Analysis of Case Mix and the Prediction of Resource Use in Medical Rehabilitation

Predicting follow-up living setting in patients with stroke

OBJECTIVE

To examine living setting at 3- to 6-month follow-up for inpatients with functional impairments discharged from medical rehabilitation.

DESIGN

Retrospective performed by using information from the Uniform Data System for Medical Rehabilitation (UDSMR) representing medical rehabilitation patients across the United States.

SETTING

National survey data.

PARTICIPANTS

Information submitted in 1997 and 1998 to the UDSMR by 167 facilities from 40 states was examined. A total of 9587 patient records were included in the final sample. The mean age +/- standard deviation was 70.2+/-12.4 years. The sample included 51.6% women and was comprised of 77.5% non-Hispanic white patients, with an average length of stay of 22.3+/-4.6 days.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Living setting (home vs not at home) at 3- to 6-month follow-up.

RESULTS

A discriminant function training model including 8 statistically significant variables correctly classified 85.1% of the patients (n=8149). The total FIM instrument score, patient age, function-related group, and marital status were found to be useful classification variables. Wilks lambda for the model was.924 (chi(2)=1031.49, P<.000). The area under the receiver operating characteristics curve was.85.

CONCLUSION

The association among functional abilities, demographic characteristics, and follow-up living setting in patients with stroke is complex. Functional variables can be used to help predict follow-up living setting. These variables change based on patient severity level.

Subacute and non-acute casemix in Australia

The costs of subacute care (palliative care, rehabilitation medicine, psychogeriatrics, and geriatric evaluation and management) and non-acute care (nursing home, convalescent and planned respite care) are not adequately described by existing casemix classifications. The predominant treatment goals in subacute care are enhancement of quality of life and/or improvement in functional status and, in non-acute care, maintenance of current health and functional status. A national classification system for this area has now been developed--the Australian National Sub-Acute and Non-Acute Patient Classification System (AN-SNAP). The AN-SNAP system, based on analysis of over 30,000 episodes of care, defines four case types of subacute care (palliative care, rehabilitation, psychogeriatric care, and geriatric evaluation and management and one case type of non-acute care (maintenance care), and classifies both overnight and ambulatory care. The AN-SNAP system reflects the goal of management--a change in functional status or improvement in quality of life--rather than the patient's diagnosis. It will complement the existing AN-DRG classification.

The influence of age on length of stay, functional independence and discharge destination of rehabilitation inpatients in Italy

Advanced age in itself does not predict a poor functional outcome or a longer length of stay in rehabilitation units. Seven hundred and sixty-four adult cases were analysed, from 14 post-acute rehabilitation facilities throughout Italy. Data came from the national database run by the agency distributing the Italian version of an internationally validated scale of disability, the FIM [symbol: see text] sm (Functional Independence Measure). The FIM is an 18-item scale rating independence in the domains of selfcare, sphincter control, mobility, locomotion, communication and social cognition. The total FIM score may range from 18 to 126 (higher score = greater independence). Patients were classified with respect to the cut-off age of 75 years (76+ and 75-, mean age 82 and 57 years, n = 203 and 561, 27% and 73% of the cases, respectively). The median interval between onset of disability and admission to the facility (onset-to-admission delay, OAD) was 36 and 45 days in the 76+ and the 75- group, respectively (p < 0.001). Mean admission FIM score was 70 (+/- 28) in the 76+ and 71 (+/- 27) in the 75- group. Discharge FIM scores were 84 +/- 29 and 93 +/- 26, respectively (p < 0.001). Median length of stay (LOS) was 34 days in the 76+ and 41 days in the 75- group, respectively (p < 0.005). The 76+ and 75- groups were discharged home in 86% and 90% of the cases, respectively (p = 0.053). The results suggest that inpatient rehabilitation is substantially effective and efficient for older as well as for younger patients.

Efficiency pattern analysis for medical rehabilitation

Efficiency pattern analysis (EPA) is a technique proposed for use in medical rehabilitation that links patient functional gain to resource use, as approximated by length of stay (LOS), after adjusting for initial severity. The Functional Independence Measure version of the Function Relation Groups (FIM-FRGs) is used to adjust for patient severity and to define the efficiency groups. The efficiency groups are based on LOS and functional gain cut point values in the statistical distribution that are above, below, or within the national interquartile range for each of 53 FRGs. Data from 32,494 patients discharged in 1990 from 123 rehabilitation facilities were used. EPA is a simple way to monitor change in functional gain in response to transformations in health care practices and resource availability. The technique could also provide individual facilities with a means to evaluate treatment efficiencies across time and to compare patterns of LOS and functional gain to national norms.