Functional gains and therapy intensity during subacute rehabilitation: a study of 20 facilities

Bridging Gaps in Neuropsychological Rehabilitation Intensity for Post-Stroke Population in Spain

OBJECTIVE

This study aims to analyze the treatment intensity applied in neurorehabilitation centers in Spain and its relationship with sociodemographic, biomedical, and cognitive variables in post-stroke patients. Current guidelines recommend rehabilitation sessions lasting at least 45 min per day, 2-5 days/week, but there is no consensus on neuropsychology intensity.

METHOD

This Spanish multicenter, observational, descriptive cross-sectional study included 163 adult participants diagnosed with stroke, collecting 48 biopsychosocial variables. Statistical analyses, including non-parametric tests and linear regressions, were conducted to assess the relationship between intervention intensity and the studied variables.

RESULTS

Our findings reveal an average neuropsychology of 59 min/week, significantly below international recommendations for intensive therapies. Patients in subacute phases (<6 months) and those with severe cognitive impairment (Montreal Cognitive Assessment <21) receive higher-intensity interventions, though still far from optimal standards. Significant differences were also identified between center types, reflecting variations in the resources available.

CONCLUSION

This study not only highlights the need to establish clear intensity criteria in neuropsychology but also provides a foundation for future experimental studies to evaluate the impact of increased intensity on cognitive outcomes. Additionally, future research should analyze whether the observed differences between center types could lead to inequalities in access to therapies. These unique data in the Spanish context can serve as a starting point for designing more equitable and effective clinical guidelines.

Flexible, adaptable, and supportive systems: qualitative description of factors underpinning an ideal mealtime delivery in rehabilitation care settings

PURPOSE

Whilst evidence about mealtime delivery exists in acute and aged care settings, there is limited understanding of patient and staff preferences for rehabilitation settings. This study aimed to explore patient and staff perceptions about how mealtimes should be delivered to support rehabilitation goals of care. Method: This qualitative descriptive study involved semi-structured interviews with nine patients (previous or current admission) and ten staff from a single metropolitan rehabilitation service. Data were analysed using qualitative content analysis.

RESULTS

Two key categories were identified, including (1) the role of mealtimes in patients' rehabilitation, and (2) factors underpinning ideal mealtime delivery for rehabilitation. Mealtimes help to facilitate recovery, support socialisation, rest, and routine, but were also a time of frustration and challenge for patients. The ideal mealtime was described as creating a therapeutic experience, integrating systems and processes that support rehabilitation, systems that offer flexibility and choice, enhancing mealtime care through interdisciplinary collaboration, and using supportive mealtime care practices.

CONCLUSION

The ideal mealtime in rehabilitation should be underpinned by principles of flexibility, adaptability, and supportive care. Incorporating rehabilitation goals of care can be enabled through mealtime systems that encourage functional therapy activity, optimal nutrition, and time for rest and social engagement.

Seizure prediction in stroke survivors who experienced an infection at skilled nursing facilities-a machine learning approach

Background

Infections and seizures are some of the most common complications in stroke survivors. Infections are the most common risk factor for seizures and stroke survivors that experience an infection are at greater risk of experiencing seizures. A predictive model to determine which stroke survivors are at the greatest risk for a seizure after an infection can be used to help providers focus on prevention of seizures in higher risk residents that experience an infection.

Methods

A predictive model was generated from a retrospective study of the Long-Term Care Minimum Data Set (MDS) 3.0 (2014-2018, n = 262,301). Techniques included three data balancing methods (SMOTE for up sampling, ENN for down sampling, and SMOTEENN for up and down sampling) and three feature selection methods (LASSO, Recursive Feature Elimination, and Principal Component Analysis). One balancing and one feature selection technique was applied, and the resulting dataset was then trained on four machine learning models (Logistic Regression, Random Forest, XGBoost, and Neural Network). Model performance was evaluated with AUC and accuracy, and interpretation used SHapley Additive exPlanations.

Results

Using data balancing methods improved the prediction performances of the machine learning models, but feature selection did not remove any features and did not affect performance. With all models having a high accuracy (76.5%-99.9%), interpretation on all four models yielded the most holistic view. SHAP values indicated that therapy (speech, physical, occupational, and respiratory), independence (activities of daily living for walking, mobility, eating, dressing, and toilet use), and mood (severity score, anti-anxiety medications, antidepressants, and antipsychotics) features contributed the most. Meaning, stroke survivors who received fewer therapy hours, were less independent, had a worse overall mood were at a greater risk of having a seizure after an infection.

Conclusion

The development of a tool to predict seizure following an infection in stroke survivors can be interpreted by providers to guide treatment and prevent complications long term. This promotes individualized treatment plans that can increase the quality of resident care.

Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation

INTRODUCTION

We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020.

DEVELOPMENT

We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research.

CONCLUSIONS

All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.

The effect of post-acute rehabilitation setting on 90-day mobility after stroke: A difference-in-difference analysis

Background

After discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge.

Methods

In this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health.

Results

We included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services (β=-3.5 (1.4), p=0.01 and β=-8.2 (1.3), p=<0.001, respectively).

Conclusions

These findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.

Chronic Phase Survival Rate in Stroke Patients With Severe Functional Limitations According to the Frequency of Rehabilitation Treatment

OBJECTIVE

To investigate the chronic phase survival rate according to the frequency of rehabilitation treatment in the acute and subacute phases in stroke patients with severe functional limitations.

DESIGN

A retrospective longitudinal cohort study.

SETTING

Population-based study using the Korean National Health Insurance Database from 2007 to 2018.

PARTICIPANTS

We enrolled 593 patients who experienced stroke in 2009 with national disability registration (NDR) grade of 3 or less (N=593).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The frequencies of rehabilitation treatment within 24 months after stroke were categorized into none, 1-50, 51-200, 201-400, and >400 treatments based on requests made to the Health Insurance Review and Assessment Service. As a dependent variable, we assessed all-cause mortality from 24 to 120 months after stroke.

RESULTS

The study enrolled 283 patients in NDR grade 1 (the most severe), 158 in grade 2, and 152 in grade 3. Groups with more severe functional limitations showed a lower chronic phase survival rate (P<.001). The groups with higher frequencies of rehabilitation treatment in the acute and subacute phases showed a higher chronic phase survival rate (P<.001). In the Cox regression analysis, a higher degree of functional limitation, lower frequency of rehabilitation treatment, older age, male sex, and chronic kidney disease were independent risk factors for chronic phase mortality in stroke patients with severe functional limitations.

CONCLUSIONS

A high frequency of rehabilitation treatment in the acute and subacute phases was associated with the long-term survival of stroke patients with severe functional limitations.

Client and service factors associated with changes in health-related quality of life following community rehabilitation

PURPOSE

To identify client and service factors associated with changes in health-related quality of life following community rehabilitation.

METHODS

We conducted a retrospective observational cohort study within a community rehabilitation program. Health-related quality of life was measured using the EuroQol five Dimensions, five response level version (EQ-5D-5L). Our primary outcome was the Visual Analogue Scale (VAS) rating of overall health. Analyses were stratified by diagnostic group: traumatic orthopaedic, elective orthopaedic, neurological, medical, and other. The association between client and service factors and discharge VAS scores, adjusted for baseline scores were determined using multivariable regression.

RESULTS

EQ-5D-5L data were available for 981 of 1350 participants. Treatment intensity was associated with a seven-point increase (β = 7.22, 95%CI 2.28-12.2, p = 0.004) in VAS scores for traumatic orthopaedic participants. For neurological participants, there was a positive interaction between comorbidities and intensity of therapy (β = 7.9, 95%CI 2.75-13.1, p = 0.003), indicating that greater therapy intensity in those with higher comorbidity scores was associated with an improvement in VAS scores. Age was negatively associated with VAS scores for traumatic orthopaedic participants and socioeconomic status was positively associated with VAS scores for elective orthopaedic participants.

CONCLUSIONS

Treatment intensity is a modifiable service factor that may positively influence health-related quality of life.Implications for rehabilitationIn addition to providing information on client progress towards attainment of individual treatment goals, routine collection of patient reported outcome measures within a community rehabilitation program can elicit information that can inform rehabilitation service improvement.Clients of a community rehabilitation program with a neurological or medical condition demonstrate the least improvement in overall health profile and may require additional rehabilitation or supports.Across all diagnostic groups, problems with anxiety and depression were least likely to improve following receipt of community rehabilitation. Improving access to psychological services and associated referral pathways in community rehabilitation services could improve these outcomes.Initiatives aimed at increasing intensity of therapy such as targeted triage and resource allocation, may improve health-related quality of life for clients of a community rehabilitation program with traumatic orthopaedic conditions.For clients with a neurological condition, initiatives aimed at increasing intensity of therapy may improve health-related quality of life in more complex patients with comorbid health conditions.

