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

Construct validity, responsiveness and minimal important difference of the cumulated ambulation score in older adults with hip fracture in sub-acute rehabilitation facility

OBJECTIVE

To assess the construct validity, responsiveness and minimal important difference of the cumulated ambulation score in patients with hip fracture in sub-acute rehabilitation facility.

DESIGN

Observational, prospective, monocenter, cohort study.

SETTING

Rehabilitation Institute.

PARTICIPANTS

456 older adults with hip fracture (≥65 years) admitted for inpatient rehabilitation.

MAIN OUTCOME MEASURES

Cumulated ambulation score, functional independence measure and functional ambulation category were collected at admission and discharge. Construct validity and responsiveness were assessed through hypothesis testing and minimal important difference was determined using the anchor-based method; floor and ceiling effects were also assessed.

RESULTS

The cumulated ambulation score showed strong correlations with the functional independence measure and functional ambulation category scores at both admission and discharge, satisfying all the hypotheses for construct validity. The effect size of cumulated ambulation score was 1.63. Changes in cumulated ambulation score had a moderate-to-strong correlation with changes of other instruments and were able to discriminate patients improved from those not-improved, and patients classified as independent ambulators from those dependent. A ceiling effect was found only at discharge. The estimated minimal important difference was 2 points.

CONCLUSIONS

The cumulated ambulation score showed high levels of construct validity and responsiveness according to the hypothesis testing. A two points improvement at the end of rehabilitation was found to be clinically important in people with hip fracture in the sub-acute phase. The ceiling effect found at discharge suggested the limitation of the scale in assessing people with a partially recovered autonomy in performing postural changes and gait.

Predictors of postoperative hospital length of stay after total knee arthroplasty

INTRODUCTION

We aimed to collect and analyse clinical and functional variables of patients undergoing rehabilitation after total knee arthroplasty (TKA), to identify the variables that influence the postoperative hospital length of stay (LOS).

METHODS

We conducted a retrospective analysis of prospectively collected data of 1,082 consecutive patients (746 females and 336 males) who underwent primary TKA and rehabilitation in our orthopaedic institute between January 2013 and July 2017. Clinical and anthropometric data were analysed using a multivariate linear regression model.

RESULTS

The average LOS was 5.08 ± 2.52 days in the Department of Orthopaedic Surgery and 12.67 ± 5.54 days in the Sports Rehabilitation Unit. Factors such as age, female sex and the presence of comorbidities were predictive of a longer stay. The presence of caregiver assistance at home was associated with shorter LOS. There was no evidence of a statistically significant positive association between body mass index and LOS.

CONCLUSION

An in-depth and early knowledge of factors that influence LOS may enable the multidisciplinary team to plan a patient-tailored rehabilitation path and better allocate resources to maximise patients' functional recovery, while reducing LOS and the overall cost of the procedure.

Effects of Aerobic Training in Patients with Subacute COVID-19: A Randomized Controlled Feasibility Trial

Many clinical practice recommendations indicate rehabilitation as essential for patients with sequelae of severe or critical COVID-19 and suggest the prompt initiation of a multicomponent rehabilitation program focused on aerobic and endurance training. However, randomized controlled trials (RCTs) regarding aerobic exercise are lacking. Therefore, we aimed to assess the feasibility and effectiveness of the addition of aerobic training to standard rehabilitation in subjects with subacute COVID-19. Participants were 32/214 patients with the sequelae of severe or critical COVID-19 in the acute phase who were eligible and agreed to participate in the study (eligibility = 15%, recruitment = 100%). After randomization and assessment with functional and strength tests, all the participants underwent an inpatient-tailored rehabilitation program (50 min/day, 5 days/week, 10 sessions); in addition, the experimental group performed a low- to moderate-intensity aerobic exercise (30 min/day, 10 sessions). No dropouts or severe adverse events were reported, with an attendance rate of 95.6%. Most of the secondary outcomes significantly improved in both groups, but the improvement in the Functional Independence Measure and Cumulated Ambulation Score-Italian version was significantly greater in the experimental group (at least, p < 0.05). This RCT showed that aerobic exercise is feasible and safe in subacute COVID-19. Moreover, it appears to be beneficial and useful in improving patients' independence and mobility.

