Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review

Functional outcomes of community-based brain injury rehabilitation clients

BACKGROUND

Community-based rehabilitation can help to maximize function following acquired brain injury (ABI); however, data on treatment outcome is limited in quantity.

OBJECTIVE

To describe and evaluate client outcomes of an outpatient programme for adults with moderate-to-severe traumatic and non-traumatic ABI.

METHODS

Two phase design involving retrospective and longitudinal study of programme completers with ABI (n = 47). Changes in functioning were measured with the Mayo-Portland Inventory (MPAI-4), administered pre- and immediately post-rehabilitation and at 3 years follow-up. Self-ratings were supplemented with MPAI-4 data from significant others (n = 32) and staff (n = 32).

RESULTS

Injured individuals and informants reported improved physical and psychosocial functioning immediately following the completion of community rehabilitation, with medium-to-large and significant treatment gains noted on the MPAI-4 ability, adjustment and participation sub-scales (Cohen's d range = 0.31-1.10). A deterioration in individuals' adjustment was further reported at follow-up, although this was based on limited data. Issues with longer-term rehabilitation service provision were additionally noted.

CONCLUSIONS

The data support the need for continuity of care, including ongoing emotional support, to cater to the complex and dynamic needs of the ABI population. However, these results need to be considered in the context of a small sample size and quasi-experimental design.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Using reliability of change analysis to evaluate post-acute neuro-rehabilitation

BACKGROUND

It is important to evaluate change in order to re-assure commissioners, staff and patients of the effectiveness of interventions, but also in order to identify areas for improvement.

OBJECTIVE

To consider whether analysis of improvement at the level of the individual, taking into account measurement error, may offer a further valuable way to assess change and inform service development over considering change at the group level in a post-acute neuro-rehabilitation unit.

METHOD

Pre and post intervention Scores on the FIM+FAM Full Scale and Cognitive and Motor subscales were considered for eighteen patients aged between 35 and 81 with mixed diagnoses who attended a post-acute inpatient neuro-rehabilitation unit for treatment.

RESULTS

Statistically significant improvements were achieved on the FIM+FAM Full Scale and Cognitive and Motor subscales in a whole group analysis. Reliable change analyses for each patient within each subscale however identified only half of the sample achieved reliable improvement within the Motor domain and just one person within the Cognitive domain (5.6%).

CONCLUSIONS

Findings are consistent with the emphasis of the rehabilitation unit on physical/motor function, and unsurprising as many of those assessed had multiple sclerosis, an often deteriorative condition. Use of reliable change analysis allowed a more detailed understanding of intervention impact, potentially identifying what services reliably work for whom, thereby informing future planning.

Trajectories of Disability Among Older Persons Before and After a Hospitalization Leading to a Skilled Nursing Facility Admission

OBJECTIVES

To identify distinct sets of disability trajectories in the year before and after a Medicare qualifying skilled nursing facility (Q-SNF) admission, evaluate the associations between the pre-and post-Q-SNF disability trajectories, and determine short-term outcomes (readmission, mortality).

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study including 754 community-dwelling older persons, 70+ years, and initially nondisabled in their basic activities of daily living. The analytic sample included 394 persons, with a first hospitalization followed by a Q-SNF admission between 1998 and 2012.

MAIN OUTCOMES AND MEASURES

Disability in the year before and after a Q-SNF admission using 13 basic, instrumental, and mobility activities. Secondary outcomes included 30-day readmission and 12-month mortality.

RESULTS

The mean (SD) age of the sample was 84.9 (5.5) years. We identified 3 disability trajectories in the year before a Q-SNF admission: minimal disability (37.3% of participants), mild disability (44.6%), and moderate disability (18.2%). In the year after a Q-SNF admission, all participants started with moderate to severe disability scores. Three disability trajectories were identified: substantial improvement (26.0% of participants), minimal improvement (36.5%), and no improvement (37.5%). Among participants with minimal disability pre-Q-SNF, 52% demonstrated substantial improvement; the other 48% demonstrated minimal improvement (32%) or no improvement (16%) and remained moderately to severely disabled in the year post-Q-SNF. Among participants with mild disability pre-Q-SNF, 5% showed substantial improvement, whereas 95% showed little to no improvement. Of participants with moderate disability pre-Q-SNF, 15% remained moderately disabled showing little improvement, whereas 85% showed no improvement. Participants who transitioned from minimal disability pre-Q-SNF to no improvement post-Q-SNF had the highest rates of 30-day readmission and 12-month mortality (rate/100 person-days 1.3 [95% CI 0.6-2.8] and 0.3 [95% CI 0.15-0.45], respectively).

CONCLUSIONS

Among older persons, distinct disability trajectories were observed in the year before and after a Q-SNF admission. The likelihood of improvement in disability was greatly constrained by the pre-Q-SNF disability trajectory. Most older persons remained moderately to severely disabled in the year following a Q-SNF admission.

Effective strategy for improving health care outcomes: Multidisciplinary care in cerebral infarction patients

Multidisciplinary teams provide effective patient treatment strategies. South Korea expanded its health program recently to include multidisciplinary treatment. This study characterized the relationship between multidisciplinary care and mortality within 30 days after hospitalization in cerebral infarction patients. We used the National Health Insurance claim data (n = 63,895) from 120 hospitals during 2010-2013 to analyze readmission within 30 days after hospitalization for cerebral infarction. We performed χ(2) tests, analysis of variance and multilevel modeling to investigate the associations between multidisciplinary care and death within 30 days after hospitalization for stroke. Deaths within 30 days of hospitalization due to cerebral infarction was 3.0% (n = 1898/63,895). Multidisciplinary care was associated with lower risk of death within 30 days in inpatients with cerebral infarction (odds ratio: 0.84, 95% confidence interval: 0.72-0.99). Patients treated by a greater number of specialists had lower risk of death within 30 days of hospitalization. Additional analyses showed that such associations varied by the combination of specialists (i.e., neurologist and neurosurgeon). In conclusion, death rates within 30 days of hospitalization for cerebral infarction were lower in hospitals with multidisciplinary care. Our findings certainly suggest that a high number of both neurosurgeon and neurologist is not always an effective alternative in managing stroke inpatients, and emphasize the importance of an optimal combination in the same number of hospital staffing.

