AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery

Evaluating the Association Between Physical Therapy Variables and Outcomes After Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to investigate how inpatient physical therapy variables impact (1) inpatient complications, (2) 90-day readmissions, (3) 1-year reoperation rates, and (4) length of stay after posterior lumbar decompression and fusion.

SUMMARY OF BACKGROUND DATA

Previous studies have emphasized the role of early ambulation in postoperative spine patients as an effective method for improving pain and decreasing length of stay, but few studies have evaluated the efficacy of inpatient physical therapy.

METHODS

Patients 18 years of age or older who underwent primary 1-level or 2-level posterior lumbar decompression and fusion from 2019 to 2020 were retrospectively identified. Physical therapy data, including time to first inpatient PT session, gait trial distance achieved, post-treatment pain rating, and Activity Measure for Post-Acute Care (Activity Measure for Post-Acute Care [AM-PAC]) scores were collected using manual chart review. Surgical outcome variables included length of stay, inpatient complications, 90-day readmissions, and reoperations within 1 year of primary surgery.

RESULTS

Overall, 425 patients were identified. There was no difference in hours to PT or total gait trial distance achieved between patients who experienced a complication and those that did not. Patients in the noncomplication group had higher AM-PAC scores than patients in the complication group. There was no difference with regards to time to PT, AM-PAC score, or gait trial distance achieved between readmitted patients and nonreadmitted patients or revision patients and nonrevision patients. Stepwise logistic regression showed that having a physical therapy session within 6 hours of surgery was predictive of a decreased length of stay both in all patients.

CONCLUSIONS

While inpatient physical therapy within 6 hours of surgery does not appear to impact readmissions, complications, or reoperations, surgeons should encourage early ambulation postoperatively to decrease extended hospital stays. Future investigation should seek to identify factors that delay inpatient PT in the 6 hours after surgery.

Interrater Reliability of the AM-PAC 6-Clicks Basic Mobility Short Form Between Nurses and Physical Therapists

OBJECTIVE

To examine the interrater reliability between nurse- and physical therapist (PT)-recorded scores from the Activity Measure for Post-Acute Care 6-Clicks Basic Mobility short form across hospitals, services, and categories of assessment timing.

DESIGN

Cross-sectional study of retrospective electronic health record data.

SETTING

Data were collected for patients in 11 hospitals between January 2020 and October 2022. Nurse- and PT-recorded 6-Clicks mobility scores were paired by date.

PARTICIPANTS

There were 535,974 unique score pairs for 127,583 patients.

INTERVENTIONS

Not applicable.

MAIN OUTCOME

Interrater reliability was examined using intraclass correlation coefficients where values <0.5, 0.5-0.75, 0.75-0.9, and >0.9 indicate poor, moderate, good, and excellent reliability, respectively. In secondary analyses, score pairs were categorized according to: (1) hospital, (2) unit type (intensive care vs other), (3) clinical service, and (4) relative timing of nurse- and PT-recorded scores.

MEASURES

6-Clicks Basic Mobility short form.

RESULTS

The interrater reliability was good overall, in 6 hospitals (moderate in 4 hospitals and poor in 1), in both intensive care and other units, for 4 out of 5 clinical services (moderate for 1), and for 4 out of 5 timing categories (moderate for 1).

CONCLUSIONS

In this large study of real-world data, nurse- and PT-recorded 6-Clicks mobility scores had moderate-to-good interrater reliability.

Higher Levels of Postoperative Mobility and Activity as Measured by the AM-PAC 6 Clicks Instrument Are Associated with Improved Outcomes after Lumbar Fusion

Introduction

Previous studies have shown that early patient mobility and activity can improve patient outcomes after lumbar fusion procedures. This study aimed to explore the relationship between patient mobility and activity, measured by the Activity Measure for Post-acute Care (AM-PAC) "6-Clicks" assessment and postoperative outcomes in lumbar fusion patients.

Methods

A retrospective review of 306 lumbar fusions (105 with 6-Clicks mobility and 289 with 6-Clicks activity scores) was conducted. Statistical analyses were performed to evaluate the relationship between 6-Clicks scores and postoperative outcomes, such as prolonged length of stay (LOS), nonhome discharge, 30-day emergency department (ED) returns and readmissions, and minimal clinically important difference (MCID) achievement on the PROMIS-PF instrument at 3-12 months postoperatively.

Results

After controlling for age, body mass index, sex, race, number of levels, and preoperative PROMIS-PF, higher 6-Clicks mobility scores decreased the likelihood of 3+ day LOS (OR: 0.72; p=0.010), non-home discharge (OR: 0.68; p<0.001), and 30-day ED return (OR: 0.78; p=0.022) and increased the likelihood of PROMIS MCID achievement (OR: 1.28; p=0.004). The odds of LOS 3+ days, non-home discharge, and ED return for each one-point increase in mobility scores all decreased by 28%, 32%, and 22%, respectively, while the odds of achieving PROMIS MCID for every one-point increase in mobility increased by 28%. After risk adjustment, higher 6-Clicks activity scores were protective against 3+ day LOS (OR: 0.78; p<0.001) and non-home discharge (OR: 0.69; p<0.001).

