Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke

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.

Meeting community ambulation criteria and confidence with walking on discharge from inpatient rehabilitation were positively associated with performance of outdoor community activities 8 weeks after discharge

PURPOSE

To assess whether meeting criteria for community ambulation and ambulatory self-confidence on discharge from inpatient rehabilitation are associated with participation in community activities.

METHODS

Prospective longitudinal observational study design. Participants were assessed within 48-hours of discharge on ability to complete tasks reflective of community ambulation (walking 315 m, ascending/descending three stairs, a ramp, and a street curb and walking at 0.44 m/s) and ambulatory self-confidence. At 8 weeks post-discharge frequency of participation in domestic, leisure/work and outdoor activities was measured using the Frenchay Activities Index (FAI). Multivariable regression analysis determined factors associated with total and outdoor FAI score.

RESULTS

Seventy-four of 79 participants were followed up at 8 weeks post-discharge. Meeting all ambulation criteria was positively associated with FAI outdoor score (β = 1.85, 95%CI 0.01-3.69, p = 0.049). Ambulatory self-confidence was positively associated with FAI outdoor score (β = 0.03, 95%CI 0-0.05, p = 0.032) and FAI total score (β = 0.05, 95%CI 0-0.1, p = 0.040). Age (β= -0.22, 95%CI -0.36 to -0.08, p = 0.003) and living alone (β = 3.36, 95%CI 0.10-6.61, p = 0.044) were associated with FAI total score.

CONCLUSIONS

Capacity to meet ambulation criteria and ambulatory self-confidence are modifiable factors that could be targeted during rehabilitation to improve participation in community activities.Implications for rehabilitationMeeting community ambulation criteria and confidence with walking on discharge from inpatient rehabilitation are positively associated with performance of outdoor community activities 8 weeks after discharge.Capacity to meet community ambulation criteria and ambulatory confidence may be useful measures for rehabilitation teams to consider when discharging patients home.Meeting ambulation criteria and ambulatory confidence are modifiable factors that could be addressed through targeted therapy to improve community integration following hospitalisation.

Does adding an integrated physical therapy and neuromuscular electrical stimulation therapy to standard rehabilitation improve functional outcome in elderly patients with pneumonia? A randomised controlled trial

OBJECTIVE

To compare the effects of an integrated programme of physical and electrical therapy to standard rehabilitation to improve physical and functional performance in elderly patients with pneumonia.

DESIGN

Randomized clinical trial. The study was registered in the ClinicalTrial.gov website (identifier: NCT02515565).

SETTING

University Hospital.

SUBJECTS

In total, 185 elderly patients with pneumonia were eligible for the study, of which 95 were finally randomized.

INTERVENTIONS

Patients were randomized to a control group which received the standard treatment or to an intervention group which received additionally an integrated programme of physical and electrical therapy.

MAIN MEASURES

Demographic and clinical information was acquired. Pulmonary function, length of hospital stay, handgrip strength, independence levels and comorbidities were assessed as descriptive outcomes. The main outcome measure was functional and physical performance, evaluated with the short physical performance battery. Secondary outcome measures were respiratory symptoms including dyspnoea, fatigue and cough.

RESULTS

Mean age of patients was 74.92 (11.03) years in the intervention group and 72.53 (9.24) years in the control group. Significant between groups differences (P < 0.05) were found in short physical performance battery chair stand test (2.17 (0.97) vs. 0.58 (0.61)) and total score (5.91 (3.61) vs. 4.15 (3.15)). The intervention group showed better performance than the control group in both cases. Fatigue (32.04 (18.58) vs. 46.22 (8.90)) and cough (18.84 (2.47) vs. 17.40 (3.67)) showed higher improvement in the intervention group, and significant differences were observed between the groups.

CONCLUSION

An integrated programme of physical and electrical therapy during hospitalization improves physical and functional performance in patients with pneumonia.

Effects of Hospital-Based Physical Therapy on Hospital Discharge Outcomes among Hospitalized Older Adults with Community-Acquired Pneumonia and Declining Physical Function

To examine whether hospital-based physical therapy is associated with functional changes and early hospital readmission among hospitalized older adults with community-acquired pneumonia and declining physical function. Study design was a retrospective observation study. Participants were community-dwelling older adults admitted to medicine floor for community-acquired pneumonia (n = 1,058). Their physical function using Katz activities of daily living (ADL) Index declined between hospital admission and 48 hours since hospital admission (Katz ADL Index 6→5). The intervention group was those receiving physical therapy for ≥ 0.5 hour/day. Outcomes were Katz ADL Index at hospital discharge and all-cause 30-day hospital readmission rate. The intervention and control groups did not differ in the Katz ADL Index at hospital discharge (p = 0.11). All-cause 30-day hospital readmission rate was lower in the intervention than in control groups (OR = 0.65, p = 0.02). Hospital-based physical therapy has the benefits toward reducing 30-day hospital readmission rate of acutely ill older adults with community-acquired pneumonia and declining physical function.

Factors Influencing Performance-Oriented Mobility After Hip Fracture

Objective: To identify the patient- and fracture-related determinants that influence performance-oriented mobility in hip fracture patients as measured by the Performance-Oriented Mobility Assessment (POMA) score. Method: A prospective study was conducted. Patients aged 65 or older ( n = 186) were prospectively recruited. Patients were assessed for mobility (Tinetti POMA), level of independence (Modified Barthel Index), emotional distress (Goldberg General Health Questionnaire), comorbidities (Charlson Comorbidity Index), and Perceived Health (categorical scale). Results: The study revealed that patient age, type of fracture, length of hospital stay, level of emotional distress, and level of independence were significant predictors of performance-oriented mobility. When combined, these factors explained 44.3% of the variance in performance-oriented mobility ( r2 = .443; r2 adjusted = .414; F = 15.46; p < .001). Discussion: Patients who are older, spend more days in hospital, have worse pre-fracture independence level or higher emotional distress levels at discharge, and sustain subtrochanteric or intertrochanteric fractures seem to have poorer performance-oriented mobility after hip fracture.