Medical day hospital care for older people versus alternative forms of care

BACKGROUND

The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location.

OBJECTIVES

To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status.

SEARCH METHODS

Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care.

MAIN RESULTS

Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14).

AUTHORS' CONCLUSIONS

There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.

Performance-based outcomes of inpatient rehabilitation facilities treating hip fracture patients in the United States

OBJECTIVE

To examine the influence of facility and aggregate patient characteristics of inpatient rehabilitation facilities (IRFs) on performance-based rehabilitation outcomes in a national sample of IRFs treating Medicare beneficiaries with hip fracture.

DESIGN

Secondary data analysis.

SETTING

U.S. Medicare-certified IRFs (N=983).

PARTICIPANTS

Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community.

RESULTS

Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P<.001] and Hispanics [P<.001], higher percentage of women [P=.030], higher motor function on admission [P<.001], longer length of stay [P<.001]) and facility characteristics (freestanding [P<.001], rural [P<.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P<.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P<.001], higher motor function on admission [P<.001]). No facility characteristics were associated with the percentage discharged to the community.

CONCLUSIONS

Performance-based measurement offers health policymakers, administrators, clinicians, and consumers a major opportunity for securing health system improvement by benchmarking or comparing their outcomes with those of other similar facilities. These results might serve as the basis for benchmarking and quality-based reimbursement to IRFs for 1 impairment group: hip fracture.

Contemporary trends and predictors of postacute service use and routine discharge home after stroke

Background

Returning home after the hospital is a primary aim for healthcare; however, additional postacute care (PAC) services are sometimes necessary for returning stroke patients to their pre‐event status. Recent trends in hospital discharge disposition specifying PAC use have not been examined across age groups or health insurance types.

Methods and Results

We examined trends in discharge to inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home with home health (HH), and home without services for 849 780 patients ≥18 years of age with ischemic or hemorrhagic stroke at 1687 hospitals participating in Get With The Guidelines—Stroke. Multivariable analysis was used to identify factors associated with discharge to any PAC (IRF, SNF, or HH) versus discharge home without services. From 2003 to 2011, there was a 2.1% increase (unadjusted P=0.001) in PAC use after a stroke hospitalization. Change was greatest in SNF use, an 8.3% decrease over the period. IRF and HH increased 6.9% and 3.6%, respectively. The 2 strongest clinical predictors of PAC use after acute care were patients not ambulating on the second day of their hospital stay (ambulation odds ratio [OR], 3.03; 95% confidence interval [CI], 2.86 to 3.23) and those who failed a dysphagia screen or had an order restricting oral intake (OR, 2.48; 95% CI, 2.37 to 2.59).

Conclusions

Four in 10 stroke patients are discharged home without services. Although little has changed overall in PAC use since 2003, further research is needed to explain the shift in service use by type and its effect on outcomes.

New rehabilitation models for neurologic inpatients in Brazil

PURPOSE

To describe the effects of a rehabilitation program in a neurological inpatient unit in terms of independence for activities of daily living and return to work.

METHOD

Retrospective study with 148 adults with stroke, traumatic brain injury (TBI), spinal cord injury, and Guillain-Barré syndrome admitted as rehabilitation inpatients within a 1-year period for hospitalization at the Instituto de Reabilitação Lucy Montoro, Brazil. According to their diagnostic groups, subjects undergone semi-standardized models of intensive multidisciplinary rehabilitation for 4-6 weeks.

PRIMARY OUTCOME MEASURES

Functional Independence Measure (FIM), Modified Rankin scale (Rankin), and Glasgow Outcome Scale (GOS Subjects were evaluated at admission, discharge, and 6 months after discharge.

RESULTS

Improvement in motor FIM™, Rankin and GOS was observed in all groups. Cognitive FIM increase was less evident in TBI patients. After 6 months, 37.6% of patients were unemployed, 34% underwent outpatient rehabilitation, and 65.2% maintained gains.

CONCLUSIONS

This is the first report on the effects from an inpatients rehabilitation model in Brazil. After a short intensive rehabilitation, there were motor and cognitive gains in all groups. Heterogeneity in functional gains suggests more individualized programs may be indicated. Controlled studies are required with larger samples to compare inpatient and outpatient programs.

