitalization increased to 9.95 (95% CI, 1.3-6.7) for patients with admission FIM motor ratings below 22 who also had other stroke-related neurologic deficits. Conclusions: The ability to predict stroke rehospitalization after inpatient rehabilitation becomes increasingly important as it relates to maximization of patients’ functional outcomes, reduction in burden of care, and significant costs associated with hospitalization.