Wenqiang Tian

Joint Replacement Rehabilitation Outcomes on Discharge From Skilled Nursing Facilities and Inpatient Rehabilitation Facilities

OBJECTIVE To compare functional outcomes at discharge across postacute settings. DESIGN Prospective observational cohort study. SETTING Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States. PARTICIPANTS Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751). INTERVENTIONS None; examination of existing practice patterns. MAIN OUTCOME MEASURE FIM discharge motor score. RESULTS Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome. CONCLUSIONS As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes.

Looking Upstream: Factors Shaping the Demand for Postacute Joint Replacement Rehabilitation

Since 1993, the numbers of hip and knee replacements in the United States have increased 2-fold to 3-fold while lengths of stay in acute care have decreased by about half, leading to a significant growth in the use of postacute rehabilitative care for patients with a joint replacement. To document these trends, this article uses secondary analysis of acute hospital discharge survey data and evaluates projections to 2030. This article uses a market approach to identify 3 sets of factors that influence the use of joint replacements: (1) increasing patient demand, (2) increasing supply of practitioners, and (3) the role of fiscal intermediaries. The article reviews underlying epidemiologic trends, growing numbers of orthopedic surgeons performing the procedure, technologic innovations, changing indications for the procedure, changing payer mix, and the effects of payer attempts to contain joint replacement costs. An unintended effect of Medicare payment policy has been to shift costs from acute care to downstream postacute care. Medicare and private health plan reimbursement policies need to take into account this broader perspective and not examine joint replacement care and payment in isolated care settings. Future research and health policy needs to consider the interdependent features of the health care system by linking changes in postacute care with upstream changes both in society at large and in the organization, delivery, and financing of acute care associated with joint replacement.

Physical Therapy Activities in Stroke, Knee Arthroplasty, and Traumatic Brain Injury Rehabilitation: Their Variation, Similarities, and Association With Functional Outcomes

Background The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown. Objective The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups. Design This was a prospective observational cohort study. Methods The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patients medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities. Results All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average=31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average=65.3 minutes per day), whereas the TBI group received the least physical therapy (average=38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome. Limitations The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities. Conclusions All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes.

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.

Analysis of rehabilitation activities within skilled nursing and inpatient rehabilitation facilities after hip replacement for acute hip fracture.

Munin MC, Putman K, Hsieh C-H, Smout RJ, Tian W, DeJong G, Horn SD: Analysis of rehabilitation activities within skilled nursing and inpatient rehabilitation facilities after hip replacement for acute hip fracture. Objective:To characterize rehabilitation services in two types of postacute facilities in patients who underwent hip replacement following a hip fracture. Design:Multisite prospective observational cohort from 6 freestanding skilled nursing facilities and 11 inpatient rehabilitation facilities. Patients (n = 218) with hip fracture who had either hemiarthroplasty or total hip arthroplasty followed by rehabilitation at skilled nursing facilities or inpatient rehabilitation facilities were enrolled. Using a point-of-care methodology, we recorded data from actual physical therapy and occupational therapy sessions completed including functional outcomes during the postacute admission. Results:Onset time from surgical repair to rehabilitation admission was not significantly different between sites. Average skilled nursing facilities length of stay was 24.7 ± 13.6 days, whereas inpatient rehabilitation facilities was 13.0 ± 5.7 days (P < 0.01). Total hours of physical therapy and occupational therapy services per patient day were 1.2 in skilled nursing facilities and 2.0 in inpatient rehabilitation facilities. For weekdays only, these data changed to 1.6 in skilled nursing facilities and 2.6 hrs per patient in inpatient rehabilitation facilities (P < 0.01). Patients in inpatient rehabilitation facilities accrued more time for gait training and exercise in physical therapy, which was found to be 48% and 40% greater, respectively, through day 8. In occupational therapy, patients of inpatient rehabilitation facilities had more time allocated to lower body dressing and transfers. Conclusions:Significant differences in rehabilitation activities were observed, and intensity was notably different within the first 8 therapy days even though baseline demographics and medical complexity were comparable across facility types. Our data suggest that after more complex hip replacement surgery, hip fracture patients can tolerate more intensive therapy earlier within the rehabilitation program.

Patterns of rehabilitation after hip arthroplasty and the association with outcomes: an episode of care view.

Tian W, DeJong G, Munin MC, Smout R: Patterns of rehabilitation after hip arthroplasty and the association with outcomes: An episode of care view. Objectives: To examine the patterns of rehabilitation after elective and nonelective hip arthroplasty and its association with outcomes over an episode of postacute care. Design: Data were obtained from a multisite prospective observational cohort study and its companion follow-up study. Patterns of care were measured by the combination of settings of care where hip arthroplasty patients received rehabilitation therapy. Main outcome measure was motor portion of the functional independence measure. Results: Approximately 90% of hip arthroplasty patients received rehabilitation care from more than one setting. Eight patterns of care were identified in the follow-up period. Patterns of subsequent care were driven more by initial setting than by etiology. Nonelective hip arthroplasty patients had lower motor functional independence measure scores and used more rehabilitation services than did elective hip arthroplasty patients. Patterns of care were modest factors (accounted for only 7% of variance) in predicting patient motor functional independence measure over an episode of postacute care. Conclusions: Etiology of hip arthroplasty is associated with amounts of rehabilitation care used and outcomes. After the initial postacute rehabilitation setting, patients continued to receive considerable amounts of therapy in various settings. It is important to look beyond a single setting of care to an entire episode of care when examining clinical outcomes.