How does cognitive impairment impact on functional improvement following the rehabilitation of elderly patients?

AIMS

It has been suggested that patients with cognitive impairment do not benefit from rehabilitation or that rehabilitation gains are reduced. Most studies focus on absolute gain rather than gains in individual functional areas. The Barthel activities of daily living (ADL) score is a tool, which is used widely and comprises 10 functional domains. This study aimed to assess the response to rehabilitation based on improvement or deterioration on the Barthel ADL score for patients with different cognitive abilities

METHODS

This independence measure was assessed at specific time periods in an observational study of 241 patients undergoing in-patient rehabilitation. Therapy was delivered formally by physiotherapists and occupational therapists and also informally by nursing staff. Patients were divided into four groups according to cognition. Group 1 (MMSE, mini-mental state examination 27-30), normal cognition, Group 2 (MMSE 21-26) mild impairment, Group 3 (MMSE 11-20) moderate impairmentand Group 4 (MMSE 0-10) severe impairment.

RESULTS

Statistically significant improvement was made in most of the functional domains by patients with normal cognition and mild cognitive impairment (p < 0.0025). The exception to this for both groups was in the areas of feeding and bowels because of the fact that most patients were independent with these aspects on admission. Group 3 patients made improvements in the domains of grooming, dressing, toileting, transferring and mobility. Group 4 patients did not demonstrate statistically significant improvement in any domain although there were trends for improvement in mobility and transferring.

CONCLUSIONS

This study demonstrated that cognitive impairment did have an impact on the ADL that patients improved in following rehabilitation. However, even patients with moderate cognitive impairment made significant gains with many ADL.

Characteristics of Mexican American elders admitted to nursing facilities in the United States: data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE) study

OBJECTIVES

The purpose of the current study was to describe the factors associated with Mexican American elders in the Southwestern United States who have spent time in a skilled nursing facility (SNF) compared with those who have not.

DESIGN

Data were collected on the Mexican American elders who reported an SNF stay within 10 years of baseline.

PARTICIPANTS

A probability sample of 3050 Mexican American elders from five Southwestern states followed from 1993 to 2005 were examined.

MEASURES

Variables examined included sociodemographics, language of interview, disabilities with instrumental activities of daily living, activities of daily living, self-reported health, cognitive status, and depression.

RESULTS

A total of 78 (3.9%) of 2020 subjects resided in SNFs. Using univariate analyses, older age, English-language interview, poorer cognitive status, and functional disabilities were independently associated with SNF admissions. Logistic regression analyses controlling for age revealed that SNF patients were older (OR = 1.08, P = .001), had an activities of daily living disability (OR = 4.94, P < .001), scored in the depressed range in the Geriatric Depression Scale (OR = 2.72, P = .001), and were more likely to interview in English (OR = 1.95, P = .042), when compared with community counterparts.

CONCLUSIONS

Mexican American elders who resided in an SNF at some point in the previous 10 years were older, and were more likely to be functionally impaired. They also were more likely to prefer English as their primary language, indicating they were more likely to agree to an SNF stay than their Spanish-speaking counterparts.

Factors predicting rehospitalization of elderly patients in a postacute skilled nursing facility rehabilitation program

OBJECTIVE

To examine potential risk factors for rehospitalization of skilled nursing facility (SNF) rehabilitation patients.

DESIGN

Retrospective review of rehabilitation charts.

SETTING

SNF rehabilitation beds (n=114) at a 514-bed urban, academic nursing home that receives patients from tertiary care hospitals.

PARTICIPANTS

Consecutive rehabilitation patients (n=50) who were rehospitalized during days 4 to 30 of rehabilitation, compared with a matched group of rehabilitation patients (n=50) who were discharged without rehospitalization.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Data on potential risk factors were collected: demographics, medical history, conditions associated with preceding hospitalization, and initial rehabilitation examination and laboratory values. The clinical conditions precipitating rehospitalizations were noted.

RESULTS

Sixty-two percent of rehospitalizations were related to complications or recurrence of the same medical condition that was treated during the preceding hospitalization. The rehospitalized group had significantly more comorbidities including anemia (P=.001) and malignant solid tumors (P<.001), index hospitalizations involving a gastrointestinal condition (P=.001), needed more assistance with eating (P=.001) and walking (P=.03), and had lower hemoglobin (P=.002) and albumin levels (P<.001). A logistic regression model found that the strongest predictors for rehospitalization are a history of a malignant solid tumor (odds ratio [OR]=10.10), a recent hospitalization involving gastrointestinal conditions (OR=4.62), and a low serum albumin level (with each unit decrease in albumin, the odds of rehospitalization are 4 times greater [OR=.24, P=.005]).

CONCLUSIONS

Comorbid conditions, reasons for index hospitalization, and laboratory values are associated with an increased risk for rehospitalization. Further studies are needed to identify high-risk elderly patients and target interventions to minimize rehospitalizations.

Does cognitive impairment affect rehabilitation outcome?

OBJECTIVES

To assess how cognitive impairment affects rehabilitation outcomes and to determine whether individual benefit regardless of cognition.

DESIGN

Prospective open observational study.