Addition of aerobic training to conventional rehabilitation after hip fracture: a randomized, controlled, pilot feasibility study

OBJECTIVES

To determine the feasibility and safety of aerobic training with an arm crank ergometer and its effectiveness in improving functional capacity and gait in patients with recent hip fracture.

DESIGN

Randomized, controlled, assessor-blinded pilot study, with intention-to-treat analysis.

SETTING

Inpatients, rehabilitation department.

SUBJECTS

40 patients with hip fracture surgically treated.

INTERVENTIONS

Training group performed aerobic exercise with an arm crank ergometer (15 sessions, 30 minutes/day) at an intensity of 64% to 76% of maximum heart rate, in addition to conventional inpatient rehabilitation.

MAIN MEASURES

Primary outcome was the feasibility (including eligibility rate, recruitment rate, number of drop-outs and adverse events, adherence). Secondary measures were the Timed Up and Go test, ability to walk independently, muscle torque of knee extensors of fractured and non-fractured leg, Functional Independence Measure.

RESULTS

Mostly due to pre-existing disability and fracture type, only 40/301 (13%) patients were eligible (age 84.6 ± 7.6 years, 75% female); all agreed to participate and 90% completed the trial, without adverse events. Adherence to aerobic exercise was good, with high attendance at sessions (93%), a strong compliance to exercise duration (95%) but lower compliance to the prescribed intensity (73%). After the program, more patients were able to walk independently in the training group (n = 18) compared to control (n = 13) (P < 0.05). Also the muscle torque of fractured leg knee extensors was higher in the training group (P < 0.05).

CONCLUSION

Aerobic training in addition to conventional rehabilitation after a hip fracture is feasible and safe and it was effective in improving gait performance and strength of fractured leg.

TRIAL REGISTRATION

NCT04025866.

Rehabilitation outcomes after brain injury: disability measures or goal achievement?

Background: The outcome of rehabilitation interventions following brain injury is commonly rated by disability scales. Goal-setting and achievement are important in inpatient rehabilitation, but seldom assessed as outcomes.

Objective: To compare the information acquired from using disability ratings and goal attainment/variances as outcome measures in brain injury rehabilitation.

Setting: An inpatient regional neurological rehabilitation unit.

Subjects: One hundred and seventy-seven patients admitted after single incident brain injury over a three-year period.

Main measures: (1) Disability outcomes by the Barthel Index and the Functional Independence Measure, (2) goal achievement and variance distribution, and (3) the influence of diagnosis and demographics on these measures.

Results: Patients improved significantly on all disability scales employed (p < 0.0001), with the baseline admission scores being inversely correlated with changes in dependency by discharge (rho∼0.4). The median attainment rate of long-term goals was 75% per patient. Nonachievement was most frequently due to cognitive problems (38%), followed by behavioural difficulties and physical limitations (18% each). Goal achievement correlated poorly with disability outcome at discharge (rho∼0.3). Patients who accomplished all their goals tended to be less disabled at admission. Diagnostic groups and demographic factors had little influence on either disability or goal achievement outcomes.

Conclusions: The use of a simple goal achievement and variance coding scheme has been relatively straight forward to incorporate into the daily practice of the unit. It provides useful information on rehabilitation process and outcome after brain injury that is complementary to the utilization of disability measures.

L'âge très élevé constitue-t-il un facteur pronostique du devenir après un premier accident vasculaire cérébral ?

AIM

To determine whether very old age, older than 80 years, after a stroke is a significant predictor of mortality, orientation to a specific care pathway after the acute phase and functional status at 6 months after the stroke.

PATIENTS

A sample of 112 consecutive patients admitted to the emergency department because of a first stroke, with hemiplegia and/or aphasia over 6 months, who satisfied strict inclusion/exclusion criteria. Forty-seven patients were older than 80.

METHOD

After initial diagnosis and enrolment in the study, follow-up assessments were conducted at 48 hours, 15 days and 6 months. Demographic, medical, and radiographic data were collected, and patients were evaluated on the NIHSS, MMSE, Barthel Index, FIM(TM) and FAM scales. Descriptive statistics were generated, as were uni- and multivariate between group comparisons.