Mobility and balance rehabilitation in multiple sclerosis: A systematic review and dose-response meta-analysis

OBJECTIVE

To assess the benefits of neurological rehabilitation and the dose-response relationship for the treatment of mobility and balance in multiple sclerosis.

METHODS

We included studies investigating the effects of neurological rehabilitation on mobility and balance with the following eligibility criteria for inclusion: Population, People with Multiple Sclerosis (PwMS); Intervention, method of rehabilitation interventions; Comparison, experimental (specific balance intervention) vs control (no intervention/no specific balance intervention); Outcome, balance clinical scales; Study Design, randomised controlled trials. We conducted a random effects dose-response meta-analysis to assess linear trend estimations and a one stage linear mixed effects meta-regression for estimating dose-response curves.

RESULTS

We retrieved 196 studies from a list of 5020 for full text review and 71 studies (n subjects=3306) were included. One study was a cross-over and 70 studies were randomized controlled trials and the mean sample size per study was 46.5 ± 28.6 (mean±SD) with a mean age of 48.3 ± 7.8years, disease duration of 11.6 ± 6.1years, and EDSS of 4.4 ± 1.4points. Twenty-nine studies (40.8%) had the balance outcome as the primary outcome, while 42 studies (59.1%) had balance as secondary outcome or did not specify primary and secondary outcomes. Thirty-three trials (46.5%) had no active intervention as comparator and 38 trials (53.5%) had an active control group. Individual level data from 20 studies (n subjects=1016) were analyzed showing a medium pooled effect size for balance interventions (SMD=0.41; 95% CIs 0.22 to 0.59). Moreover, we analyzed 14 studies (n subjects=696) having balance as primary outcome and BBS as primary endpoint yielding a mean difference of 3.58 points (95% CIs 1.79 to 5.38, p<0.0001). Finally, we performed meta regression of the 20 studies showing an association between better outcome, log of intensity defined as minutes per session (β=1.26; SEβ=0.51; p = 0.02) and task-oriented intervention (β=0.38; SEβ=0.17; p = 0.05).

CONCLUSION

Our analyses provide level 1 evidence on the effect of balance intervention to improve mobility. Furthermore, according to principles of neurological rehabilitation, high intensity and task-specific interventions are associated with better treatment outcomes.

Rehabilitation of Patients With Acute Ischemic Stroke Who Required Assistance Before Hospitalization Contributes to Improvement in Activities of Daily Living: A Nationwide Database Cohort Study

OBJECTIVE

To assess the effect of early implementation of and longer daily duration of rehabilitation on patients with acute ischemic stroke who require assistance with activities of daily living (ADL) before hospital admission.

DESIGN

Nationwide, cohort, observational study from April 2018 to March 2019.

SETTING

Acute care hospitals in Japan.

PARTICIPANTS

The Japanese national Diagnosis Procedure Combination database was searched for the period between April 2018 and March 2019. Of the 330,672 patients with ischemic strokes identified, 53,523 met the inclusion criteria of being older than 20 years, having a prehospital modified Rankin Scale score of 3, 4, or 5, and having undergone rehabilitation (N=53,523).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Improvement in ADL from admission to discharge using the Barthel Index. The effects of the following 3 rehabilitation variables on ADL improvement were evaluated: (1) average daily duration of rehabilitation; (2) rehabilitation started within 3 days after admission (early rehabilitation); and (3) rehabilitation started 1 day after admission (very early rehabilitation).

RESULTS

Early rehabilitation was significantly associated with improvements in ADL (odds ratio, 1.19; 95% confidence interval, 1.10-1.28; P≤.001). A longer duration of rehabilitation was also significantly associated with ADL improvement (≥2.0 hours: odds ratio, 2.49; 95% confidence interval, 2.26-2.75; P≤.001) compared with a ≤1 hour of rehabilitation (1.1-2.0 hours: odds ratio, 1.35; 95% confidence interval, 1.29-1.42; P≤.001).

CONCLUSIONS

Early implementation of rehabilitation and a longer duration of rehabilitation per day improved the ADL of patients who required assistance before the onset of cerebral infarction.

Is there a relationship between intensity of occupational therapy and functional outcomes in hospitalised older patients? A prospective cohort study

INTRODUCTION

Delivering high-intensity occupational therapy can improve functional outcomes for patients and reduce length of stay. However, there is little published evidence of this in the aged rehabilitation setting. This study aims to explore the association between intensity of occupational therapy interventions and functional outcomes in geriatric rehabilitation inpatients.

METHODS

A prospective cohort study was conducted with adult inpatients admitted to a geriatric rehabilitation program. The intervention was the intensity of occupational therapy measured as high (≥30 minutes per day) versus low (<30 minutes per day). The primary outcome measured was change in functional performance, defined as a minimum of half a point improvement in the Katz Index of Activities of Daily Living (ADL) and/or the Lawton and Brody Scale of Instrumental ADL (IADL) at admission to rehabilitation, discharge and 3months post-discharge.

RESULTS

A total of 693 patients were included in the analysis. The mean age was 82.2 years (standard deviation [SD] = 7.9), 57% were females, and 64% had cognitive impairment. Patients (n = 210) who received greater than or equal to 30 minutes of occupational therapy daily were more likely to have clinically relevant functional improvements.; for both ADL (odds ratio [OR] = 1.87, 95% confidence interval [CI]: 1.24-2.83) and IADL (OR = 3.00, 95% CI: 1.96-4.61), after adjusting for age, sex, severity of function (ADL ≤ 2) at admission, frailty and cognitive impairment. Improvements in ADL and IADL were maintained for at least 3 months following discharge.

CONCLUSION

This study found that geriatric rehabilitation inpatients who received higher intensity of occupational therapy interventions were more likely to functionally improve than those who received lower intensity. Further research is required to determine if other factors, such as therapy type, influence functional outcomes.

The influence of personal factors, unmet need and service obstacles on the relationship between health service use and outcome after brain injury

Background

This exploratory study aimed to: (i) examine the relationship between health service use and quality of life, psychological wellbeing, global function and participation after discharge from brain injury inpatient rehabilitation, and (ii) determine the influence of personal factors, unmet need for services and service obstacles on the relationship between service use and these outcomes.

Methods

Using a prospective cohort design, 41 adults with acquired brain injury (median age = 46 years; 71% male; 61% severe traumatic injury) were followed for 6-months after discharge from specialist brain injury inpatient rehabilitation. Service use was continuously recorded and obtained through data linkage methods, focusing on the use of: outpatient medical services, outpatient nursing, outpatient allied health; medical acute services; incidents of re-hospitalization; and transitional rehabilitation service use. Outcome questionnaire measures were completed via telephone, at 6-months after discharge, and included: the EuroQol-5D; Depression Anxiety and Stress Scale, Mayo-Portland Adaptability Inventory and Sydney Psychosocial Reintegration Scale. Data were analyzed in a heterogeneous treatment effects framework, using Bayesian Additive Regression Trees.

Results

There was weak evidence that transitional rehabilitation service use was associated with better psychological wellbeing scores. The posterior probability of lower depression, anxiety and stress scores was .87, .81 and .86, respectively (average treatment effect). There was also weak evidence that re-hospitalization was associated with worse independent living skills scores. The posterior probability of worse scores was .87. However, most re-hospitalizations were due to unavoidable medical complications. We did not find that place of residence at discharge, marital status, unmet need, or service obstacles affected the relationship between service use and the studied outcomes.

Conclusions

This study may highlight the importance of participation in transitional rehabilitation, in the 6-months after discharge from brain injury rehabilitation. Replication in a larger sample size is required to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07811-y.

Emulating Three Clinical Trials that Compare Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities

OBJECTIVE

To inform the design of a potential future randomized controlled trial, we emulated three trials where patient-level outcomes were compared following stroke rehabilitation at Inpatient Rehabilitation Facilities (IRFs) to Skilled Nursing Facilities (SNFs).