SETTING

Two rehabilitation wards admitting older adults after admissions with medical or surgical problems.

PARTICIPANTS

Two hundred forty-one individuals admitted to two rehabilitation wards, 144 female, mean age 84.4 ± 7.3 (range: 59-103).

MEASUREMENTS

The Mini-Mental State Examination (MMSE) was administered, and participants were categorized into four groups: cognitively intact (MMSE score: 27-30), mildly impaired (MMSE score: 21-26), moderately impaired (MMSE score: 11-20), and severely impaired (MMSE score: 0-10). Barthel activity of daily living score was calculated on admission, at 2 and 6 weeks (if appropriate), and at discharge to assess level of independence and improvement or deterioration in function. Information relating to mortality, discharge destination, and length of stay was also collected.

RESULTS

After adjusting for comorbidities and age, all four groups showed improvement in Barthel score from admission to discharge. This improvement was highly significant (P = .005) in participants with normal cognition and mild to moderate impairment. Severely impaired participants also made significant improvement (P = .01). Length of stay was significantly longer for participants with lower cognitive scores. Discharge of 50% of participants occurred by 26, 28, 38, and 47 days for Groups 1 to 4, respectively (P = .001). Higher rates of institutionalization and mortality (P = .02) were associated with lower MMSE score.

CONCLUSION

All participants improved functionally regardless of cognition. Likelihood of institutionalization, mortality, length of stay, and adverse incidents was higher with lower MMSE scores.

Post-acute care services received by older adults following a cardiac event: a population-based analysis

BACKGROUND

Post-acute care (PAC) is available for older adults who need additional services after hospitalization for acute cardiac events. With the aging population and an increase in the prevalence of cardiac disease, it is important to determine current PAC use for cardiac patients to assist health care workers to meet the needs of older cardiac patients. The purpose of this study was to determine the current PAC use and factors associated with PAC use for older adults following hospitalization for a cardiac event that includes coronary artery bypass graft and valve surgeries, myocardial infarction (MI), percutaneous coronary intervention (PCI), and heart failure (HF).

METHODS AND RESULTS

A cross-sectional design and the 2003 Medicare part A database were used for this study. The sample (n = 1493521) consisted of patients 65 years and older discharged after their first cardiac event. Multinomial logistic regression was used to examine factors associated with PAC use. Overall, PAC use was 55% for cardiac valve surgery, 50% for MI, 45% for HF, 44% for coronary artery bypass graft, and 5% for PCI. Medical patients use more skilled nursing facility care, and surgical patients use more home health care. Only 0.1% to 3.4% of the cardiac patients use intermediate rehabilitation facilities. Compared with those who do not use PAC, those who use home health care and skilled nursing facility care are older and female, have a longer hospital length of stay, and have more comorbidity. Asians, Hispanics, and Native Americans were less likely to use PAC after hospitalization for an MI or HF.

CONCLUSIONS

The current rate of PAC use indicates that almost half of nondisabled Medicare patients discharged from the hospital following a cardiac event use one of these services. Health care professionals can increase PAC use for Asians, Hispanics, and Native Americans by including culturally targeted communication. Optimizing recovery for cardiac patients who use PAC may require focused cardiac rehabilitation strategies.

Hip fractures among elderly women: longitudinal comparison of physiological function changes and health care utilization

OBJECTIVE

To compare physiological and functional impairments and their impact on health care use patterns among disabled older women with and without hip fracture.

METHODS

Data from the 3-year longitudinal Women's Health and Aging Study I (WHAS-I) and Medicare Current Beneficiaries Survey (MCBS) were used for this comparison study. Outcome variables include physiological measures (eg, hip and knee strength, functional reach), functional impairments (ADLs, IADLs), and health care use (physician visits). Generalized Estimation Equation (GEE) models were used to examine the differences between groups on physiological and functional change and health service use over time.

RESULTS

Three-year crude mortality rates were significantly higher in the hip fracture group (25%) than in the comparison group (18%); however, statistical significance did not persist after adjusting for age, race, education, living arrangement, depression, and comorbidity (RR = 1.5; P = .17). All physiological and functional measures deteriorated over time, regardless of presence or absence of hip fractures. After adjusting for covariates, the fracture group was significantly worse in knee strength (beta = -0.91; P = .01), usual walking speed (beta = -0.04; P = .01) and rapid walking speed (beta = -0.05; P = .02), and worse IADL function (beta = 0.26; P = .002) than the non-hip fracture group. The rate of additional impairment for both hip fracture group and non-hip fracture group was 0.013 IADL units per month (P = .001). However, there were no significant differences in health care use between the groups.

CONCLUSION

In spite of worse physiological and IADL impairments, once the women recovered from hip fracture surgery, they did not necessarily use more health care resources than non-hip fracture patients. To prevent functional deterioration, interventions need to focus on knee strength and mobility training.

Recovery of activities of daily living in older adults after hospitalization for acute medical illness

OBJECTIVES

To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge.

DESIGN

Observational.

SETTING

Tertiary care hospital, community teaching hospital.

PARTICIPANTS

Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998).

MEASUREMENTS

Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point.

RESULTS

By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover.

CONCLUSION

For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.