Effectiveness of 'rehabilitation in the home' service

Objectives Rehabilitation in the home (RITH) services increasingly provide hospital substitution services. This study examines clinical outcomes in a large metropolitan RITH service in Western Australia. Methods The 2010 database of Fremantle Hospital RITH service was interrogated to identify the clinical profile of cases, length of stay (LOS) and clinical outcomes. Negative outcomes included death or unexpected hospital readmission. Multiple logistic regression modelling was used to explore associations with negative outcomes. This study was reviewed by the Institutional Review Board which deemed it not to require ethics approval. Results There were 1348 cases managed by RITH: 70.6% were aged ≥ 65 years; elective joint replacement (29.7%), medical conditions (20%), stroke (13%), hip fractures (10%) were major contributors. The majority (93.3%) were discharged after a median of 9 days. Negative outcomes occurred in 90 cases (6.7%), including five deaths (0.4%) and 85 readmissions (6.3%). Independent associations with negative outcomes included older age (odds ratio (OR) (95% CI); 1.02, P = 0.006), orthopaedic conditions (OR 1.91, P = 0.004) and longer inpatient LOS (OR 1.96, P = 0.003). Age above 80 years was independently associated with risk of negative outcome (OR 2.99, P = 0.004). Conclusions RITH had a low rate of negative outcomes. The database proved useful for monitoring quality of service provision. What is known about the topic? Rehabilitation in the home environment has proven cost effective for multiple conditions, particularly stroke and elective joint surgery, among others, facilitating better quality of life, with reduced rates of delirium and mortality. Overall there are few negative outcomes and death is rare. What does this paper add? Although RITH services are widely utilised as bed substitution services, there is scant literature on clinical outcomes while within the service. This study focuses on frequency of good and poor clinical outcomes in a well-established RITH service in Western Australia, suggesting pattern recognition of an at-risk cohort by identifying potentially useful predictors of poor outcome. What are the implications for practitioners? RITH services are a safe alternative for many, including older people. Health administration databases are useful tools to monitor clinical outcomes. Clinical indicators such as older age, long hospital stay and orthopaedic diagnoses may be useful predictors of poor outcomes in such services.

The health outcomes and costs of people attending an interdisciplinary chronic disease service in regional Australia: protocol for a longitudinal cohort investigation

BACKGROUND

Rates of chronic disease are escalating around the world. To date health service evaluations have focused on interventions for single chronic diseases. However, evaluations of the effectiveness of new intervention strategies that target single chronic diseases as well as multimorbidity are required, particularly in areas outside major metropolitan centres where access to services, such as specialist care, is difficult and where the retention and recruitment of health professionals affects service provision.

METHODS

This study is a longitudinal investigation with a baseline and three follow-up assessments comparing the health and health costs of people with chronic disease before and after intervention at a chronic disease clinic, in regional Australia. The clinic is led by students under the supervision of health professionals. The study will provide preliminary evidence regarding the effectiveness of the intervention, and evaluate the influence of a range of factors on the health outcomes and costs of the patients attending the clinic. Patients will be evaluated at baseline (intake to the service), and at 3-, 6-, and 12-months after intake to the service. Health will be measured using the SF-36 and health costs will be measured using government and medical record sources. The intervention involves students and health professionals from multiple professions working together to treat patients with programs that include education and exercise therapy programs for back pain, and Healthy Lifestyle programs; as well as individual consultations involving single professions.

DISCUSSION

Understanding the effect of a range of factors on the health state and health costs of people attending an interdisciplinary clinic will inform health service provision for this clinical group and will determine which factors need to be controlled for in future observational studies. Preliminary evidence regarding changes in health and health costs associated with the intervention will be a platform for future clinical trials of intervention effectiveness. The results will be of interest to teams investigating new chronic disease programs particularly for people with multimorbidity, and in areas outside major metropolitan centres.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: ACTRN12611000724976.

Effect of Rehabilitation Setting on Dependence Following Stroke

Background. In France in 2009, patients admitted to Multidisciplinary Inpatient Rehabilitation for stroke were sent to a neurological rehabilitation center (NRC) or a general or geriatric rehabilitation (GRC) service. Objective. To describe the functional outcome of stroke patients admitted for rehabilitation in France in 2009, both globally and as a function of the rehabilitation setting (GRC or NRC). Methods. Data from the French Hospital Discharge Diagnosis databases for 2009 were included. Two logistic regression models were used to analyze factors related to improvement in dependence score and discharge home. Odds ratios (ORs) were also calculated. Results. Among the 83 505 survivors of acute stroke in 2009, 28 201 were admitted for rehabilitation (33.8%). Of these, 19 553 went to GRC (69%) and 8648 to NRC (31%). On average, patients admitted to GRC were older (78.6 years vs 66.4 years), P < .001). At the start of rehabilitation, 50% of NRC patients and 56% of GRC patients were heavily dependent, but level of dependence was similar within each age-group. Rehabilitation in NRC lead to a greater probability of functional improvement (OR = 1.75, P < .001) and home discharge (OR = 1.61, P < .001) after adjustment for gender, age, Charlson’s comorbidity index, initial level of dependence, type of stroke, and total length of stay. Conclusion. This study confirms, on a national level, the functional benefit of specialized rehabilitation in NRC. These results should be useful in the improvement of care pathways, organization of rehabilitation, and discharge planning.

The study of activity in older ICU patients: an integrative review

The purpose of this study was to review relevant literature on activity of older critically ill patients, including activity interventions conducted in this population, with a focus on activity measurement and technology. Literature published between 1996 and 2012 was reviewed using keywords older adults, inactivity, mobility, progressive mobility, rehabilitation, ambulation, early mobilization, ICU (intensive care unit), and accelerometry using CINAHL, MEDLINE, and the Cochrane Database of Systematic Reviews. Previous relevant research is discussed and includes intervention and nonintervention studies. Although studies have demonstrated the benefits of early mobilization in the ICU setting, this research has not focused on the high-risk older adult ICU population, nor has it addressed how best to quantify these clinical activities. Current technologies, such as accelerometry, may assist in measuring patient activity and in mobilizing high-risk patients during acute, critical illness.

Relationship of patient volume and service concentration with outcome in geriatric rehabilitation

OBJECTIVE

Although geriatric rehabilitation (GR) is beneficial for restoration of activities and participation after hospitalization of vulnerable older persons, little is known about the optimal organization of care of these postacute facilities. This study examines the relationship of patient volume and service concentration with successful GR (short length of stay and discharge home) in skilled nursing facilities (SNFs).

DESIGN

A national multicenter retrospective cohort study.

SETTING AND PARTICIPANTS

All patients indicated for GR in a Dutch SNF.