DESIGN

Trials were emulated using a 1:1 matched propensity score analysis. The three trials differed as facilities from rehabilitation networks with different case-volumes were compared. Rehabilitation network case-volumes were based on the number of stroke patients that each hospital discharged to each specific IRF or SNF. Trial 1 included 60,529 patients from all networks, trial 2 included 34,444 patients from networks with medium- and large case-volumes (i.e., ≥5 patients), trial 3 included 19,161 patients from networks with large case-volumes (i.e., ≥10 patients). E-values were calculated to estimate the minimum strength that an unmeasured confounder would need to be to nullify the results.

SETTING

A national sample of IRFs and SNFs from across the United States.

PARTICIPANTS

Acute Fee-for-service Medicare stroke patients who received IRF or SNF based rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

1-year successful community discharge (home for >30 consecutive days) and all-cause mortality.

RESULTS

Overall, 29,500, 15,156, and 7,450 patients were matched for trials 1, 2 and 3. For 1-year successful community discharge, absolute risk differences for IRF patients were 0.21 (95% CI: 0.20, 0.22), 0.17 (95% CI: 0.16, 0.19), and 0.12 (95% CI: 0.10, 0.14) in trials 1, 2 and 3, respectively. For 1-year all-cause mortality, corresponding risk differences were -0.11 (95% CI: -0.12, -0.11), -0.11 (95% CI: -0.12, -0.09), and -0.08 (95% CI: -0.10, -0.06). E-values indicated that a moderately sized unmeasured confounder, with a relative risk of 1.6 to 2.0 would nullify differences in successful community discharge.

CONCLUSION(S)

IRF patients had superior outcomes, but differences were attenuated when IRFs and SNFs from larger rehabilitation networks were compared. The vulnerability of the findings to unmeasured confounding supports the need for an RCT.

Effectiveness of facility-based transition care on health-related outcomes for older adults: A systematic review and meta-analysis

BACKGROUND

Although Transition Care Programmes (TCP) are designed to assist older adults to regain functional ability after hospitalisation, it is unclear whether TCP improve older adults' health-related outcomes.

OBJECTIVES

The objective of the review was to synthesise the best available evidence for the effectiveness of TCP on health-related outcomes for older adults admitted to a transition care facility after hospitalisation.

METHODS

Searches were conducted using the databases PubMed, AMED (Ovid), Embase (Ovid), PscyINFO (Ovid) and CINAHL (Full text) and grey literature from January 2000 to May 2020 in English only. Studies that reported health-related outcomes of older adults (aged 65 and above) who received TCP in a facility setting were deemed eligible for inclusion following critical appraisal by two reviewers. Data were pooled in meta-analysis where possible, or reported narratively.

RESULTS

A total of 21 studies from seven countries [(n = 5 RCT, n = 16 observational cohort studies) participants' mean age 80.2 (±8.3)] were included. Pooled analysis (2069 participants, 7 studies) demonstrated that 80% of older adults undertaking TCP were discharged home [95% CI (0.78-0.82, p < 0.001), I² = 21.99%, very low GRADE evidence]. Proportions of older adults discharged home varied widely between countries (33.3%-86.4%). There was a significant improvement in ability to perform activities of daily living (2001 participants, 7 studies) as measured by the Modified Barthel Index [17.65 points (95% CI 5.68-29.62, p = 0.004), I²  = 0.00%, very low GRADE evidence].

CONCLUSIONS

The proportion of older adults discharged home from TCP compared to other discharge destinations differs between countries. This could be due to the intensity of the rehabilitation delivered and the maximum length of stay allowed prior to discharge.

IMPLICATIONS FOR PRACTICE

Future studies that comprehensively evaluate the efficacy of TCP on health-related outcomes including quality of life are required. Further investigation is required to identify which aspects of TCP affect successful discharge home.

Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities

Therapy staffing declined in response to Medicare payment policy that removes incentives for intensive physical and occupational therapy in skilled nursing facilities, with therapy assistant staffing more impacted than therapist staffing. However, it is unknown whether therapy assistant staffing is associated with patient outcomes. Using 2017 national data, we examined associations between therapy assistant staffing and three outcomes: patient functional improvement, community discharge, and hospital readmissions, controlling for therapy intensity and facility characteristics. Assistant staffing was not associated with functional improvement. Compared with employing no assistants, staffing 25% to 75% occupational therapy assistants and 25% to 50% physical therapist assistants were associated with more community discharges. Higher occupational therapy assistant staffing was associated with higher readmissions. Higher intensity physical therapy was associated with better quality across outcomes. Skilled nursing facilities seeking to maximize profit while maintaining quality may be successful by choosing to employ more physical therapy assistants rather than sacrificing physical therapy intensity.

Factors Associated with Duration of Rehabilitation Among Older Adults with Prolonged Hospitalization

BACKGROUND/OBJECTIVES

Older adults are prone to functional decline during prolonged hospitalization. Although rehabilitation therapy is critical to preserving function, little is known about rehabilitation duration (RD) in this population. We sought to determine the extent of rehabilitation therapy provided to older adults during prolonged hospitalization, and whether this differs by sociodemographic and clinical characteristics.

DESIGN

Retrospective cohort.

SETTING

Single-site safety-net hospital.

PARTICIPANTS

Older adults (≥65 years) hospitalized for ≥14 days between 2016 and 2017.

MEASUREMENTS

The primary outcome was RD, defined as the average number of minutes of physical and occupational therapy per week. We used a multivariable generalized linear model to assess for differences in RD by sociodemographic and clinical characteristics. For a sub-cohort of hospitalizations with a baseline mobility assessment, we repeated analyses including mobility limitation as a covariate.

RESULTS

Among 1,031 hospitalizations by 925 unique patients (median age 72, 49% female, 79% non-white, 40% non-English speaking), the median RD was 61.3 minutes/week (interquartile range = 16.5-127.3). Covariates associated with lesser RD included black (57.2 fewer minutes/week; 95% confidence interval (CI) = 22.9-91.4) and Hispanic (75.6 fewer minutes/week; 95% CI = 33.8-117.4) race/ethnicity, speaking a language other than English or Spanish (51.7 fewer minutes/week; 95% CI = 21.3-82.0), prolonged mechanical ventilation (30.0 fewer minutes/week; 95% CI = 6.6-53.3), and do-not-resuscitate code status (36.0 fewer minutes/week; 95% CI = 17.1-54.8). The inclusion of mobility limitation among the sub-cohort (n = 350) did not meaningfully change the associations.

CONCLUSION

We found large disparities in RD for racial/ethnic and language minorities and clinically vulnerable older adults (mechanical ventilation and do-not-resuscitate code status), independent of clinical severity and functional and cognitive impairment. Greater RD for these groups may improve functional outcomes and narrow the disparity gap.

Functional Recovery Rate: A Feasible Method for Evaluating and Comparing Rehabilitation Outcomes Between Skilled Nursing Facilities

OBJECTIVES

The recovery of patients' physical function and the rate at which this occurs are important parameters for evaluating value in post-acute care (PAC). However, no metrics are presently used to compare skilled nursing facilities (SNFs) based on the functional recovery rates (FRRs) for patients in their care. The objectives of this study were to examine whether the average FRR differed significantly among SNFs and to compare the FRR to other measures currently used to assess care quality in SNFs.

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

3913 patients discharged from hospitals in one health system to one of 10 partner SNFs between January 2017 and September 2019.

METHODS

The FRR-the difference in Activity Measure for Post-Acute Care 6-Clicks basic mobility score from SNF admission to discharge relative to the SNF length of stay (in days)-was the primary outcome. Secondary outcomes included metrics from the SNF Quality Reporting Program (functional recovery alone, discharge to the community, and 30-day hospital readmission). Differences in patients' outcomes between SNFs were tested using multiple regression in order to adjust for patient characteristics.

RESULTS

Across the 10 SNFs, the highest adjusted mean FRR was 0.70 [95% confidence interval (CI): 0.55, 0.90] and the lowest was 0.39 (95% CI: 0.33, 0.46) points per day. Two SNFs had an adjusted mean FRR statistically higher, and 2 had an FRR statistically lower, than the sample mean (0.50, 95% CI: 0.48-0.52). SNF rankings varied by metric.