Tracking mobility-related assistive technology in an outcomes study

The objective of this follow-up study was to describe changes in the mobility-related assistive technology devices (ATDs) that are used from shortly after discharge from a hospital setting until 5-6 months later. One hundred and thirty-nine participants who had one or more mobility ATDs (canes, crutches, walkers, and wheelchairs) that had been recommended during hospitalization were interviewed an average of 5.5 weeks after discharge and an average of 23.2 weeks later. Information about mobility ATD usage was obtained by questionnaire during face-to-face interviews. The SF-36 was used to assess perceived health status, both physical and mental, as an additional outcome. Results show that at follow-up, only 23.3% of participants were using the ATD provided at baseline as their primary aid. Seven distinct groups of participants were noted based on individual experience with ATD use from the time of discharge to follow-up. Those groups varied according to continued versus discontinued use of an ATD, single versus multiple ATD use across time, and primary versus secondary importance attributed to the ATD. The groups also differed in terms of their differential association with rehabilitation diagnosis, age, as well as physical and mental perceived health status. The findings have implications for designing ATD outcome studies and for interpreting the relationship of ATD outcomes to other variables. The information about changes in mobility-related ATDs can also help rehabilitation specialists at the point of device referral target their patients for interventions that will either increase their adherence to device prescriptions or support nondevice strategies for managing disabilities.

Correlates of post-hospital physical function at 1 year in skilled nursing facility residents

AIM

This paper is a report of a study to examine the relationship between health-related admission factors and post-hospital physical function at 3, 6, 9 and 12 months in older adult nursing facility residents.

BACKGROUND

Physical functional decline is a significant health problem for older adults and has far-reaching effects. In particular, the immediate post-hospital period is a high-risk time, because shortened hospital stays make it likely that older patients are discharged in a state of incomplete recovery.

METHOD

Data spanning from July 2002 to June 2005 were extracted from a comprehensive assessment tool, the Minimum Data Set, for 38,591 beneficiaries of a federal health insurance programme covering older adults in the Midwestern region of the United States of America. We investigated relationships between admission factors and post-hospital physical function at 3, 6, 9 and 12 months. The admission factors were health-related variables assessed at the time of skilled nursing facility admission from an acute care hospital.

FINDINGS

The most important admission factors related to post-hospital physical function at 3, 6, 9 and 12 months were baseline physical function, urinary incontinence and pressure ulcer. Cognitive impairment at admission demonstrated a stronger relationship with poor physical function as resident length of stay increased.

CONCLUSION

Nurses in skilled nursing facilities should screen post-hospital older adults for risk of physical functional decline at admission using identified admission factors. For continuous nursing care, older adults need to be assessed at least once a month during the first 3 months after hospital discharge.

Do cognitively impaired patients benefit from rehabilitation?

Rehabilitation in broad terms is a process aimed at restoring a person's functional capacity particularly in relation to activities of daily living. Studies have shown that hospitalization of older patients is a major risk factor for an often irreversible decline in function, and that functional decline from baseline occurs as early as day two of admission. Rehabilitation is therefore often required for older patients following an admission to an acute hospital. Older patients admitted for rehabilitation are more likely to be functionally impaired and are more medically complex than younger patients.

Predictors of successful rehabilitation in geriatric patients: subgroup analysis of patients with cognitive impairment

BACKGROUND AND AIMS

Understanding which patients benefit from rehabilitation programs may be useful in balancing resources and needs. The aim of this study was to evaluate whether cognitive and nutritional status are associated with functional improvement after rehabilitation in old persons.

METHODS

2650 patients (aged > or =60 years) consecutively admitted to a geriatric rehabilitation unit in Italy between August 2001 and December 2005, were included. Functional status was evaluated with the Tinetti scale, cognitive status with the Mini-Mental State Examination (MMSE), and nutritional status with the Mini-Nutritional Assessment Short Form (MNA-SF). To identify predictors of functional recovery, multiple logistic regression models were run, with improvement on the Tinetti scale score as dependent variable.

RESULTS

Eighty per cent of old persons functionally improved after rehabilitation, ranges being 84% of those with MMSE> or =24 to 58% of those with MMSE<10. Persons with both good cognition and good nutritional status were most likely to improve [odds ratio (OR)=2.5; 95% confidence interval (95% CI)=1.9-3.2]. Stratifying the sample according to cognitive status, we found that in patients with MMSE> or =18 better nutritional status emerged as a factor associated with functional improvement, whereas in patients with severe cognitive impairment (MMSE<18), the only associated factor was a higher MMSE score.

CONCLUSIONS

The results of the present study suggest that both good cognition and good nutritional status are associated with functional improvement in older persons. However, patients with poor cognition can also improve, depending on their degree of cognitive impairment, and they should not be routinely excluded from rehabilitation.

Predictors of Rehabilitation Outcomes: A Comparison of Israeli and Italian Geriatric Post-Acute Care (PAC) Facilities Using the Minimum Data Set (MDS)

OBJECTIVES

To understand the relative contribution of sociodemographic, clinical, and health care features to rehabilitation outcomes in Israel and in Italy in post-acute care (PAC) facilities.

DESIGN

Prospective cross-national study

SETTING

Two hospital geriatric PAC departments: Harzfeld Geriatric Hospital, Gedera, Israel, and Catholic University of Sacred Heart Geriatric Hospital, Rome, Italy.

PARTICIPANTS

Post-acute care patients aged 65 and older admitted consecutively for stabilization, improvement, or rehabilitation to 3 departments in Harzfeld Geriatric Hospital, Gedera, Israel from April, 1999 through February, 2002 (N = 364), and to the post-acute Geriatric Rehabilitation Unit of the "A. Gemelli" Hospital, Catholic University of Sacred Heart, Rome, Italy, between February, 1999, and April, 2002 (N = 351), for whom there were complete assessments at admission and discharge (the total number admitted in Israel was 505, and in Italy, 409).

MEASUREMENTS

Minimum Data Set for Post-Acute Care (MDS-PAC) assessments conducted within 4 days of admission and at discharge; data collected identically in both sites. Predictors of functional recovery> were identified using multivariate binary logistic regression. The dependent variable: improvement of 1 or more points in the ADL scale.