MEASUREMENTS

Nurses filled out digital registration forms from patient records. Patients were studied in 3 predefined diagnostic groups: total joint replacement, traumatic injuries, and stroke. Facility characteristics were obtained by structured telephone interviews with facility managers. Volume was based on the number of discharges in a 3-month period and categorized in low-, medium-, and high-volume facilities. Concentration was defined at the organizational level in which the population consists of 80% or more of 1 or 2 diagnostic groups, with the prerequisite of having a minimum of 10 rehabilitation beds.

RESULTS

From 88 facilities, 2269 GR patients (mean age 78.2 years [SD 9.7]; 68.2% female) were included. The median length of stay in the SNF was 45 days (interquartile range 23-81), 57% of the patients were discharged home, and 9.8% died during GR. Of patients with total joint replacement (n = 501), concentration was related to successful rehabilitation (odds ratio 5.7; 95% confidence interval 1.3-24.3; P = .020, adjusted for age and gender); this relationship was not found for patients with traumatic injuries or stroke. Volume showed no relation with successful rehabilitation in any of the 3 diagnostic groups.

CONCLUSION

This study may indicate that concentration in an SNF, as a proxy for specialization, favors successful GR in total joint replacement. This relationship was not found for the traumatic injuries or stroke groups, or for volume. The relation on functional outcome in GR needs further investigation.

The sociodemographic and health-related characteristics of a regional population with chronic disease at an interprofessional student-assisted clinic in Queensland Capricornia Allied Health Partnership

OBJECTIVE

This paper describes the sociodemographic and health-related characteristics of people with chronic disease attending an interprofessional student-assisted clinic in regional Queensland.

DESIGN

A retrospective review of data collected during the first 10 months of operation of the clinic was conducted. SETTING, PARTICIPANTS AND OUTCOME MEASURES: Data was collected on up to 378 patients during an intake appointment at the Capricornia Allied Health Partnership (CAHP) community-based clinic and compared with normative reference groups where available. Sociodemographic characteristics included age, gender and education level; health-related characteristics included body mass index and hospitalisations in the previous 12 months; and risk factors included prescribed medications, smoking status and general practitioner-diagnosed medical conditions.

RESULTS

Patients attending the CAHP clinic had a mean number of chronic conditions of 4.9 ± 2.1 per patient, and 97% of patients had multimorbidities. A high level of socioeconomic disadvantage was found in comparison with normative comparison groups based on employment, highest level of schooling completed and the index of social disadvantage. Patients predominantly lived in inner regional areas (76.7%). The most common diagnoses of patients attending the clinic for the first time were hypertension, osteoarthritis, high cholesterol, diabetes and chronic back pain.

CONCLUSIONS

The CAHP clinic offers a unique student-assisted service model for interprofessional management of patients who are socioeconomically disadvantaged, have multimorbid chronic disease and live in regional areas. The description of baseline data in this paper is important to refine clinic services, to guide other chronic disease clinics and to inform future research study designs.

Hyperbaric oxygen induces late neuroplasticity in post stroke patients--randomized, prospective trial

BACKGROUND

Recovery after stroke correlates with non-active (stunned) brain regions, which may persist for years. The current study aimed to evaluate whether increasing the level of dissolved oxygen by Hyperbaric Oxygen Therapy (HBOT) could activate neuroplasticity in patients with chronic neurologic deficiencies due to stroke.

METHODS AND FINDINGS

A prospective, randomized, controlled trial including 74 patients (15 were excluded). All participants suffered a stroke 6-36 months prior to inclusion and had at least one motor dysfunction. After inclusion, patients were randomly assigned to "treated" or "cross" groups. Brain activity was assessed by SPECT imaging; neurologic functions were evaluated by NIHSS, ADL, and life quality. Patients in the treated group were evaluated twice: at baseline and after 40 HBOT sessions. Patients in the cross group were evaluated three times: at baseline, after a 2-month control period of no treatment, and after subsequent 2-months of 40 HBOT sessions. HBOT protocol: Two months of 40 sessions (5 days/week), 90 minutes each, 100% oxygen at 2 ATA. We found that the neurological functions and life quality of all patients in both groups were significantly improved following the HBOT sessions while no improvement was found during the control period of the patients in the cross group. Results of SPECT imaging were well correlated with clinical improvement. Elevated brain activity was detected mostly in regions of live cells (as confirmed by CT) with low activity (based on SPECT) - regions of noticeable discrepancy between anatomy and physiology.

CONCLUSIONS

The results indicate that HBOT can lead to significant neurological improvements in post stroke patients even at chronic late stages. The observed clinical improvements imply that neuroplasticity can still be activated long after damage onset in regions where there is a brain SPECT/CT (anatomy/physiology) mismatch.

Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis

PURPOSE

Multidisciplinary tracheostomy teams have been implemented in acute hospitals over the past 10 years. This systematic review of the literature and meta-analysis aimed to assess the effect of tracheostomy teams on patient outcomes.

MATERIALS AND METHODS

We conducted an electronic search of the literature in the following databases: MEDLINE, CINAHL, EMBASE, and AMED. Inclusion/exclusion criteria were applied, and included articles were assessed against quality criteria. Qualitative synthesis and meta-analysis were completed.

RESULTS

Seven studies were included. The studies were all pre-post cohort designs of low-moderate quality. Meta-analysis showed that tracheostomy teams were associated with reductions in total tracheostomy time (4 studies; mean difference, 8 days; 95% confidence interval, 6-11; P < .01; I(2) = 0%) and hospital length of stay (LOS) (3 studies; mean difference, -14 days; 95% confidence interval, -39 to 9; P = .23; I(2) = 50%). Reductions in intensive care unit LOS (3 studies) and increases in speaking valve (3 studies) use were also reported with tracheostomy teams.