CONCLUSIONS AND IMPLICATIONS

Individual SNFs vary in their mean FRR for patients making it a potentially useful measure of value for comparing SNFs. Standardized measurement and reporting of FRR could be beneficial to patients and their families as they consider specific SNFs for necessary post-acute rehabilitation and to hospital systems seeking to identify high-value PAC providers with whom to partner in collaborative care models.

Effect of intensive rehabilitation on improvement of activity of daily living after intracerebral hemorrhage: a retrospective observational study

Between 2008 and 2012, the intensity of rehabilitation therapy for the recovery phase of stroke was gradually increased at our hospital in line with the policy of Japan's National Insurance System. Training hours increased from 0.8 to 2.5 hours/day without introducing any new techniques, programs, or equipment. The aim of this study was to investigate the effectiveness of the increased intensity of rehabilitation on the improvement of activity of daily living of patients with intracerebral hemorrhage. We retrospectively compared patient outcomes for the periods 2013-2017 (N = 162) and 2003-2007 (N = 116) using the gain in Barthel Index as an indicator of improvement in activity of daily living. The median (interquartile range) gain was significantly higher in 2013-2017 than in 2003-2007 [30 (20-45) vs. 15 (5-30); P < 0.001]. A stratified analysis showed that this improvement was independent of sex, the patient's Barthel Index on admission, or the side of the brain lesion, but it varied with age or time to admission from onset of the disease. These results, based on a considerable difference in the intensity of rehabilitation between the two periods, support the consensus that increased time spent on rehabilitation results in better functional outcome in post-stroke patients. The results also suggest that age and the timing of starting rehabilitation are important factors to examine the effectiveness of intense rehabilitation in patients with intracerebral hemorrhage.

Occupational and Physical Therapy Activities and Level of Effort in Patients With Traumatic Brain Injury: Association With Functional Outcomes

BACKGROUND

Although some attention has been given to the association of functional outcomes with rehabilitation intensity, the evidence is still sparse in this field.

OBJECTIVE

To investigate the effect of inpatient rehabilitation (IR) on discharge cognitive and motor function and the association of time spent in occupational and physical therapy and level of effort with cognitive and motor function in patients with traumatic brain injury (TBI).

DESIGN

Secondary analysis of TBI-Practice Based Evidence dataset.

SETTINGS

Inpatient rehabilitation.

PARTICIPANTS

One hundred forty-nine patients with TBI who were consecutively admitted for IR between 2008 and 2011 in Ontario, Canada.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Admission and discharge Functional Independence Measure-Rasch Cognitive and Motor Scores.

RESULTS

Patients showed significant improvement in cognitive and motor function from admission to discharge (P < .0001). After controlling for confounding factors, discharge FIM-Rasch cognitive and motor scores were not associated with either level of effort or time spent in physical therapy activities. Discharge motor, but not cognitive function, was associated with more time spent in the complex (β = 0.20, confidence interval [CI] 0.005, 0.05) and less time spent in simple OT activities (β = -0.13, CI -0.13, -0.01).

CONCLUSION

This study provides valuable information for clinicians about the effectiveness of IR on the improvement of motor and cognitive outcomes and the importance of considering the amount of time spent in activities based on their level of complexity rather than the total time of therapy to improve motor outcomes in this population.

LEVEL OF EVIDENCE

III.

[Impact of a centralised hospital admission system on the efficacy and efficiency of a geriatric functional recovery unit]

OBJECTIVE

To evaluate the influence of a change in the management of admissions on the activity and care outcomes of a Geriatric Functional Recovery Unit (GFRU).

MATERIAL AND METHODS

A retrospective observational study was conducted. Since 2000, the Hospital Central Cruz Roja GFRU has been collecting data grouped into periods of 4 years, except for the centralised admissions (September 2016-December 2018). The data collected on admission included the Red Cross Functional and Mental scales, the Barthel index, the main diagnosis of the functional decline (grouped into stroke, orthopaedic problem, and multifactorial immobility episodes), and comorbidity evaluated by the Charlson index. The following outcome variables were analysed: the overall and relative functional gain at discharge; length of hospital stay; the functional efficiency, discharges to nursing homes, and transfers to acute care units. An analysis was made of the relationship between the admissions from the centralised unit and the previous period (directly admission managed by GFRU), using multivariate analysis (linear regression for continuous outcome variables and logistic regression for the dichotomous ones), adjusted for admission variables.

RESULTS

Patients admitted from the centralised unit showed a greater overall and relative functional gain (difference between both means: 3.49 points, 95% CI; 1.65-5.33, and 12.41%, 95% CI; 0.74-24.08, respectively), longer stay (12.92 days, 95% CI; 11.54-14.30) and lower efficiency (-0.36, 95% CI; -0.16 to -0.57), higher risk of institutionalisation (OR 1.61, 95% CI; 1.19-2.16), and transfers to acute care units (OR 3.16, 95% CI; 2.24-4.47).

CONCLUSIONS

A centralised admissions system had an influence on the improvement of functional parameters in the patients, but with a longer length of hospital stay, and lower efficiency. Increases in institutionalisation at discharge and transfers to acute care units were also observed.

Improvement During Inpatient Rehabilitation Among Older Adults With Guillain-Barré Syndrome, Multiple Sclerosis, Parkinson Disease, and Stroke

OBJECTIVE

The aim of the study was to quantify the improvement in independence experienced by patients with the following diagnoses: Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke after inpatient rehabilitation.

DESIGN

Subjects who were admitted to inpatient rehabilitation hospitals in 2012-2013 with an incident diagnosis of the following: Guillain-Barré syndrome (n = 1079), multiple sclerosis (n = 1438), Parkinson disease (n = 11,834), or stroke (n = 131,313), were included. The main outcome measure was improvement in Functional Independence Measure scores on self-care, mobility, and cognition during inpatient rehabilitation. We estimated percent improvement from a linear mixed-effects model adjusted for patients' age, sex, race/ethnicity, comorbidity count, diagnostic group (Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke), and admission score.

RESULTS

All patient diagnostic groups receiving inpatient rehabilitation improved across all three domains. The largest adjusted percent improvements were observed in the mobility domain and the smallest in the cognition domain for all groups. Percent improvement in mobility ranged from 84.9% (multiple sclerosis) to 144.0% (Guillain-Barré syndrome), self-care from 49.5% (multiple sclerosis) to 84.1% (Guillain-Barré syndrome), and cognition from 34.0% (Parkinson disease) to 51.7% (Guillain-Barré syndrome). Patients with Guillain-Barré syndrome demonstrated the greatest percent improvement across all three domains.

CONCLUSIONS

Patients with Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke should improve during inpatient rehabilitation but anticipated outcomes for patients with Guillain-Barré syndrome should be even higher.

The Efficacy and Safety of Inpatient Rehabilitation Compared With Home Discharge After Hip or Knee Arthroplasty: A Meta-Analysis and Systematic Review

BACKGROUND

Total hip and knee arthroplasties (THKAs) are successful procedures in managing end-stage arthritis when nonoperative treatments fail. The immediate postoperative period is an important time for the body to recuperate and rehabilitate. Studies have shown that early intensive rehabilitation can enhance recovery. Rehabilitation can be provided as inpatient rehabilitation (IR) or discharge with home rehabilitation. These options have been studied, but literature on the efficacy and safety of IR compared to home discharge is scarce, and evidence is not well established. This meta-analysis aims to compare the efficacy and safety of IR to home discharge with rehabilitation after THKA.

METHODS

A multidatabase search was performed according to PRISMA guidelines. Data from studies assessing the efficacy and safety of IR and home as discharge destinations after THKA were extracted and analyzed.

RESULTS

Fifteen studies were included, consisting of 37,411 IR patients and 172,219 home discharge patients. These studies had heterogeneous reporting methods, with some conflicting results. There was no clinically significant difference in clinical outcomes between the groups. Readmission was nearly 5 times (odds ratio = 4.87, 95% confidence interval = 3.24-7.33, P < .001) and periprosthetic complications nearly 3 times (odds ratio = 2.82, 95% confidence interval: 1.54-5.24, P < .001) higher in IR patients than those discharged home after THKA.

CONCLUSION

Although IR is associated with higher risks of complications and readmissions, this may be because of patient selection bias in the clinical setting. Following THKA, it is safe to discharge patients to home with rehabilitation whenever possible.

EVIDENCE LEVEL

Level II, Meta-analysis of heterogeneous studies.

Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation: A Randomized Clinical Trial

IMPORTANCE

Enhanced medical rehabilitation (EMR) is a systematic and standardized approach for physical and occupational therapists to engage patients. Higher patient engagement in therapy might lead to improved functional recovery in rehabilitation settings, such as skilled nursing facilities (SNFs).

OBJECTIVE

To determine whether EMR improves older adults' functional recovery.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, parallel-group, randomized clinical trial was conducted from July 29, 2014, to July 13, 2018, in 229 adults aged 65 years or older admitted to 2 US SNFs. Participants were randomized to receive EMR (n = 114) vs standard-of-care rehabilitation (n = 115). Intention-to-treat analysis was used.

INTERVENTIONS

The intervention group received their physical and occupational therapy from therapists trained in EMR. Based on models of motivation and behavior change, EMR is a toolkit of techniques to increase patient engagement and therapy intensity. The control group received standard-of-care rehabilitation from physical and occupational therapists not trained in EMR.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in function in activities of daily living and mobility, as assessed with the Barthel Index, which measures 10 basic activities of daily living or mobility items (scale range, 0-100), from SNF admission to discharge; secondary outcomes were gait speed for 10 m, 6-minute walk test, discharge disposition, rehospitalizations, and self-reported functional status at days 30, 60, and 90. To examine the rehabilitation process, therapists' engagement with patients and patient active time during therapy were measured for a sample of the sessions.

RESULTS

Of the 229 participants, 149 (65.1%) were women; 177 (77.3%) were white, and 51 (22.3%) were black; mean (SD) age was 79.3 (8.0) years. Participants assigned to EMR showed greater recovery of function than those assigned to standard of care (mean increase in Barthel Index score, 35 points; 95% CI, 31.6-38.3 vs 28 points; 95% CI, 25.2-31.7 points; P = .007). There was no evidence of a difference in the length of stay (mean [SD], 23.5 [13.1] days). However, there were no group by time differences in secondary outcome measures, including self-reported function after SNF discharge out to 90 days as measured on the Barthel Index (mean [SE] score: EMR, 83.65 [2.20]; standard of care, 84.67 [2.16]; P = .96). The EMR therapists used a median (interquartile range) of 24.4 (21.0-37.3) motivational messages per therapy session vs 2.3 (1.1-2.9) for nontrained therapists (P < .001), and EMR patients were active during a mean (SD) of 52.5 (6.6%) of the therapy session time vs 41.2 (6.8%) for nontrained therapists (P = .001).

CONCLUSIONS AND RELEVANCE

Enhanced medical rehabilitation modestly improved short-term functional recovery for selected older adults rehabilitating in SNFs. However, there was no evidence that the benefits persisted over the longer term. This study demonstrates the value of engaging and motivating older adults in rehabilitation therapy, but more work is needed to extend these benefits to longer-term outcomes after discharge home.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02114879.

In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study

QUESTIONS

When a hospital gymnasium used for inpatient rehabilitation is set up to allow semi-supervised practice: what percentage of practice is performed as semi-supervised practice, what percentage of patients in the gym are actively engaged in practice at one time, and is the semi-supervised practice that occurs safe?

DESIGN

An observational study using periodic behaviour mapping.

PARTICIPANTS

Patients in general and stroke rehabilitation units of a metropolitan hospital.

OUTCOME MEASURES

Observations in the rehabilitation gym quantified the number of patients in the gym and the numbers of patients practising and resting. In observations of patients practising, the condition of practice was recorded as being with a therapist, with a family member, or with no direct supervision. The number of adverse events during the data collection period was collected from the hospital Incident Information Management System.

RESULTS

The rehabilitation gym was observed on 113 occasions, resulting in 1319 individual patient observations. An average of 12 patients were in the gym during the observations. Practice was being performed with family supervision in 15% of observations and with no direct supervision in 26% of observations, resulting in semi-supervised practice accounting for 41% of all observations of practice. The percentage of observations that were of patients taking part in active practice was 78%. There were no adverse events in the gym.

CONCLUSION

In an inpatient setting, a large percentage of practice can be performed as semi-supervised practice. This does not appear to compromise the time spent in active practice or patient safety.

Role of rehabilitation in the elderly after an acute event: insights from a real-life prospective study in the subacute care setting

BACKGROUND

Any acute event, either primary or secondary to a chronic disease, is generally followed by some degree of physical impairment. Subacute care (SAC) represents one of the inpatient intermediate care settings aimed at completing recovery and restoring functional capacity. Debate exists on the role of the rehabilitation treatment in the SAC setting.

AIM

The aim of this study was to compare the outcomes of patients managed in two different SAC Units where A) patients undergo an individualized rehabilitation program on top of optimal medical therapy (OMT) B) patients receive OMT only.

DESIGN

Real-life prospective study.

SETTING

SAC units.

POPULATION

Seventy-five chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) patients transferred after an acute hospitalization.

METHODS

Upon SAC admission, the following scales were obtained: cumulative illness rating scale comorbidity and severity (CIRSC and CIRSS), mini mental state examination (MMSE), Performance-Oriented Mobility Assessment (POMA), Barthel Index (BI), the 10-meter walking test (10MWT). Pre-admission BI was also collected based on history. Upon SAC discharge, BI, POMA, and 10MWT were repeated.

RESULTS

Patients (44 in Group A, 31 in Group B) were similar with regard to age, gender, MMSE, clinical complexity, pre-admission BI, admission 10MWT, POMA, and bedrest conditions. Admission BI was lower in Group A. In both groups BI was lower when compared to the respective pre-admission score. Upon discharge, Group A patients were characterized by a higher BI and POMA compared to Group B. Indeed, BI and POMA improved at discharge only in Group A patients. Only this latter group reached the pre-morbid BI. Upon discharge the number of bedrest patients decreased only in Group A. The percentage of patients discharged home was also much higher in Group A, while a greater number of Group B patients were transferred to a rehabilitation ward or were enrolled in an integrated home care assistance program.

CONCLUSIONS

In a real-life prospective experience, a better outcome is demonstrated in elderly CHF and COPD patients undergoing a rehabilitative approach during their in-hospital SAC stay.

CLINICAL REHABILITATION IMPACT

An individualized rehabilitation program should integrate medical treatment of CHF and BPCO patients in the SAC setting. This approach demonstrates a better cost-effectiveness management of these patients.

An Evaluation of the Role of an Intermediate Care Facility in the Continuum of Care in Western Cape, South Africa

Background: A comprehensive primary healthcare (PHC) approach requires clear referral and continuity of care pathways. South Africa is a lower-middle income country (LMIC) that lacks data on the role of intermediate care (IC) services in the health system. This study described the model of service provision at one facility in Cape Town, including reason for admission, the mix of services and skills provided and needed, patient satisfaction, patient outcome and articulation with other services across the spectrum of care.

Methods: A multi-method design was used. Sixty-eight patients were recruited over one month in mid-2011 in a prospective cohort. Patient data were collected from clinical record review and an interviewer-administered questionnaire, administered shortly after admission to assess primary and secondary diagnosis, referring institution, knowledge of and previous use of home based care (HBC) services, reason for admission and demographics. A telephonic questionnaire at 9-weeks post-discharge recorded their vital status, use of HBC post-discharge and their satisfaction with care received. Staff members completed a self-administered questionnaire to describe demographics and skills. Cox regression was used to identify predictors of survival.

Results: Of the 68 participants, 38% and 24% were referred from a secondary and tertiary hospital, respectively. Stroke (35%) was the most common single reason for admission. The three most common reasons reported why care was better at the IC facility were staff attitude, the presence of physiotherapy and the wound care. Even though most patients reported admission to another health facility in the preceding year, only 13 patients (21%) had ever accessed HBC and only 25% (n=15) of discharged patients used HBC post-discharge. Of the 57 patients traced on follow-up, 21(37%) had died. The presence of a Care-plan was significantly associated with a 62% lower risk of death (hazard ratio: 0.38; CI 0.15–0.97). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks.

Conclusion: Clients understood this service as a caring environment primarily responsible for rehabilitation services. A Care-plan beyond admission could significantly reduce mortality. There was poor referral to and poor articulation with HBC services. IC services should be recognised as an integral part of the health system and should be accessible.