RESULTS

The staffing pattern of the PAC department in Italy had about double the physicians and physio- and occupational therapists than in Israel, but about the same number of nurses and somewhat fewer aides than in Israel. Multivariate binary logistic regression that includes country, age, sex, and marital status, found that the patients in Italy had about triple the probability of improvement in ADL function (OR 3.3, CI 2.4-4.6) (P < .001) than PAC patients in Israel. Even after health system characteristics were added to the model, ADL improvement was most significantly associated with higher cognitive ability and a diagnosis of hip fracture, as well as longer length of stay and being admitted to PAC directly from an acute hospital. For each additional point (worse cognition) in a cognitive scale, there was a 30% decrease in the probability of ADL improvement (OR 0.7, CI 0.6-0.8, P < .001). Those who had a stroke were about half as likely to show ADL improvement (OR 0.5, CI 0.3-0.7) than those without stroke, but those with a hip fracture had more than double the probability of ADL improvement (OR 2.7, CI 1.7-4.2) than those without hip fracture. Those who stayed in the PAC ward an additional block of time had a 30% higher probability of ADL improvement (P < .1), and those who were admitted directly to PAC from an acute hospital had more than 4 times the probability of ADL improvement (OR 4.1, CI 2.3-7.0, P < .001) than those who were admitted from a private home.

CONCLUSIONS

We found support for the hypothesis that differences in sociodemographic and clinical factors cannot account for all differences in ADL improvement, and that the organization of care and constraints of the health system also influence functional outcomes. Policymakers should examine the policy-amenable features of the Italian and Israeli systems so that optimal ADL recovery can be encouraged. Any reduction in disability will help both patients and the health care system; slightly higher short-term PAC treatment costs may have large long-term future benefits, if they result in the reduction of ADL disability. This study is one of the first to examine outcomes of PAC in 2 countries, and can provide an initial assessment of how rehabilitation can be enhanced or limited by health policies and staffing patterns.

Functional recovery after hip fracture in the subacute setting

OBJECTIVE

To measure functional recovery after hip fracture in the subacute setting.

BACKGROUND

There are over 340,000 hip fractures that occur in the United States annually. Three out of five hospitalizations attributable to injury among persons over 75 were for fractures. Greater than 50% were hip fractures.

PURPOSE

The purpose of this study is to describe the functional recovery after hip fracture in the subacute setting utilizing performance-based measures (PBMs).

METHOD

This is a prospective observational cohort.

DATA ANALYSIS

Descriptive statistics were used for baseline characteristics. Repeated measures analysis using a Bonferroni correction was utilized to compare admission and discharge PBM scores.

RESULTS

Eighty residents were enrolled in the study, of which seven were withdrawn because of medical complications and one subject died within 1 week of admission. Data were analyzed for 72 subjects. There were 59 women and 13 men ranging in age from 63-99. Mean age was 85.3. The patients' profiles were as follows: 53% lived alone, 63% were Medicare recipients, 50% used an assistive device before hip fracture, 46% sustained a femoral neck fracture, 57% underwent a bipolar hemiarthroplasty, 90% received epidural anesthesia, and 90% had a weight-bearing status as weight-bearing was tolerated. The PBM results are as follows: [table: see text]

CONCLUSION

There was a significant improvement between admission and discharge TUG test, Tinetti gait and balance test, and 6MW test scores in patients who underwent surgical repair of a hip fracture after a fall.

Elderly patients with hip fracture with positive affect have better functional recovery over 2 years

OBJECTIVES

To evaluate whether patients with hip fracture with high positive affect had better functioning than those with low positive affect or depressive symptoms in three performance-based measures over 2 years after the fracture.

DESIGN

Longitudinal study with assessments at baseline and 2, 6, 12, 18, and 24 months posthospitalization.

SETTING

Community.

PARTICIPANTS

Four hundred thirty-two patients, aged 65 and older, hospitalized for hip fracture in Baltimore, Maryland, between 1990 and 1991.

MEASUREMENTS

High and low positive affect and depressive symptoms were based on baseline Center for Epidemiologic Studies Depression Scale score, usual and rapid walking speed, one chair stand, demographic factors, comorbidities, and history of cognitive impairment.

RESULTS

At each follow-up point, respondents with high positive affect at baseline (36% of sample) had faster walking and chair stand speeds than those with low positive affect (13%) and depressive symptoms (51%). For example, at 6 months, the mean usual walking pace was 0.4 m/s (standard error (SE)=0.02) for respondents with high positive affect, versus 0.4 m/s (SE=0.03) and 0.35 m/s (SE=0.02) for patients with low positive affect and depressive symptoms, respectively; adjusted differences were 0.02 (95% confidence interval (CI)=-0.06-0.09) and 0.06 (95% CI=0.01-0.11). Respondents with high positive affect appeared to achieve their maximum improvement in usual pace approximately 6 months before other respondents, but this interaction was not statistically significant. Respondents with consistently high positive affect had the best functioning over the follow-up period.

CONCLUSION

High positive affect seems to have a beneficial influence on performance-based functioning after hip fracture.

An imperative to improve discharge planning: predictors of physical function among residents of a medicare skilled nursing facility

Given the pressure to effects of shorter length of stay among older adults, it is important to understand factors that predict trajectories of physical function in a posthospital recovery period. Data were collected from the medical records of 131 older adults following lower extremity surgery to identify admission factors that predict physical function at discharge, length of stay, and discharge disposition in a Medicare skilled nursing facility. Knowing on admission those who are most at risk for poor physical function at discharge can arm nurse administrators with critical information for better discharge planning for continuing services.

Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare

OBJECTIVES

To assess the impact of a specifically designed model of orthopedic-geriatric cocare on hip fracture (HF) outcomes.

SETTING

Tertiary teaching hospital (level I trauma center).

DESIGN

Prospective observational study with a retrospective (historical) control. Data on 951 consecutive patients 60 years of age or older admitted to the authors' institution with a nonpathologic HF over a 7-year period (1995 to 2002) were analyzed. Between 1995 and 1997, medical problems were managed by a geriatric medicine (GM) consultation-only service (retrospective audit). In 1998, a GM registrar began overseeing daily medical care with weekly geriatrician consultant review (prospective study). Outcomes for 2 time periods were compared: a 3-year period before (no GM; 504 patients) and a 4-year period after (GM; 447 patients) the introduction of GM cocare.

MAIN OUTCOME MEASUREMENTS

Postoperative medical complications, mortality, length of stay, discharge destination, use of thromboprophylaxis, and antiosteoporotic treatment.

RESULTS

While comparing 2 periods (GM and no GM), significant reductions in postoperative medical complications and comorbid conditions (in total 49.5% vs. 71.0%, P<0.001) and mortality (4.7% vs. 7.7%, P<0.01) occurred and rehospitalization to medical wards within 6 months decreased (28% vs. 7.6%). However, no differences were observed in median length of hospital stay (10.8 vs. 11.0 days) or in discharge destination. Antiosteoporotic treatment (12% to 69%) and specific thromboprophylaxis (63% to 94%) increased in the GM period.

CONCLUSIONS

Orthopedic-geriatric cocare for the older patients with HF was associated with significant reductions in morbidity and mortality, and increases in optimal postoperative care. Options for further improvement of orthopedic-GM cocare need to be investigated.

Factors affecting outpatient rehabilitation outcomes in elders

PURPOSE

To identify factors affecting outpatient rehabilitation outcomes in elders.

DESIGN

A retrospective cohort design was used to explore factors affecting outpatient rehabilitation outcomes in elders.

METHODS

Analyses of health records from a nurse-managed comprehensive outpatient rehabilitation facility were conducted. Data pertinent to the study were abstracted from 201 health records, including scores from three standard instruments: the Functional Independence Measure, the Mini-Mental State Examination, and the Geriatric Depression Scale, to construct study variables. Multivariate and stepwise regression analyses were performed.

FINDINGS

Cognitive impairment was associated with lower admission and discharge function, but not with rehabilitation outcomes (functional gain, rehabilitation efficiency, days of service, and discharge location). Age > or = 80 years, admission function, and the interaction of age > or = 80 years and admission function affected functional gain and rehabilitation efficiency. Older age, being Black, and having more medical comorbidities were associated with days of service. None of these factors contributed to discharge location.

CONCLUSIONS

Cognitive impairment was not associated with outpatient rehabilitation outcomes. Rather, age > or = 80 years and function when admitted affected functional gain and rehabilitation efficiency in elders who participated in outpatient rehabilitation services.

Rehabilitation services after the implementation of the nursing home prospective payment system: differences related to patient and nursing home characteristics

BACKGROUND

The prospective payment system (PPS) for nursing homes was designed to curtail the rapid expansion of Medicare costs for skilled nursing care. This study examines the changes that occurred in nursing home patients and rehabilitation services following the PPS.

SETTING

Free-standing Medicare and/or Medicaid certified nursing homes in Ohio.

PRIMARY OUTCOMES

The percent of new admissions receiving therapy and the amount of rehabilitation therapy provided.

SAMPLE

A total of 7006 first admissions in 1994-6 (pre-PPS) and 61,569 first admissions in 2000-1 (post-PPS).

METHODS

A logistic model predicting likelihood of rehabilitation was developed and validated in pre-PPS admissions and applied to the post-PPS patients. Rehabilitation services were compared in the pre-PPS and post-PPS cohorts overall, stratified by quintile of predicted score, diagnosis group, and by nursing home profit status.

RESULTS

Post-PPS patients had less cognitive impairment, more depression, and more family support. The amount of rehabilitation services declined the most in the higher quintiles of predicted likelihood of rehabilitation and among patients with stroke. The percent of patients receiving rehabilitation services increased the most in the lowest quintile and among patients with medical conditions. These changes were greater in for-profit nursing homes.

CONCLUSIONS

The implementation of the PPS in nursing homes has been associated with a decrease in the amount of rehabilitation services, targeted at those predicted to receive higher amounts and an increased frequency of providing services targeted at those predicted to be less likely to receive them. The outcomes of the changes deserve further study.

Rules for rehabilitation: an agenda for research

Rehabilitation services have grown tremendously in the United States over the past 2 decades. Rules originally designed to guide Medicare reimbursement policies have had substantial effects in shaping the design of clinical services. This article traces the development of the most significant federal rules regarding rehabilitation, outlines the existing empirical evidence to support these rules, and discusses an agenda for research to improve the evidence for future policy development.

Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people

Agitation is a major problem for older people and is present in over half of the hospitalizations for people > 65 years of age. In a previous study by the authors, results indicated that nursing actions often did not meet best-practice standards in the care of older, agitated patients. This paper builds on these results by reviewing the literature pertaining to the use of restraints and contributes to the body of knowledge surrounding the impact of the acute-care experience on rehabilitation outcomes. Successful rehabilitation relies on the improvement of functional health outcomes and, for this to happen, physical and emotional well-being are important. The sequelae of restraint use in acute care have the potential to alter peoples' ability to participate fully in a rehabilitation programme, thereby placing their future placement at risk. This paper explores the outcomes of restraint use in the acute-care setting and presents the argument that their effects are likely to be detrimental to rehabilitation outcomes.