CONCLUSION

There is low-quality evidence that multidisciplinary tracheostomy care contributes to a reduction in total tracheostomy time and increase speaking valve use for patients leading to improved quality of life. There is insufficient evidence to determine that multidisciplinary tracheostomy teams reduce hospital or intensive care unit LOS.

Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation

BACKGROUND

Millions of patients who survive medical and surgical general intensive care unit care every year experience newly acquired long-term cognitive impairment and profound physical and functional disabilities. To overcome the current reality in which patients receive inadequate rehabilitation, we devised a multifaceted, in-home, telerehabilitation program implemented using social workers and psychology technicians with the goal of improving cognitive and functional outcomes.

METHODS

This was a single-site, feasibility, pilot, randomized trial of 21 general medical/surgical intensive care unit survivors (8 controls and 13 intervention patients) with either cognitive or functional impairment at hospital discharge. After discharge, study controls received usual care (sporadic rehabilitation), whereas intervention patients received a combination of in-home cognitive, physical, and functional rehabilitation over a 3-month period via a social worker or master's level psychology technician utilizing telemedicine to allow specialized multidisciplinary treatment. Interventions over 12 wks included six in-person visits for cognitive rehabilitation and six televisits for physical/functional rehabilitation. Outcomes were measured at the completion of the rehabilitation program (i.e., at 3 months), with cognitive functioning as the primary outcome. Analyses were conducted using linear regression to examine differences in 3-month outcomes between treatment groups while adjusting for baseline scores.

RESULTS

Patients tolerated the program with only one adverse event reported. At baseline both groups were well-matched. At 3-month follow-up, intervention group patients demonstrated significantly improved cognitive executive functioning on the widely used and well-normed Tower test (for planning and strategic thinking) vs. controls (median [interquartile range], 13.0 [11.5-14.0] vs. 7.5 [4.0-8.5]; adjusted p < .01). Intervention group patients also reported better performance (i.e., lower score) on one of the most frequently used measures of functional status (Functional Activities Questionnaire at 3 months vs. controls, 1.0 [0.0 -3.0] vs. 8.0 [6.0-11.8], adjusted p = .04).

CONCLUSIONS

A multicomponent rehabilitation program for intensive care unit survivors combining cognitive, physical, and functional training appears feasible and possibly effective in improving cognitive performance and functional outcomes in just 3 months. Future investigations with a larger sample size should be conducted to build on this pilot feasibility program and to confirm these results, as well as to elucidate the elements of rehabilitation contributing most to improved outcomes.

Clinical telerehabilitation: applications for physiatrists

Telemedicine offers an innovative approach to increase access to rehabilitation medicine services for patients who live in areas where physiatrists are scarce or absent. This article reviews the current status of telerehabilitation services delivered through real-time videoconferencing to provide support, assessment, and interventions to individuals with impairments or disabilities. A literature review demonstrates various uses of telerehabilitation by physical therapists, occupational therapists, speech and language pathologists, audiologists, recreational therapists, neuropsychologists, nurses, other physician specialists, and physiatrists. We also provide more in-depth examples of 2 current programs that involve physiatrists: One furnishes telerehabilitation services to adult stroke survivors, and the other addresses the special health care needs of children with developmental disabilities. We discuss the benefits of using telemedicine via real-time videoconferencing to care for individuals with disabilities, outline the challenges of successfully implementing a physiatric telerehabilitation program, and finish with a list of potential applications for physiatrists interested in incorporating telemedicine into their practice. Further investigation of the use of telehealth technologies to deliver physiatric services, care coordination, and education is needed. We recommend that our professional societies develop and publish guidelines to facilitate development and use of telerehabilitation technologies to increase access to physiatric services.

Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases

OBJECTIVE

To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke.

DESIGN

Cross-sectional analysis of data for 2 years (2005-2006) from the State Inpatient Databases.

SETTING

All short-term acute-care hospitals in 4 demographically and geographically diverse states.

PARTICIPANTS

Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

(1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply.

RESULTS

Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location.

CONCLUSIONS

Several sociodemographic and geographic disparities in PARC use were identified.

Patient self-management and pharmacist-led patient self-management in Hong Kong: a focus group study from different healthcare professionals' perspectives

Background

Patient self-management is a key approach to manage non-communicable diseases. A pharmacist-led approach in patient self-management means collaborative care between pharmacists and patients. However, the development of both patient self-management and role of pharmacists is limited in Hong Kong. The objectives of this study are to understand the perspectives of physicians, pharmacists, traditional Chinese medicine (TCM) practitioners, and dispensers on self-management of patients with chronic conditions, in addition to exploring the possibilities of developing pharmacist-led patient self-management in Hong Kong.

Methods

Participants were invited through the University as well as professional networks. Fifty-one participants comprised of physicians, pharmacists, TCM practitioners and dispensers participated in homogenous focus group discussions. Perspectives in patient self-management and pharmacist-led patient self-management were discussed. The discussions were audio recorded, transcribed and analysed accordingly.

Results

The majority of the participants were in support of patients with stable chronic diseases engaging in self-management. Medication compliance, monitoring of disease parameters and complications, lifestyle modification and identifying situations to seek help from health professionals were generally agreed to be covered in patient self-management. All pharmacists believed that they had extended roles in addition to drug management but the other three professionals believed that pharmacists were drug experts only and could only play an assisting role. Physicians, TCM practitioners, and dispensers were concerned that pharmacist-led patient self-management could be hindered, due to unfamiliarity with the pharmacy profession, the perception of insufficient training in disease management, and lack of trust of patients.

Conclusions

An effective chronic disease management model should involve patients in stable condition to participate in self-management in order to prevent health deterioration and to save healthcare costs. The role of pharmacists should not be limited to drugs and should be extended in the primary healthcare system. Pharmacist-led patient self-management could be developed gradually with the support of government by enhancing pharmacists' responsibilities in health services and developing public-private partnership with community pharmacists. Developing facilitating measures to enhance the implementation of the pharmacist-led approach should also be considered, such as allowing pharmacists to access electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines.