Justifying Rehabilitation Intensity Through Functional Performance Measures in Postacute Care

The Centers for Medicare and Medicaid Services (CMS) has scrutinized the provision of rehabilitation services in skilled nursing facilities (SNFs) for some time. Little research guidance exists on appropriate dosage or rehabilitation intensity (RI) among SNF patients or patients in other postacute care (PAC) settings. CMS developed a PAC assessment, the Continuity Assessment Record and Evaluation (CARE) Tool, in response to questions about what issues drive placement in various PAC settings under Medicare. The ability to adequately assess functional outcomes and correlate them to the RI provided by using the CARE Tool is promising. However, further research, policy advocacy, and practice analysis must be undertaken to promote and protect adequate access to occupational therapy and physical therapy in SNFs and other PAC settings. Individual practitioners must participate in data gathering to ensure that the data for analysis are fully informed by the occupational therapy perspective.

Comparison of postarthroplasty functional outcomes in skilled nursing facilities among Medicare and Managed Care beneficiaries

Background

After home health care, the skilled nursing facility (SNF) is the most commonly used postacute care modality, among Medicare beneficiaries, after total joint arthroplasty. Prior studies demonstrated that a loss in postsurgical ambulatory gains is incurred in the interval between hospital discharge and arrival at the SNF. The aim of this present study is to determine the consequences of that loss in function, as well as compare SNF-related outcomes in patients with Medicare vs Managed Care (MC) insurance.

Methods

We conducted a retrospective analysis of 80 patients (54 Medicare and 26 MC) who attended an SNF after hospitalization for total joint arthroplasty. Outcomes from physical therapy records were abstracted from each patient's SNF file.

Results

There was an approximately 40% drop-off in gait achievements between hospital discharge and SNF admission. This decline in ambulation was significantly greater in Medicare patients (Medicare: 94.6 ± 123.2 ft, MC: 40.0 ± 48.9 ft, P = .034). Larger reductions in gait achievements between hospital discharge and SNF admission were significantly correlated with longer SNF lengths of stay and poorer gait achievements by SNF discharge. Patients with MC insurance made significant improvements in gait training at the SNF beyond that which was acquired at the hospital, whereas Medicare patients did not (P_Medicare = .28, P_MC = .003).

Conclusions

Large losses in motor function between hospital discharge and SNF admission were associated with poor functional outcomes and longer stays at the SNF. These effects were more pronounced in Medicare patients than those with MC insurance.

Postacute Care Setting, Facility Characteristics, and Poststroke Outcomes: A Systematic Review

OBJECTIVES

To synthesize research comparing poststroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and those in inpatient rehabilitation facilities (IRFs) as well as to evaluate relations between facility characteristics and outcomes.

DATA SOURCES

PubMed and CINAHL searches spanned January 1, 1998, to October 6, 2016, and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Searches were restricted to peer-reviewed research in humans published in English.

STUDY SELECTION

Observational and experimental studies examining outcomes of adult patients with stroke rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report ≥1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by 1 author, and when uncertain, discussion with study coauthors achieved consensus. Fourteen titles (0.3%) were included.

DATA EXTRACTION

The types of data, time period, size, design, and primary outcomes were extracted. We also extracted 2 secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by 1 author, and the accuracy was verified by a second reviewer.

DATA SYNTHESIS

Two studies evaluating community discharge, 1 study evaluating the predicted probability of readmission, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation.

CONCLUSIONS

The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.

Community Use of Physical and Occupational Therapy After Stroke and Risk of Hospital Readmission

OBJECTIVES

To determine whether receipt of therapy and number and timing of therapy visits decreased hospital readmission risk in stroke survivors discharged home.

DESIGN

Retrospective cohort analysis of Medicare claims (2010-2013).

SETTING

Acute care hospital and community.

PARTICIPANTS

Patients hospitalized for stroke who were discharged home and survived the first 30 days (N=23,413; mean age ± SD, 77.6±7.5y).

INTERVENTIONS

Physical and occupational therapist use in the home and/or outpatient setting in the first 30 days after discharge (any use, number of visits, and days to first visit).

MAIN OUTCOME MEASURES

Hospital readmission 30 to 60 days after discharge. Covariates included demographic characteristics, proxy variables for functional status, hospitalization characteristics, comorbidities, and prior health care use. Multivariate logistic regression analyses were conducted to examine the relation between therapist use and readmission.

RESULTS

During the first 30 days after discharge, 31% of patients saw a therapist in the home, 11% saw a therapist in an outpatient setting, and 59% did not see a therapist. Relative to patients who had no therapist contact, those who saw an outpatient therapist were less likely to be readmitted to the hospital (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Although the point estimates did not reach statistical significance, there was some suggestion that the greater the number of therapist visits in the home and the sooner the visits started, the lower the risk of hospital readmission.

CONCLUSIONS

After controlling for observable demographic-, clinical-, and health-related differences, we found that individuals who received outpatient therapy in the first 30 days after discharge home after stroke were less likely to be readmitted to the hospital in the subsequent 30 days, relative to those who received no therapy.

Impact of Therapy on Recovery during Rehabilitation in Patients with Traumatic Spinal Cord Injury

Evidence-based planning of rehabilitation interventions is important to improving cost efficiency while maintaining patient and system outcomes. This article aims to explore the relationship between rehabilitation therapy, functional outcome, bed utilization, and care costs after traumatic spinal cord injury (tSCI). A retrospective review of 262 persons with tSCI admitted to an inpatient rehabilitation facility from 2005–2012 was conducted. Treatment variables and outcome measures included rehabilitation length of stay (LOS), days to rehabilitation (onset), hours and intensity of therapy, and Functional Independence Measure (FIM). Polynomial regression models and generalized additive models were applied to explore the relationship between therapy hours and motor FIM change. Simulation modeling was used to assess the impact of hypothetically increasing therapy intensity. Patients were grouped by injury as: C1–4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A,B,C; C5–8 AIS A,B,C; T1–S5 AIS A,B,C; and AIS D. The sample was 85% male, mean age 45.9, median LOS 102 days, and mean therapy intensity 5.7 h/week. Motor FIM change was positively associated with total hours of therapy (β = 0.40, p < 0.0001) up to a certain time point, adjusted for age, gender, injury, complications, and rehabilitation onset. Hypothetically increasing therapy intensity by 50% and 100% resulted in average motor FIM efficiency gain ranging between 0.04–0.07 and 0.1–0.17, respectively, across injury groups. The hypothetical changes resulted in reductions in the average LOS and bed utilization rate, translating to cost savings of $20,000 and $50,000 (2011 CAD) for the +50% and +100% scenarios, respectively. The results highlight the importance of monitoring functional change throughout rehabilitation after tSCI and the need for customized therapeutic strategies.

Impact of Rehabilitation on Outcomes in Patients With Ischemic Stroke

Background and Purpose—

We aimed to examine the concurrent effects of timing and intensity of rehabilitation on improving activities of daily living (ADL) among patients with ischemic stroke.

Methods—

Using the Japanese Diagnosis Procedure Combination inpatient database, we retrospectively analyzed consecutive patients with ischemic stroke at admission who received rehabilitation (n=100 719) from April 2012 to March 2014. Early rehabilitation was defined as that starting within 3 days after admission. The average rehabilitation intensity per day was calculated as the total units of rehabilitation during hospitalization divided by the length of hospital stay. A multivariable logistic regression analysis with multiple imputation and an instrumental variable analysis were performed to examine the association of early and intensive rehabilitation with the proportion of improved ADL score.

Results—

The proportion of improved ADL score was higher in the early and intensive rehabilitation group. The multivariable logistic regression analysis showed that significant improvements in ADL were observed for early rehabilitation (odds ratio: 1.08; 95% confidence interval: 1.04–1.13; P <0.01) and intensive rehabilitation of >5.0 U/d (odds ratio: 1.87; 95% confidence interval: 1.69–2.07; P <0.01). The instrumental variable analysis showed that an increased proportion of improved ADL was associated with early rehabilitation (risk difference: 2.8%; 95% confidence interval: 2.0–3.4%; P <0.001) and intensive rehabilitation (risk difference: 5.6%; 95% confidence interval: 4.6–6.6%; P <0.001).

Conclusions—

The present results suggested that early and intensive rehabilitation improved ADL during hospitalization in patients with ischemic stroke.

Length of Stay in Skilled Nursing Facilities Following Total Joint Arthroplasty

BACKGROUND

The most commonly used postacute care facility after total joint arthroplasty is a skilled nursing facility (SNF). However, little is known regarding the role of physical therapy achievements and insurance status on the decision to discharge from an SNF. In this study, we aim to compare functional outcomes and length of stay (LOS) at an SNF among patients with Medicare vs private health coverage.