Development of a conceptual framework for the assessment of geriatric rehabilitation outcomes

The objective of the study was to develop a conceptual framework of key assessment areas for the evaluation of rehabilitation outcomes in older persons. The study was designed in four stages. First, a review of the literature generated a list of 84 potential outcome variables. Second, semi-structured interviews were conducted with older adults informants (n = 19) to record their thoughts about important rehabilitation outcomes. From the analyses of the transcripts, 20 recurrent themes became apparent. Third, relevant assessment areas were determined based on the merged data from the literature and the interviews. Fourth, a focus group was held with a panel of eight interdisciplinary experts with strong involvement in geriatric rehabilitation to evaluate, improve, and validate the preliminary work. As a result of the study, the conceptual framework for the assessment of geriatric rehabilitation outcomes (FAGRO) is composed of four primary outcome domains related to important activities for community-living older persons: mobility activities, basic activities of daily living, activities of independent living, and leisure activities. The models also allows for four brief evaluations of underlying functioning components, including: physical functioning, psychological functioning, social functioning, and factors related to the caregiver status and available resources. The model has the potential to become a valuable additional tool for outcome assessment, researched and developed specifically for geriatric rehabilitation.

Does Payment Structure Influence Change in Physical Functioning After Rehabilitation Therapy?

PURPOSE

To determine if there are differences by payment structure (Medicare managed care versus fee-for-service) in the duration and intensity of geriatric rehabilitation therapy treatments and measure their effect on change in physical functioning at discharge.

METHODS

Sixty-eight Medicare managed care (MCO) and 32 fee-for-service (FFS) subjects from 3 skilled nursing facilities (SNFs) in Southern California answered the physical functioning dimension of the Sickness Impact Profile (SIP-PFD) before and after rehabilitation therapy. Patient characteristics at admission, therapy treatments, and discharge physical functioning were compared by payment structure using chi-square and t-tests; logistic and ordinary least squares (OLS) regressions were employed to determine significant predictors of enrollment in managed care and change in physical functioning at discharge.

RESULTS

Payment structure yielded no significant differences in patient characteristics (physical functioning, socio-demographics, and clinical characteristics) at admission to rehabilitation. Compared to MCO subjects, FFS subjects received significantly more minutes per day (intensity) of rehabilitation therapy (Mean difference = - 16.90; t-test = - 4.504; p =.000). On average, all subjects reported significant, positive change in physical functioning from admission to discharge after rehabilitation (Mean change = 7.98, SD = 12.96; t-test = 6.157; p =.000); but change in physical functioning between MCO and FFS subjects was not significant.

CONCLUSIONS

Payment structure did not significantly influence change in physical functioning at discharge. Future studies, using a larger sample- size, should consider the effects of structural elements, process, and patient behavior on therapy treatments and physical functioning outcomes.

Correlates of Recovery Among Older Adults After Major Abdominal Surgery

BACKGROUND

Little research has examined the recovery patterns of older adults who have had major abdominal surgery.

OBJECTIVE

To determine whether pain, depression, and fatigue are significant factors in the return of older adults who had major abdominal surgery to functional status and self-perception of recovery in the first 3 months after discharge from the hospital.

METHODS

A correlational predictive study involved adults 60 years of age or older who had undergone major abdominal surgery. Data were collected during hospitalization (n = 192), then 3 to 5 days (n = 141), 1 month (n = 132), and 3 months after discharge to home (n = 126) using the Brief Pain Inventory, the Geriatric Depression Scale-Short Form, the Modified Fatigue Symptom Checklist, the Enforced Social Dependency Scale, and the Self-Perception of Recovery Scale.

RESULTS

Multiple regression analysis indicated that pain, depression, and fatigue are significantly related to patients' self-perception of recovery and functional status. Pain, depression, and fatigue explain 13.4% of the variation in functional status at 3 to 5 days, 30.8% at 1 month, and 29.1% at 3 months after discharge. These three factors also explain 5.6% of the variation in self-perception of recovery during hospitalization, 12.3% at 3 to 5 days, 33.2% at 1 month, and 16.1% at 3 months after discharge.

CONCLUSIONS

Pain, depression, and fatigue are important factors to consider in the provision of care to abdominal surgery patients with a relatively uncomplicated postoperative course. Specific interventions to reduce pain, depression, and fatigue need to be evaluated for their impact on the postoperative recovery of older adults.

Variations in nursing home discharge rates for urban and rural nursing facility residents with hip fracture

CONTEXT

The more limited availability and use of community-based long-term care services in rural areas may be a factor in higher rates of nursing home use among rural residents.

PURPOSE

This study examined differences in the rates of nursing home discharge for older adults receiving posthospital care in a nursing facility.

METHODS

The study sample was comprised of a cohort of rural and urban residents newly admitted to nursing home care in Maine following surgery for hip fracture.

FINDINGS

The results indicated that rural residents who were hospitalized for hip fracture and subsequently admitted to a nursing facility for rehabilitation were significantly less likely than urban residents to be discharged within the first 30 days of their admission. Rural residents who stayed in the nursing facility beyond 30 days were also less likely to be discharged in the first 6 months. These geographic differences were not explained by service use and resident characteristics such as age, health, or functional status.

CONCLUSIONS

The finding of lower discharge rates among rural nursing facility residents appears to be consistent with previous studies demonstrating higher rates of nursing home use among rural residents. There continues to be a need for a better understanding of the role that service supply and accessibility and other factors play in the patterns and outcomes of rural long-term care.