RESULTS

Our study shows that after a first stroke, old age is significantly associated with a high rate of death, a low rate of orientation to a physical medicine and rehabilitation unit and return to home but not poorer functional outcome.

CONCLUSION

Old age is therefore a determinant of post stroke management. Further studies are needed to evaluate whether in patient rehabilitation would result in significant functional benefit, considering the high cost of care, high risk of recurrent stroke, and high rate of death.

Toward a New Payment System for Inpatient Rehabilitation

BACKGROUND

The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs.

OBJECTIVES

We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models.

RESEARCH DESIGN

A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting.

RESULTS

We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed.

CONCLUSION

We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.

Assessing and adjusting for cross-cultural validity of impairment and activity limitation scales through differential item functioning within the framework of the Rasch model: the PRO-ESOR project

INTRODUCTION

In Europe it is common for outcome measures to be translated for use in other languages. This adaptation may be complicated by culturally specific approaches to certain tasks; for example, bathing. In this context the issue of cross-cultural validity becomes paramount.

OBJECTIVE

To facilitate the pooling of data in international studies, a project set out to evaluate the cross-cultural validity of impairment and activity limitation measures used in rehabilitation from the perspective of the Rasch measurement model.

METHODS

Cross-cultural validity is assessed through an analysis of Differential Item Functioning (DIF) within the context of additive conjoint measurement expressed through the Rasch model. Data from patients undergoing rehabilitation for stroke was provided from 62 centers across Europe. Two commonly used outcome measures, the Mini-Mental State Examination (MMSE) and the Functional Independence Measure (FIM) motor scale are used to illustrate the approach.

RESULTS

Pooled data from 3 countries for the MMSE were shown to fit the Rasch model with only 1 item displaying DIF by country. In contrast, many items from the FIM expressed DIF and misfit to the model. Consequently they were allowed to be unique across countries, so resolving the lack of fit to the model.

CONCLUSIONS

Where data are to be pooled for international studies, analysis of DIF by culture is essential. Where DIF is observed, adjustments can be made to allow for cultural differences in outcome measurement.

Rehabilitation of cognitive and motor functions in younger and older patients with vascular brain damage, rheumatologic illness and in post-surgery patients

This study presents results of inpatient rehabilitation (as monitored by Functional Independence Measure (FIM)) of patients with vascular brain damage (n = 78), post surgery patients (n = 62) and of patients with rheumatologic illness (n = 45). These patients were divided into two age groups (cut off point 65 years). There were significant differences in the FIM scores in all three diagnosis groups between the younger and the older patients at discharge, the younger patients reaching a higher FIM score. However, there were no substantial differences between the two age groups in FIM gains the length of stay in any of the diagnosis groups. This study indicates that although younger patients reach higher FIM score at admission and at discharge the patients older than 65 improved in a comparable way during the same length of stay thus requiring comparable financial resources.

Predicting follow-up living setting in patients with stroke

OBJECTIVE

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

DESIGN

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

SETTING

National survey data.

PARTICIPANTS

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

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSION

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

Delayed discharges from Oxford city hospitals: who and why?

OBJECTIVE

To determine the extent and characteristics of discharge delays of younger patients from acute hospital beds in Oxford, England.

DESIGN

Three-month prospective analysis of patients deemed to have delayed discharge.

MEASURES

The primary measure was the number of days from the patient being no longer in need of acute medical inpatient care to eventual discharge. Additional assessments included demographic data, primary diagnosis, Motricity Index, Short Orientation-Memory-Concentration Test (SOMC), Barthel Index and contextual data.

SETTING

The major acute hospitals serving the county of Oxfordshire (560,000 people).

SUBJECTS

Fifty patients aged 18-70 years identified by referrals, delayed discharge lists and ward visits whose discharge from hospital had been delayed.