METHODS

We retrospectively collected physical therapy data for 114 patients who attended an SNF following acute hospitalization for total joint arthroplasty. Medicare beneficiaries were compared with patients covered by Managed Care (MC) policies (health maintenance organization [HMO] and preferred provider organization [PPO]) using several SNF discharge outcomes, including LOS, distance ambulated, and functional independence in gait, transfers, and bed mobility.

RESULTS

LOS at the SNF was significantly longer for Medicare patients (Medicare: 24 ± 22 days, MC: 12 ± 7 days, P = .007). After adjusting for LOS and covariates, MC patients had significantly greater achievements in all functional outcomes measured. In a study subanalysis, Medicare patients were found to achieve similar functional outcomes by SNF day 14 as MC patients achieved by their day of discharge on approximately day 12. Yet, the Medicare group was not discharged until several days later.

CONCLUSION

Medicare status is associated with poor functional outcomes, long LOS, and slow progress in the SNF. Our results suggest that insurance reimbursement may be a primary factor in the decision to discharge, rather than the achievement of functional milestones.

Place orientation and visual construction subdomains of the Mini Mental State Examination test as predictors of rehabilitation outcome of post-acute hip-fractured patients

PURPOSE

The study aimed at assessing the relationship between various Mini Mental State Examination (MMSE) subdomains and rehabilitation achievements in post-acute hip-fractured patients.

METHOD

Six hundred and five hip-fractured patients admitted during 2010-2013 to a post-acute geriatric rehabilitation center were included in the study. Main outcome measures were the Functional Independence Measure (FIM) instrument, the motor FIM (mFIM), the Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). A logistic regression analysis tested the predictive value of MMSE subdomains for achieving a satisfactory functional gain (mFIM MRFS >30%) on operated patients admitted from community.

RESULTS

Of all the six MMSE subdomains, place orientation and visual construction demonstrated significant predictive values for rehabilitation outcome. Patients who did not err on place orientation and visual construction MMSE domains had better probabilities [(OR 1.28, 95%CI, 1.05-1.58; p = 0.017); (OR 2.15, 95%CI, 1.28-3.59; p = 0.004), respectively] of achieving better rehabilitation achievements. Similar results were obtained for cognitively impaired patient groups [(OR 1.40 95%CI, 1.11-1.77; p = 0.005); (OR 2.47, 95%CI, 1.15-5.30; p = 0.021), respectively]. For the cognitively intact patient group, the variables with significant predictive value were time orientation and visual construction MMSE subdomains [(OR 2.26, 95%CI, 1.18-4.33; p = 0.014); (OR 2.87, 95%CI, 1.16-7.09; p = 0.022), respectively].

CONCLUSIONS

Post-acute hip-fractured patients scoring normally on place orientation and visual construction MMSE subdomains have a better chance of achieving favorable rehabilitation outcome. Implications for Rehabilitation Post-acute hip-fractured patients have a better chance to achieve a favorable rehabilitation outcome when scoring normally on place orientation and visual construction MMSE subdomains. Patients having difficulties in orientation and visual construction may need more rehabilitation time as they lack planning and organizational capacity to follow instructions. Assessing MMSE subdomains may reveal subtle cognitive impairment in patients scored within the normal range on the MMSE test. Identifying subtle cognitive impairment may assist in coordinating the patients and their caregivers' expectations, efficiently allocating resources and help in advanced care planning.

Post-stroke depression inhibits improvement in activities of daily living in patients in a convalescent rehabilitation ward

[Purpose] There have been no investigations into the improvement of activities of daily living among patients suffering from post-stroke depression on admission to convalescent rehabilitation wards in Japan. This study aimed to assess the improvement of activities in daily living in patients with or without post-stroke depression at the time of admission to a convalescent rehabilitation ward. [Subjects and Methods] This retrospective study included 108 stroke patients divided into two groups according to their Geriatric Depression Scale 15-item short form scores. Activities of daily living were assessed using the Functional Independence Measure. The degree of improvement on the Functional Independence Measure was defined as the difference between scores on admission and at discharge. [Results] The Functional Independence Measure gain score was significantly different from the Functional Independence Measure total score. There was a significant interaction between time period and post-stroke depression factors for the Functional Independence Measure total score. A multiple regression analysis revealed a significant association between Geriatric Depression Scale score and Functional Independence Measure total score. [Conclusion] The present study suggests that post-stroke depression has a negative impact on recovery of activities of daily living and on rehabilitation outcomes in a convalescent rehabilitation ward setting.

A Multidimensional Rasch Analysis of the Functional Independence Measure Based on the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database

A number of studies have evaluated the psychometric properties of the Functional Independence Measure (FIM™) using Rasch analysis, although none has done so using the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database, a longitudinal database that captures demographic and outcome information on persons with moderate to severe traumatic brain injury across the United States. In the current study, we examine the psychometric properties of the FIM as represented by persons within this database and demonstrate that the FIM comprises three subscales representing cognitive, self-care, and mobility domains. These subscales were analyzed simultaneously using a multivariate Rasch model in combination with a time dependent concurrent calibration scheme with the goal of creating a raw score-to-logit transformation that can be used to improve the accuracy of parametric statistical analyses. The bowel and bladder function items were removed because of misfit with the motor and cognitive items. Some motor items exhibited step disorder, which was addressed by collapsing Categories 1-3 for Toileting, Stairs, Locomotion, Tub/Shower Transfers; Categories 1 and 2 for Toilet and Bed Transfers; and Categories 2 and 3 for Grooming. The strong correlations (r = 0.82-0.96) among the three subscales suggest they should be modeled together. Coefficient alpha of 0.98 indicates high internal consistency. Keyform maps are provided to enhance clinical interpretation and application of study results.

Does More Therapy in Skilled Nursing Facilities Lead to Better Outcomes in Patients With Hip Fracture?

BACKGROUND

Skilled nursing facilities (SNFs) have increasingly been providing more therapy hours to beneficiaries of Medicare. It is not known whether these increases have improved patient outcomes.

OBJECTIVE

The study objectives were: (1) to examine temporal trends in therapy hour volumes and (2) to evaluate whether more therapy hours are associated with improved patient outcomes.

DESIGN

This was a retrospective cohort study.

METHODS

Data sources included the Minimum Data Set, Medicare inpatient claims, and the Online Survey, Certification, and Reporting System. The study population consisted of 481,908 beneficiaries of Medicare fee-for-service who were admitted to 15,496 SNFs after hip fracture from 2000 to 2009. Linear regression models with facility and time fixed effects were used to estimate the association between the quantity of therapy provided in SNFs and the likelihood of discharge to home.

RESULTS

The average number of therapy hours increased by 52% during the study period, with relatively little change in case mix at SNF admission. An additional hour of therapy per week was associated with a 3.1-percentage-point (95% confidence interval=3.0, 3.1) increase in the likelihood of discharge to home. The effect of additional therapy decreased as the Resource Utilization Group category increased, and additional therapy did not benefit patients in the highest Resource Utilization Group category.

LIMITATIONS

Minimum Data Set assessments did not cover details of therapeutic interventions throughout the entire SNF stay and captured only a 7-day retrospective period for measures of the quantity of therapy provided.

CONCLUSIONS

Increases in the quantity of therapy during the study period cannot be explained by changes in case mix at SNF admission. More therapy hours in SNFs appear to improve outcomes, except for patients with the greatest need.

After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review

QUESTION

In adults undergoing inpatient rehabilitation, does additional after-hours rehabilitation decrease length of stay and improve functional outcome, activities of daily living performance and physical activity?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adults participating in an inpatient rehabilitation program.

INTERVENTION

Additional rehabilitation provided after hours (evening or weekend).

OUTCOME MEASURES

Function was measured with tests such as the Motor Assessment Scale, 10-m walk test, the Timed Up and Go test, and Berg Balance Scale. Performance on activities of daily living was measured with the Barthel index or the Functional Independence Measure. Length of stay was measured in days. Physical activity levels were measured as number of steps or time spent upright. Standardised mean differences (SMD) or mean differences (MD) were used to combine these outcomes. Adverse events were summarised using relative risks (RR). Study quality was assessed using PEDro scores.