Conclusions

The AM-PAC 6-Clicks mobility and activity scores hold value as early indicators of prolonged LOS and nonhome discharge, while mobility scores may help identify patients who are at risk for ED returns and who fail to experience clinically significant improvement in physical function. These tools may be used to identify patients requiring additional resources and can inform discussions surrounding patient expectations.

AM-PAC 6-Clicks Basic Mobility and Daily Activities Scores Predict 90-Day Modified Rankin Score in Patients with Acute Ischemic Stroke Secondary to Large Vessel Occlusion

Background: The relative level of functional impairment in stroke patients is a significant determinant of post-acute care. The Activity Measure for Post Acute Care 6-Clicks (AM-PAC) scores for basic mobility and daily activity are rapid standardized assessments whose utilities in predicting long-term stroke outcomes have not yet been studied. Methods: We performed a retrospective analysis of acute ischemic stroke patients and their outcomes. We evaluated the distribution of outcomes using the chi-square test. We then compared the proportions of patients with good stroke outcomes for different combinations of favorable scores. We performed two-proportion z-tests to determine the significance, and p < 0.05 was considered significant. Results: 282 patients met all of the inclusion criteria between 12 January 2017 and 19 March 2023 (M age = 66.4, 59.9% female). After dichotomizing the scores as "favorable" vs. "unfavorable", we found that 128/155 (82.6%) patients with favorable basic mobility had good stroke outcomes vs. 20/127 (15.7%) with unfavorable basic mobility (p < 0.0001). Similarly, for favorable daily activity, it was 103/113 (91.2%) vs. 45/169 (26.6%), for both favorable, it was 100/109 (91.7%) vs. 48/173 (27.7%), and for neither favorable, it was 17/123 (13.8%) vs. 131/159 (82.4%), all with p < 0.0001. When comparing among groups, both favorable patients differed significantly from those with favorable basic mobility alone (p = 0.033) but not those with favorable daily activity alone (p = 0.875). Even after adjusting for age, the odds ratios of favorable scores were greater than 20 for any combination (p < 0.001). Conclusions: Basic mobility and daily activity AM-PAC scores at discharge are independent predictors of anterior circulation acute ischemic stroke outcomes at 90 days.

Dynamic Prediction of Post-Acute Care Needs for Hospitalized Medicine Patients

OBJECTIVES

Use patient demographic and clinical characteristics at admission and time-varying in-hospital measures of patient mobility to predict patient post-acute care (PAC) discharge.

DESIGN

Retrospective cohort analysis of electronic medical records.

SETTING AND PARTICIPANTS

Patients admitted to the two participating Hospitals from November 2016 through December 2019 with ≥72 hours in a general medicine service.

METHODS

Discharge location (PAC vs home) was the primary outcome, and 2 time-varying measures of patient mobility, Activity Measure for Post-Acute Care (AM-PAC) Mobility "6-clicks" and Johns Hopkins Highest Level of Mobility, were the primary predictors. Other predictors included demographic and clinical characteristics. For each day of hospitalization, we predicted discharge to PAC using the demographic and clinical characteristics and most recent mobility data within a random forest (RF) for survival, longitudinal, and multivariate (RF-SLAM) data. A regression tree for the daily predicted probabilities of discharge to PAC was constructed to represent a global summary of the RF.

RESULTS

There were 23,090 total patients and compared to PAC, those discharged home were younger (64 vs 71), had shorter length of stay (5 vs 8 days), higher AM-PAC at admission (43 vs 32), and average AM-PAC throughout hospitalization (45 vs 35). AM-PAC was the most important predictor, followed by age, and whether the patient lives alone. The area under the hospital day-specific receiver operating characteristic curve ranged from 0.76 to 0.79 during the first 5 days. The global summary tree explained 75% of the variation in predicted probabilities for PAC from the RF. Sensitivity (75%), specificity (70%), and accuracy (72%) were maximized at a PAC probability threshold of 40%.

CONCLUSIONS AND IMPLICATIONS

Daily assessment of patient mobility should be part of routine practice to help inform care planning by hospital teams. Our prediction model could be used as a valuable tool by multidisciplinary teams in the discharge planning process.

Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery

BACKGROUND CONTEXT

Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients.

PURPOSE

To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery.

DESIGN

Retrospective review.

PATIENT SAMPLE

Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained.

OUTCOME MEASURES

The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute.

METHODS

Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM.

RESULTS

LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM.

CONCLUSIONS

Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery.

LEVEL OF EVIDENCE

III.