Social rehabilitation in long-term conditions: learning about the process

AIM

This paper is a report of a study of the process of social rehabilitation, and the analysis of the main elements and influencing factors which are important in the process.

BACKGROUND

The process of social rehabilitation lacks conceptual and empirical understanding in Neurology because most rehabilitation programmes have focused on cognitive and physical recovery.

METHODS

An action research project was undertaken in two neurological wards of a highly specialized hospital in Spain, and was completed in 2006. A social rehabilitation programme based on the assessment of social needs and individualized social education was planned with health professionals, and implemented and evaluated with patients and carers. Several instruments were used to explore how patients and carers perceived the process of social rehabilitation before and after the programme: semi-structured interviews, socio-demographic forms, field notes, participant observations, and scales of activities of daily living, social impairment and adjustment. Comparative content and statistical analyses were undertaken.

FINDINGS

Social rehabilitation was identified as a dynamic process in which the environment, activities, social interaction, self-recognition and awareness of social problems, coping and satisfaction played an essential role. Some defining criteria for social rehabilitation related to patients' and carers' attitudes, behaviour and the external implications that the socialization process had for them.

CONCLUSION

This study shows the advantages of multidisciplinary work, and user and family involvement in social rehabilitation and provides in-depth knowledge about how patients and carers experience and could face barriers to develop a role in their family environment, social groups and society.

Physical and occupational therapy in inpatient stroke rehabilitation: the contribution of therapy extenders

OBJECTIVE

To understand the use of therapy extenders in stroke rehabilitation.

DESIGN

Descriptive analysis of a prospective observational cohort study.

RESULTS

Two hundred ninety-eight patients with moderate stroke and 284 with severe stroke from 5 inpatient rehabilitation facilities with complete physical and occupational therapy data are included in the study. Overall, occupational therapists and assistants contributed ∼70% and 21% of all occupational therapy hours, respectively. For physical therapy, these percentages in moderate group (60% vs. 31%) differ from those in severe group (65% vs. 23%). Some variations in the use of therapy extenders are noted in both disciplines across sites. Physical and occupational therapists spend more time in delivering advanced activities that include ongoing integrated evaluation and treatment planning or modification. Their assistants spend more time in delivering lower-level activities, such as bed mobility, transfers, dressing, or nonfunctional activities. Also, therapists are more likely to assign responsibility to assistants to treat moderate motor impairment among patients with stroke.

CONCLUSIONS

Characterizing therapy practice in stroke rehabilitation is not straightforward. It is multifactorial and takes into account the (1) type of therapy, (2) therapy activity, (3) therapy provider including extender personnel, (4) specific training in stroke, and (5) years of experience. Future research to examine the association between use of therapy extenders and outcomes is recommended.

Multidisciplinary rehabilitation after primary total knee arthroplasty: a randomized controlled study of its effects on functional capacity and quality of life

OBJECTIVE

To examine whether a multidisciplinary rehabilitation programme can improve functional recovery and quality of life and reduce the use of rehabilitation services compared with conventional care one year after total knee arthroplasty.

DESIGN

Prospective, randomized, non-blinded, controlled trial.

SETTING

An outpatient centre-based setting.

SUBJECTS

Eighty-six patients who were scheduled for primary total knee arthroplasty due to osteoarthritis of the knee.

INTERVENTIONS

A ten-day multidisciplinary rehabilitation programme, which was focused on enhancing functional capacity, was organized 2-4 months after surgery. In both groups, a standard amount of physiotherapy was included in conventional care.

MAIN MEASURES

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the 15D, 15-m walk test, stair test, isometric strength measurement of the knee. Use of rehabilitation services was asked about with a questionnaire. Outcomes were assessed preoperatively and at 2-, 6- and 12-month follow-ups.

RESULTS

In both groups, functional capacity and quality of life improved significantly. The mean absolute change in the WOMAC function score was -32.4 mm (SD 26.4) in the rehabilitation group and -32.8 mm (SD 20.1) in the control group (P-time*group = 0.40). No difference was found between groups in any outcome measure or in the use of rehabilitation services during the study period.

CONCLUSIONS

This study indicates that for knee osteoarthritis patients treated with primary total knee arthroplasty, a 10-day multidisciplinary outpatient rehabilitation programme 2-4 months after surgery does not yield faster attainment of functional recovery or improvement in quality of life than can be achieved with conventional care.

A comprehensive model of care for rehabilitation of children with acquired brain injuries

BACKGROUND

Acquired brain injury (ABI) is a leading cause of death and lifelong acquired disability in children and remains a significant public health issue. Deficits may only become fully apparent when developmental demands increase and once cognitive processes are expected to be fully developed. It is therefore necessary to provide organized long-term follow-up for children post ABI. Despite these recommendations, it has been shown that only a small proportion of children received specialized rehabilitation and adequate follow-up after ABI.

AIMS

The aims are: (i) to describe a comprehensive model of care devoted to children with acquired brain injuries; and (ii) to provide descriptive data analysing the characteristics of children followed up, the type/amount of services provided and general outcomes.

PROGRAMME DESCRIPTION

The programme features an in- and outpatient rehabilitation facility, where multidisciplinary rehabilitation and specialized schooling are provided. The ultimate goal of the programme is to promote each child's successful reintegration in school and in the community. Adequate preparation of discharge is essential, long-term follow-up is organized, and an outreach programme has been developed to deal with the complex delayed psychosocial issues.

RESULTS

Overall outcome, as measured by the Glasgow Outcome Scale, improved dramatically between admission (3.3; SD = 0.45) and discharge (2.15; SD = 0.74). Most of the children were discharged home with an adequate personalized plan for ongoing rehabilitation and school adaptations. Analysis of the outreach programme underlines the more challenging issues arising in late adolescence-early adulthood.