RESULTS

Seven trials were included in the review. All trials had strong methodological quality, scoring 8/10 on the PEDro scale. Among the measures of function, only balance showed a significant effect: the MD was 14 points better (95% CI 5 to 23) with additional after-hours rehabilitation on a 0-to-56-point scale. The improvement in activities of daily living performance with additional after-hours rehabilitation was of borderline statistical significance (SMD 0.10, 95% CI 0.00 to 0.21). Hospital length of stay did not differ significantly (MD -1.8 days, 95% CI -5.1 to 1.6). Those receiving additional rehabilitation had significantly higher step counts and spent significantly more time upright. Overall, the risk of adverse events was not increased by the provision of after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10).

CONCLUSION

Additional after-hours rehabilitation can increase physical activity and may improve activities of daily living, but does not seem to affect the hospital length of stay.

REVIEW REGISTRATION

PROSPERO CRD42014007648. [Scrivener K, Jones T, Schurr K, Graham PL, Dean CM (2015) After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review.Journal of Physiotherapy61: 61-67].

Development and Validation of Prognostic Indices for Recovery of Physical Functioning Following Stroke: Part 1

OBJECTIVE

To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning.

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Centers throughout the United States.

PARTICIPANTS

Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment.

MAIN OUTCOME MEASURE

Achievement of physical grade IV or above at final rehabilitation assessment.

RESULTS

Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, ≤69 years = 2, 70-79 years = 1, ≥80 years = 0; initial physical grade, I = 0, II = 3, III = 4; initial cognitive stage, I or II = 0, III = 2, IV or V = 3, VI or VII = 4; absence of renal failure = 1; no serious nutritional compromise = 3; the type of rehabilitation services received, consultative = 0, comprehensive = 4; and recovery time between admission and discharge physical grade assessment, 1-2 days = 0, 3-7 days = 4, and ≥8 days = 5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant (P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score ≥9), second (score = 10-12), third (score = 13-15), and fourth (score >15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively.

CONCLUSION

By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.

Development and Validation of Prognostic Indices for Recovery of Physical Functioning Following Stroke: Part 2

OBJECTIVE

To develop a prognostic index for achievement of modified independence (Functional Independence Measure grade VI) after completion of either comprehensive or consultative rehabilitation after stroke.

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Centers (VAMCs) throughout the United States.

PARTICIPANTS

Data included 5316 patients with stroke discharged from VAMCs who received rehabilitation services while hospitalized and who were physically dependent at initial assessment. The index was derived with use of 60% of the sample and validated in the remaining 40% of the sample. Points derived from the β coefficients of a multivariable logistic model were added to scores that were associated with the probability of recovery.

MAIN OUTCOME MEASURE

Recovery to modified independence or above at final rehabilitation assessment, defined as when patients no longer need physical assistance with eating; grooming; dressing the upper and lower body; toileting; sphincter management; bed to chair, toilet, and tub transfers; and walking/wheelchair use and when they require no more than supervision with bathing or climbing stairs.

RESULTS

Seven independent predictors were identified through logistic regression in the derivation sample: initial physical grade (I or II = 0 points; III = 2 points; IV = 4 points; V = 5 points), initial cognitive stage (I or II = 0 points; III = 2 points; IV = 3 points, V or VI = 4 points; VII =5 points), type of rehabilitation (consultative = 0 points; comprehensive = 4 points), age (<60 years = 3 points; 60-79 years = 2 points; ≥80 years = 0 points), time from initial to final physical grade assessment (1-2 days = 0 points; ≥3 days = 2 points), absence of urinary procedures (3 points), and absence of diabetes with complications (1 point). The following proportions of patients recovered to physical grade VI for the first, second, third, and fourth quartile scores, respectively: 0.59% (score ≤9), 3.87% (score = 9-11), 14.19% (score = 12-15), and 37.38% (score ≥16).

CONCLUSION

Functional recovery to physical grade VI can be predicted on the basis of patients' initial status after a stroke occurs and the type of rehabilitation services to be provided by using a simple scoring system.

A Rehabilitation Program for Patients Recovering from Severe Stroke

Objective:

The purpose of this study was to describe the outcomes of patients with a severe stroke admitted to a specialized “slow stream” rehabilitation program and to develop a model to predict discharge destination.

Methods:

Chart review of 196 consecutive non-ambulatory (“lower-band”) stroke patients admitted between 1996-2001, to a specialized in-patient rehabilitation unit designed to accommodate the needs of patients with profound disabilities, and who were considered inappropriate for conventional inpatient rehabilitation programs. Special features of this program included the availability of an independent living unit, therapies tailored to individual tolerance and the opportunity to remain on the unit for an extended period until such time that the patients' rehabilitation potential had been maximized.

Results:

Patients were admitted to the unit after a median of 49 days following stroke onset. Their median admission and discharge functional independence measure (FIMTM) scores were 46 and 70, respectively. The improvement in ability to perform self-care tasks was statistically significant (Z= -11.18, p<0.0001). By discharge, 54 patients (28%) were able to ambulate independently (with or without an assistive device), while 142 patients (72%) remained wheelchair dependent. Eighty-five patients (43%) returned to their own home upon rehabilitation discharge, while the remainder were admitted to nursing homes or hospitals closer to the patients' home. Admission FIM score, age, no previous history of stroke and male sex were the variables found to most strongly predict discharge home.

Conclusions:

Patients with severe strokes who received individualized care on a highly specialized stroke rehabilitation unit achieved impressive functional outcomes despite a lag of seven weeks post stroke before rehabilitation was initiated. Many patients were no longer wheelchair dependent and almost half returned home. Active rehabilitation should not be limited to “middle-band” stroke patients.

Are we asking the right question about postacute settings of care?

This issue of Archives includes an article by Mallinson et al that compares the outcomes of patients with hip fracture who received rehabilitation services in 3 different postacute settings: skilled nursing facilities, inpatient rehabilitation facilities, or home health. Except in 1 instance, Mallinson found no setting-specific effects and noted that the issue of defining an optimum postacute rehabilitation program is complex and requires more investigation. Mallinson's findings are interesting in their own right but raise a more fundamental issue. This commentary observes that rehabilitation patients typically use multiple postacute settings, not just 1 setting of care, for the same episode of care. This commentary asks whether we should be examining episode outcomes and not just setting-specific outcomes, especially in the face of bundled payment and value-based payment reforms in the Affordable Care Act.

Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation

OBJECTIVE

To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization.

DESIGN

Prospective observational cohort study.

SETTING

Six geographically dispersed rehabilitation centers in the U.S.

PARTICIPANTS

Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations.

RESULTS

More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered.

CONCLUSIONS

Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

Factors that predict discharge destination for patients in transitional care: a prospective observational cohort study

Objective. To investigate factors that predict discharge destination for patients making the transition from hospital to the community. Methods. Using a prospective cohort design, 696 patients from 11 Transition Care Programs were recruited. Baseline patient and program characteristics were considered for predicting discharge destination, functional status, and patient length of stay. Results. An increased physiotherapy staffing ratio in Transition Care Program was associated with an increased likelihood that a patient was discharged home, with an improved functional or mobility status, and after a shorter length of stay. The other factor that predicted discharge to home included having an Aged Care Assessment Service classification of low level care or home with a support package. An increased physiotherapy staffing level also reduced the likelihood of discharge to low level or high level care. The other factors that predicted discharge to low level care were having higher mobility status and older age; the other factor associated with increased likelihood of predicting discharge to high level care was having an Aged Care Assessment Service classification of high level care. Conclusions. Factors on admission that predicted discharge destination were program physiotherapy staffing ratios, Aged Care Assessment Service assessment, age and mobility status. What is known about the topic? In 2004/05 Australia introduced a program called the Transition Care Program (TCP), which targets older persons at the conclusion of an acute hospital episode who require more time and support in a non-acute setting to complete their restorative process and optimise their functional capacity. This program has a particular objective to prevent inappropriate admission to a residential aged care facility. To date, there are no published papers that report the factors that predict discharge destination for patients in the Transition Care Program. What does this paper add? This study provides evidence that program physiotherapy staffing ratios, Aged Care Assessment Service assessment, age and mobility status are predictive of an increased likelihood that a patient will be discharged home with an improved functional/mobility status, after a shorter length of stay. What are the implications for practitioners? Knowledge of factors that predict discharge destination may assist healthcare practitioners and health managers in managing TCP patients and planning services.