Efficient rehabilitation care for joint replacement patients: skilled nursing facility or inpatient rehabilitation facility?

Objective. There has been lengthy debate as to which setting, skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF), is more efficient in treating joint replacement patients. This study aims to determine the efficiency of rehabilitation care provided by SNF and IRF to joint replacement patients with respect to both payment and length of stay (LOS). Methods. This study used a prospective multisite observational cohort design. Tobit models were used to examine the association between setting of care and efficiency. The study enrolled 948 knee replacement patients and 618 hip replacement patients from 11 IRFs and 7 SNFs between February 2006 and February 2007. Output was measured by motor functional independence measure (FIM) score at discharge. Efficiency was measured in 3 ways: payment efficiency, LOS efficiency, and stochastic frontier analysis efficiency. Results. IRF patients incurred higher expenditures per case but also achieved larger motor FIM gains in shorter LOS than did SNF patients. Setting of care was not a strong predictor of overall efficiency of rehabilitation care. Great variation in characteristics existed within IRFs or SNFs and severity groups. Medium-volume facilities among both SNFs and IRFs were most efficient. Early rehabilitation was consistently predictive of efficient treatment. Conclusions. The advantage of either setting is not clear-cut. Definition of efficiency depends in part on preference between cost and time. SNFs are more payment efficient; IRFs are more LOS efficient. Variation within SNFs and IRFs blurred setting differences; a simple comparison between SNF and IRF may not be appropriate.

Long-Term Outcomes of Joint Replacement Rehabilitation Patients Discharged From Skilled Nursing and Inpatient Rehabilitation Facilities

OBJECTIVE To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). DESIGN Postdischarge follow-up interview study at 7.5 months after admission. SETTING Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs. PARTICIPANTS Patients (N=856): 561 with knee replacement and 295 with hip replacement. INTERVENTIONS None. MAIN OUTCOME MEASURES FIM and Short-Form 12-Item Health Survey (SF-12). RESULTS Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12-related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes. CONCLUSIONS At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes.

Comparing Rehabilitation Services and Outcomes Between Older and Younger People With Spinal Cord Injury

OBJECTIVE To compare patient and injury characteristics, rehabilitation services, and outcomes between people incurring traumatic spinal cord injury (SCI) at younger and older ages. DESIGN Multisite prospective observational cohort study. SETTING Six acute rehabilitation facilities. PARTICIPANTS Patients (N=866) aged ≥ 16 years admitted to participating centers for their initial rehabilitation after SCI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Motor FIM scores at discharge and 1 year postinjury, discharge location, and postacute clinical pathways. RESULTS Patients were divided into 4 age-at-injury groups: 16 to 29, 30 to 44, 45 to 60, and >60 years of age. Older adults (>60 y) incurring SCI were more likely to be married, retired/unemployed, on Medicare, and to have attained more education. Their injuries mostly resulted from falls and were incomplete in nature. The oldest group had the highest severity of illness, lowest admission and discharge motor FIM scores, and longer rehabilitation stay. They received relatively less rehabilitation than younger groups. They spent proportionately more time in occupational therapy working on preparatory activities and less time on self-care activities during inpatient rehabilitation. In the aged >60 years group, 80% went home at discharge; 17.2% were discharged to a nursing home. Younger groups were less likely to go to a nursing home. Admission motor FIM was the most significant predictor of motor FIM at discharge and 1-year anniversary across age groups. But the age groups differed significantly in patient and treatment factors that explained their respective outcomes. CONCLUSIONS Older injured individuals experienced a different clinical pathway from younger patients. The present study suggests the need for development of a rehabilitation program tailored specifically to older adults.

Racial disparities in stroke functional outcomes upon discharge from inpatient rehabilitation facilities.

Purpose. Analyse racial disparities in clinical outcomes after stroke in inpatient rehabilitation facilities (IRF). Methods. Analyses based on data from a multi-center prospective observational cohort study on inpatient stroke rehabilitation in six IRFs from across the United States. Multivariate models examined racial disparities in functional outcomes upon discharge, taking into account patient characteristics and detailed information on processes of care. Results. In the moderate stroke group (N = 397), functional scores on admission were not significantly different between African-Americans and whites. In the severe stroke group (N = 335), whites showed significantly lower functional scores at admission [Functional Independence Measurement, (FIM)], mean scores, 44 versus 49 for African-Americans, p < 0.001). Multivariate analyses predicting discharge motor FIM score found no significant differences between African-American and white stroke patients (p = 0.2194 and p = 0.3547 in the moderate and severe stroke group, respectively). Conclusion. Controlling for patient characteristics, therapy intensity and processes of care results in non-significant differences between African-Americans and whites in motor FIM scores upon discharge. The absence of significant differences in recovery while patients were on the rehabilitation unit suggests that racial disparities in long-term functional recovery after stroke are likely to have originated before or after the inpatient rehabilitation stay.