CONCLUSION

Given the specificities of childhood ABI, long-term specific care must be organized and co-ordinated, regardless of injury severity.

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals

BACKGROUND

The quality of discharge documentation in patients discharged to rehabilitation centers and other subacute facilities is less well studied than that of patients discharged home.

OBJECTIVE

To evaluate the quality of information transfer among patients discharged from acute hospitals to subacute facilities across an integrated healthcare delivery system.

DESIGN

Retrospective evaluation of discharge documentation packets of selected patients.

SETTING

Five acute care hospitals of the Partners Healthcare System.

MEASUREMENTS

We measured the presence of specific data elements required to safely care for patients after discharge, including all data elements required by the Joint Commission on Accreditation of Healthcare Organizations (TJC).

RESULTS

A total of 1501 discharge documentation packets were reviewed from March 2005 through June 2007. Only 1055 (70.3%) discharge summaries had all the information required by TJC, with physical examination at admission and condition at discharge most often missing (in 11.4% and 14.2% of cases, respectively). Other deficiencies not mandated by TJC included a list of preadmission medications (missing in 20.3%) and reasons for changes in these medications at discharge (35.3%), mention of pending test results (47.2%), and postdischarge management and follow-up plans (11.1%).

CONCLUSIONS

We found room for improvement in the inclusion of data elements required for the safe transfer of patients from acute hospitals to subacute facilities, especially in areas such as medication reconciliation, pending test results, and adequate follow-up plans.

Factors associated with recovery of prehospital function among older persons admitted to a nursing home with disability after an acute hospitalization

BACKGROUND

The objective of this study was to identify the factors associated with recovery of prehospital function among older persons admitted to a nursing home with disability after an acute hospitalization.

METHODS

The analytic sample included 292 participants of an ongoing cohort study who had one or more admissions to a nursing home with disability after an acute hospitalization during nearly 10 years of follow-up, yielding a total of 364 "index" nursing home admissions. Information on nursing home admissions, hospitalizations, and disability in essential activities of daily living was ascertained during monthly telephone interviews. Data on potential predictors of functional recovery were collected during comprehensive assessments, which were completed every 18 months for 90 months. Participants were considered to have recovered if they were discharged home within 6 months of their nursing home admission at (or above) their prehospital level of function.

RESULTS

Recovery of prehospital function was observed for 115 (31.6%) of the 364 index nursing home admissions. In the multivariate analysis, the strongest associations were observed for the best category of performance, relative to the poorest category, for gross motor coordination (hazard ratio [HR] 13.5, 95% confidence interval [CI] 4.02-45.0) and manual dexterity (HR 10.0, 95% CI 2.94-34.3). Only two other factors were independently associated with recovery of prehospital function: not cognitively impaired (HR 3.0, 95% CI 1.46-6.14) and no significant weight loss (HR 1.96, 95% CI 1.06-3.63).

CONCLUSIONS

In the setting of an acute hospitalization leading to a nursing home admission with disability, the likelihood of recovering prehospital function is low. The factors associated with recovery include faster performance on tests of gross motor coordination and manual dexterity and the absence of cognitive impairment and significant weight loss.

Severe disease activity and complications of immunosuppressive therapy: a challenge for acute hospital-based rehabilitation in rheumatology

Acute rehabilitation refers to the multidisciplinary rehabilitative treatment of patients in continuing need of integrated acute and rehabilitative longterm care. As a result of the advances in acute rheumatology and improved emergency services, an increasing number of patients survive episodes of severe disease and complications of immunosuppressive therapy. These patients require not only treatment of their acute medical problems but also specialized multidisciplinary acute rehabilitation starting as early as possible during their hospital stay. We describe 4 typical cases from the major fields of rheumatology. (1) Acute rehabilitation of a 63-year-old woman with rheumatoid arthritis after replacement of both preexisting knee endoprostheses in one session and removal of the left hip endoprosthesis due to infection and sepsis. (2) Rehabilitation of a 29-year-old man with a 7-year history of ankylosing spondylitis who lived in an adjustable easy chair for 2 years due to severe pain prior to admission. (3) A 61-year-old woman with active refractory Wegener's granulomatosis who developed respiratory insufficiency due to aspergillus and pseudomonas pneumonia. (4) The acute rehabilitation of a 21-year-old woman with systemic lupus erythematosus and a history of 14 laparotomies due to severe acute pancreatitis and multiple gut perforations. Acute rehabilitation was complicated by a large defect of the abdominal wall and significant critical illness polyneuropathy. Our report points out differences between acute, postacute, and longterm rehabilitation, describes the mobilization of patients in acute rheumatology units, and defines specific problems encountered in acute hospital-based rehabilitation of rheumatological patients.

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation

BACKGROUND

Anticoagulation is a commonly prescribed and effective therapy for several medical conditions but requires detailed communication among clinicians to avoid adverse patient outcomes following hospital discharge.

METHODS

Discharge documentation packets of a sample of patients discharged from all five acute care hospitals of the Partners Healthcare System to 30 subacute facilities in Boston and prescribed anticoagulation for treatment or prophylaxis of thromboembolic disease were evaluated. Required data elements included information on anticoagulation indication, duration, dosing, monitoring, and follow-up. Discharge documentation packets were randomly selected for reviewers at acute sites, whereas reviewers at subacute sites selected which packets to review.

