Medicare's New Restrictions on Rehabilitation Admissions: Impact on the Elderly

Higher Hospital Spending on Occupational Therapy Is Associated With Lower Readmission Rates

Hospital executives are under continual pressure to control spending and improve quality. While prior studies have focused on the relationship between overall hospital spending and quality, the relationship between spending on specific services and quality has received minimal attention. The literature thus provides executives limited guidance regarding how they should allocate scarce resources. Using Medicare claims and cost report data, we examined the association between hospital spending for specific services and 30-day readmission rates for heart failure, pneumonia, and acute myocardial infarction. We found that occupational therapy is the only spending category where additional spending has a statistically significant association with lower readmission rates for all three medical conditions. One possible explanation is that occupational therapy places a unique and immediate focus on patients’ functional and social needs, which can be important drivers of readmission if left unaddressed.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk factors and acute in-hospital costs for infected pressure ulcers among gunshot-spinal cord injury victims in southeastern Michigan

BACKGROUND

Management of pressure ulcers (PrUs) in patients with gunshot-spinal cord injuries (SCIs) presents unique medical and economic challenges for practitioners.

METHODS

A retrospective chart review was conducted at 3 acute care hospitals in metropolitan Detroit for patients admitted with PrUs due to gunshot-SCIs between January 2004 and December 2008. Multivariate analysis using logistic regression was conducted to choose for the independent predictors of infected PrUs. Mean adjusted in-hospital costs per patient and per hospitalization were calculated and compared between infected and noninfected PrUs.

RESULTS

The study cohort included 201 gunshot-SCI patients with PrUs contributing to 395 admissions, including readmissions, between 2004 and 2008. Seventy-six patients (38%) had infected PrUs at time of the index admission. Independent predictors of infected PrUs on index admission included Charlson Comorbidity Index ≥2 (odds ratio, 2.18, P = .026) and stage III/IV PrU (odds ratio, 4.82; P <.0001). During the study period, the cumulative median duration of hospitalization per patient was 12 days (interquartile range, 6-24 days), resulting in a mean adjusted cost of $19,969 ± $6639 per patient. The mean adjusted cost per hospitalization for patients with infected PrUs was significantly higher than that for patients with noninfected PrUs ($16,735 ± $8310 vs $12,356 ± $7007; P <.001).

CONCLUSIONS

A multidisciplinary approach including home-based rehabilitation programs and SCI wound clinics might help prevent PrUs and their complications and reduce associated costs.

Freestanding Inpatient Rehabilitation Facility Performance Following the 60 Percent Rule

The 60 percent rule has served as a controversial policy change within the postacute care sector since its revision in 2004, requiring inpatient rehabilitation facilities (IRFs) to admit no less than 60% of patients according to 1 of 13 specific conditions or else risk the loss of IRF designation according to Medicare’s prospective payment system. Using a contingency theory framework, this study proposes that the 60 percent rule introduced considerable uncertainty into freestanding IRFs’ operational environment, and as a result, IRFs’ operational performance varied according to their “fit” between certain structural characteristics and the pervasive environmental uncertainty. The results suggest that operational performance, as measured by facility Malmquist Index scores, decreased on average for freestanding IRFs following the 60 percent rule’s enforcement in 2005. In contrast, organizations possessing structural characteristics that better “fit” the heightened environmental uncertainty exhibited improved performance on average during the study’s 6-year time period.

Democratizing information creation from health care data for quality improvement, research, and education-the Montefiore Medical Center Experience

The National Research Council recently reviewed the capabilities of health care software implemented in the United States and described a health care information technology chasm that is threatening the medical community's ability to meet the health care quality goals enumerated in Institute of Medicine reports. Among the critical gaps is the inability of health care software systems to allow users to convert data into meaningful information supporting quality improvement, analysis, and research. In this article, the authors describe the Montefiore Medical Center's decade-long experience developing software for the purpose of converting data into useful information and integrating software use into the clinical culture. The program at Montefiore could serve as a potential national model.

Weight bearing on the affected lower limb in residents of a geriatric rehabilitation hospital

OBJECTIVES

The purpose of the study was to determine whether and to what extent the treatment goal of enhancement of weight bearing on an affected lower limb is achieved in the gait rehabilitation of patients with poststroke hemiparesis, postprosthetic fitting due to unilateral transtibial amputation, or postunilateral hip or knee arthroplasty.

DESIGN

Nonrandomized prepost study. Subjects were 26 residents of a geriatric rehabilitation hospital in the initial stage of gait rehabilitation after poststroke hemiparesis (n = 9), unilateral total hip or knee joint replacement (n = 11), or unilateral transtibial amputation with a fitted prosthesis (n = 6). Weight bearing on the hindfoot and forefoot of the affected limb was measured by using the SmartStep system version 2.2.0, at least once a week, both before and immediately after a gait-training session. Measurements were performed with the patients using their assistive devices.

RESULTS

In the patients with hemiparesis, there was no significant difference found between the initial pretraining maximal weight bearing on the afflicted limb (39% and 50% of body weight on the hindfoot and forefoot, respectively) and that at discharge (47% and 50% of body weight, respectively). In patients after hip or knee arthroplasty and in those who underwent prosthetic fitting, there was a substantial increase found in the loading of the forefoot, but not of the hindfoot, from the initial evaluation to the time of discharge (from 43% to 54% of body weight, P = 0.05, in the arthroplasty group, and from 49.6% to 69.5%, P = 0.09, in the prosthetic group).

CONCLUSIONS

For elderly individuals belonging to the studied diagnostic groups, the goal of enhancing normal weight bearing on the afflicted limb during the time course of 2-3 wks might be unrealistic.

Physiatrists as expert decision makers or understanding the efficiency bashing mismanagement of evidence-based medicine

The practice of inpatient rehabilitation addresses the extensive and complex needs of a very small but needy percent of the overall population. This uniqueness makes most physiatric inpatients outliers relative to the best evidence-based medicine practices. Evidence-based medicine studies focus on simple one problem issues averaged statistically over the entire population or a representative sample. Our inpatients rarely have one problem, and often the multiplicity of problems means contradictory guidance to care. To care for these patients efficiently, feedback to optimize and individualize care is necessary. To try to make all patients fit simplistic evidence-based medicine care paths without individualization leads to less cost-efficient and at times harmful care.