Disparity in health services and outcomes for persons with hip fracture and lower extremity joint replacement

OBJECTIVE

Examine disparity in health services and outcomes for adults with a hip fracture or lower extremity joint replacement.

MATERIALS AND METHODS

This study examined 28,522 patient records including 12,328 (mean age 76.6 years) with hip fracture and 16,194 (mean age 71.8 years) with joint replacement.

RESULTS

Non-Hispanic white and black patients were significantly (P < 0.05) more likely to be discharged home alone and responsible for their own care than were Asian or Hispanic patients. Sixty-four percent of Hispanic patients received inpatient rehabilitation after hip fracture and 36% after hip or knee arthroplasty. In contrast, 58% of non-Hispanic white persons, 67% of black persons, and 56% of Asian persons received inpatient medical rehabilitation after hip or knee joint replacement.

CONCLUSION

Disparity in outcomes appeared to be related to family structure and social support.

Outcome of stroke patients admitted to intensive care: experience from an Australian teaching hospital

The objective of this study was to determine the mortality rate and the functional outcomes of stroke patients admitted to the intensive care unit (ICU) and to identify predictors of poor outcome in this population. The records of all patients admitted to the ICU with the diagnosis of stroke between January 1994 and December 1999 were reviewed. Patients with subarachnoid haemorrhage were excluded. Data were collected on clinical and biological variables, risk factors for stroke and the presence of comorbidities. Mortality (ICU, in-hospital and three-month) and functional outcome were used as end-points. In the six-year-period, 61 patients were admitted to the ICU with either haemorrhagic or ischaemic stroke. Medical records were available for only 58 patients. There were 23 ischaemic and 35 haemorrhagic strokes. The ICU, in-hospital and three-month mortality rates were 36%, 47% and 52% respectively. There were no significant differences in the prevalence of premorbid risk factors between survivors and non-survivors. The mean Barthel score was significantly different between the independent and dependent survivors (94+/-6 vs 45+/-26, P<0.001). A substantial number of patients with good functional outcomes had lower Rankin scores (92% vs 11%, P<0.001). Only 46% of those who were alive at three months were functionally independent. Intensive care admission was associated with a high mortality rate and a high likelihood of dependent lifestyle after hospital discharge. Haemorrhagic stroke, fixed dilated pupil(s) and GCS <10 during assessment were associated with increased mortality and poor functional outcome.

Patients with hip fracture: subgroups and their outcomes

OBJECTIVES

To present several alternative approaches to describing the range and functional outcomes of patients with hip fracture.

DESIGN

Prospective study with concurrent medical records data collection and patient and proxy interviews at the time of hospitalization and 6 months later.

SETTING

Four hospitals in the New York metropolitan area.

PARTICIPANTS

Five hundred seventy-one hospitalized adults aged 50 and older with hip fracture between July 1997 and August 1998.

MEASUREMENTS

Rates of return to function in four physical domains, mortality, and nursing home residence at 6 months. Cluster analysis was used to describe the heterogeneity among the sample and identify variations in 6-month mortality, nursing home residence, and level of functioning and to develop a patient classification tree with associated patient outcomes at 6 months postfracture.

RESULTS

In locomotion, transfers, and self-care, 33% to 37% of patients returned to their prior level of function by 6 months, including those needing assistance, but only 24% were independent in locomotion at 6 months. Cluster analysis identified eight patient subgroups that had distinct baseline features and variable outcomes at 6 months. The patient classification tree used four variables: atypical functional status (independent in locomotion but dependent in other domains); nursing home residence; independence/dependence in self-care; and age younger than 85 or 85 and older that identified five subgroups with variable 6-month outcomes that clinicians may use to predict likely outcomes for their patients.

CONCLUSION

Patients with hip fracture are heterogeneous with respect to baseline and outcome characteristics. Clinicians may be better able to give patients and caregivers information on expected outcomes based on presenting characteristics used in the classification tree.

Health status and functional status in relationship to nursing home subacute rehabilitation program outcomes

OBJECTIVE

To assess the relationship of health status and functional status to key nursing home subacute rehabilitation program outcomes: motor function at discharge, discharge destination, and length of stay in the program.

DESIGN

Using a prospective cohort study design, 164 patients were assessed on entering the rehabilitation program for the first time after discharge from an acute hospital. Their median length of stay was 40 days.

RESULTS

The patients' motor function improved over time (P < 0.0001), and a large majority were discharged to the community. At admission, health status was positively associated with motor function (P < 0.05) and cognitive function (P < 0.01). Higher cognitive function and higher motor function at admission were correlated with higher motor function at discharge (rs = 0.386, P < 0.0001; rs = 0.563, P < 0.0001 respectively). Better health status was independently associated with discharge to the community (P < 0.01). Only motor function at admission was independently associated with length of stay (P < 0.01).

CONCLUSION

Health status and functional status are related, and both are independently associated with nursing home subacute rehabilitation program outcomes. Therefore, an improvement in one may result in an improvement in the other, and both aid in the attainment of positive subacute rehabilitation outcomes.

Outcomes among orthopedic patients in skilled nursing facilities: does managed care make a difference?

The use of rehabilitative care has increased greatly. This study evaluates whether managed care affects health outcomes among Medicare orthopedic patients receiving rehabilitative treatments. Managed care versus fee-for-service patients had better outcomes at four months following discharge from skilled nursing facilities. It is important to address predictive factors, such as age, length of hospital stay, debilitation and social living arrangements, which can also influence health outcomes when planning rehabilitative treatment for older patients.