RESULTS

Of 757 patients prescribed anticoagulation at discharge from March 2005 through June 2007, duration of therapy (for unfractionated or low-molecular-weight heparin [UFH/LMWH]) and recent dosing and monitoring information (for warfarin) were the areas with the biggest deficits. Of the patients prescribed UFH/LMWH or warfarin, 45.4% and 16.4%, respectively, had all the required information in the discharge summary. Patients discharged from community hospitals were more likely to be discharged with all the information needed for the use of warfarin (Odds Ratio [OR], 2.56; 95% confidence interval [CI], 1.20-5.46) or UFH/LMWH (OR, 2.97; 95% CI, 1.98-4.44) than patients discharged from academic medical centers.

DISCUSSION

Important information to safely prescribe anticoagulation after discharge was often missing from the discharge summaries of patients transferred from acute hospitals to subacute facilities. Future research should focus on developing, implementing, and evaluating quality improvement interventions to address this gap.

Functional trajectories in older persons admitted to a nursing home with disability after an acute hospitalization

OBJECTIVES

To characterize the functional trajectories of older persons admitted to a nursing home with disability after an acute hospitalization.

DESIGN

Prospective cohort study of 754 community-living persons aged 70 and older who were initially nondisabled in four essential activities of daily living (ADLs).

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

The analytical sample included 296 participants who were newly admitted to a nursing home with disability after an acute hospitalization.

MEASUREMENTS

Information on nursing home admissions, hospitalizations, and disability in essential ADLs was ascertained during monthly telephone interviews for up to 9 years. Disability was defined as the need for personal assistance in bathing, dressing, walking inside one's home, or transferring from a chair.

RESULTS

The median time to the first nursing home admission with disability after an acute hospitalization was 46 months (interquartile range 27.5-75.5), and the mean number+/-standard deviation of ADLs that participants were disabled in upon admission was 3.0+/-1.2. In the month preceding hospitalization, 189 (63.9%) participants had no disability. The most common functional trajectory was discharged home with disability (46.3%), followed by continuous disability in the nursing home (27.4%), discharged home without disability (21.6%), and noncontinuous disability in the nursing home (4.4%). Only 96 (32.4%) participants returned home at (or above) their premorbid level of function.

CONCLUSION

The functional trajectories of older persons admitted to a nursing home with disability after an acute hospitalization are generally poor. Additional research is needed to identify the factors responsible for these poor outcomes.

State of the science on postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy. An introduction

The Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness along with academic, professional, provider, accreditor, and other organizations sponsored a 2-day State of the Science of Post-Acute Rehabilitation Symposium in February 2007. The aim of this symposium was to serve as a catalyst for expanded research on post-acute care (PAC) rehabilitation so that health policy is founded on a solid evidence base. The goals were to (1) describe the state of our knowledge regarding utilization, organization, and outcomes of postacute rehabilitation settings, (2) identify methodologic and measurement challenges to conducting research, (3) foster the exchange of ideas among researchers, policymakers, industry representatives, funding agency staff, consumers, and advocacy groups, and (4) identify critical issues related to setting, delivery, payment, and effectiveness of rehabilitation services. Plenary presentation and state-of-the-science summaries were organized around four themes: (1) the need for improved measurement of key rehabilitation variables and methods to collect and analyze this information, (2) factors that influence access to postacute rehabilitation care, (3) similarities and differences in quality and quantity of services across PAC settings, and (4) effectiveness of postacute rehabilitation services. The full set of symposium articles, including recommendations for future research, appear in Archives of Physical Medicine and Rehabilitation.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

The proportion of the world's population aged 60 or over is increasing. This review sets out to examine the effectiveness and resource implications of geriatric medical day hospital attendance for elderly people. This is an update of a Cochrane review first published in 1999.

OBJECTIVES

To examine the effectiveness of attendance at a medical day hospital for elderly people in preventing death, disability, and institutionalisation and improving subjective health status.

SEARCH STRATEGY

We searched the EPOC group specialist register (March 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2008), MEDLINE (1996 to January 2008), EMBASE (1996 to 2008 week 5), and other databases.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing attendance at a geriatric medical day hospital with alternative forms of care for elderly medical patients (usually > 60 years).

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed research reports to determine eligibility, categorise trial type and extract data.

MAIN RESULTS

Thirteen trials involving 3007 participants were included. These compared day hospital with a) comprehensive elderly care (five trials), b) domiciliary care (five trials), or c) no comprehensive elderly care (three trials).There were no significant differences between day hospital attendance and the sub-categories of comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio (OR) 0.73; 95% confidence interval (CI) 0.53 to 1.00; P < 0.05).Dependency was measured in 12 trials using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remaining trials there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed a reduced odds of deterioration when compared with those receiving no comprehensive elderly care (OR 0.60; 95% CI 0.38 to 0.97; P < 0.05).When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care.

AUTHORS' CONCLUSIONS

Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.

State of the science on postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy. An introduction

The Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness along with academic, professional, provider, accreditor, and other organizations sponsored a 2-day State of the Science of Post-Acute Rehabilitation Symposium in February 2007. The aim of this symposium was to serve as a catalyst for expanded research on postacute care (PAC) rehabilitation so that health policy is founded on a solid evidence base. The goals were to (1) describe the state of our knowledge regarding utilization, organization, and outcomes of postacute rehabilitation settings; (2) identify methodologic and measurement challenges to conducting research; (3) foster the exchange of ideas among researchers, policymakers, industry representatives, funding agency staff, consumers, and advocacy groups; and (4) identify critical questions related to setting, delivery, payment, and effectiveness of rehabilitation services. Plenary presentation and state-of-the-science summaries were organized around 4 themes: (1) the need for improved measurement of key rehabilitation variables and methods to collect and analyze this information, (2) factors that influence access to postacute rehabilitation care, (3) similarities and differences in quality and quantity of services across PAC settings, and (4) effectiveness of postacute rehabilitation services. The full set of symposium articles, including recommendations for future research, appear in Archives of Physical Medicine and Rehabilitation.