RESULTS

The mean (standard deviation, SD) delay period was 36.1 (26.8) days. The mean prevalence and incidence of discharge delays for each three-day period was 19.7 (SD 1.7) and one (SD 1.7) respectively. Most (88%, n = 44) had a primary neurological diagnosis. Twenty-four (48%) patients had Motricity Index scores of less than 50% in one or more limbs and 16 (32%) in two or more limbs. Twenty-six (52%) patients had cognitive impairment (SOMC <18/28). Thirty-nine (78%) patients had a Barthel Index score of less than 15/20 and 24 (48%) of less than 10/20. The period of discharge delay did not correlate with SOMC, Motricity or Barthel Index scores. Only nine had appropriate accommodation available.

CONCLUSION

Patients whose discharge is delayed were common; most had a neurological disability and cognitive impairment; and accommodation was unsuitable or absent for most. Reorganizing services to give patients access to specialized disability services might both improve the care of these patients and increase the efficiency of the health service.

The FIM instrument in the United States and Italy: a comparative study

OBJECTIVE

To compare FIM instrument ratings between Italy and the United States.

DESIGN

This study utilized 169,835 United States and 4,536 Italian FIM instrument records for stroke with the left side of the body affected, stroke with the right side of the body affected, and orthopedic conditions.

RESULTS

Case-mix, patient age, and admission and discharge FIM instrument scores were similar. The delays between onset of disability and admission to rehabilitation and lengths of stay in rehabilitation were 2-4 times longer in Italy. In Italy, some 88-95% of the subjects were discharged to the community vs. 74-88% in the United States. Hierarchies of FIM instrument ratings across the motor and cognitive items were similar, but there were interesting differences. The hierarchical patterns showed that dressing, bathing, perineal hygiene, and tub or shower transfer were relatively more difficult in Italy compared with the Unites States, whereas walking was easier in Italy compared to the United States.

CONCLUSION

The Italian health care payment system offers less incentive for early discharges from acute care and rehabilitation. In Italy, nursing homes are less accessible, whereas family support is more available. Apparently less intensive treatment is applied in Italy, where a minimum time per day for rehabilitation services is not mandatory for payment. Occupational therapy is not used in Italy and the focus is more on physical therapy.

Medical comorbidity and rehabilitation efficiency in geriatric inpatients

OBJECTIVES

To measure and describe medical comorbidity in geriatric rehabilitation patients and investigate its relationship to rehabilitation efficiency.

DESIGN

Prospective, multivariate, within-subject design.

SETTING

The Geriatric Rehabilitation inpatient unit of the SCO Health Service in Ottawa, Canada.

PARTICIPANTS

One hundred ten patients, with a mean age of 82 years.

MEASUREMENTS

The rehabilitation efficiency ratio, based on gains in functional status achieved with rehabilitation treatment, and the length of stay were computed for all patients. Values were regressed on the scores of the Cumulative Illness Rating Scale (CIRS), the Mini-Mental State Examination, and the Geriatric Depression Scale to establish predictive power.

RESULTS

The findings suggest that geriatric rehabilitation patients experience considerable medical comorbidity. Sixty percent of patients had impairments across six of the 13 dimensions of the CIRS, whereas 36% of patients had impairments across 11 of the 13 dimensions. In addition, medical comorbidity was negatively related to rehabilitation efficiency. This relationship was significant even after controlling for age, cognitive status, depressive symptoms, and functional independence status at admission.

CONCLUSION

Medical comorbidity was a significant predictor of rehabilitation efficiency in geriatric patients. Comorbidity scores >5 were prognostic of poorer rehabilitation outcomes and can serve as an empirical guide in estimating a patient's suitability for rehabilitation. Medical comorbidity predicted both the overall functional change achieved with retabilitation (Functional Independence Measure gains) and the rate at with which those gains were reached (rehabilitation efficiency ratio).

A study of the factors which influence the length of hospital stay of stroke patients

OBJECTIVE

To examine the factors which influence the length of hospitalization of stroke patients.

DESIGN

Analysis of the relative importance of 10 preselected variables on the length of hospital stay of all patients admitted with a clinical diagnosis of stroke. The data were collected prospectively.

SETTING

Two teaching hospitals serving the city of Southampton and southwest Hampshire, England (approximate population 450000).

SUBJECTS

Forty-six consecutive stroke patients.

RESULTS

Data were complete on 38 patients. The mean and (median) length of hospital stay was 74.9 (80.5) days for men and 74.7 (73.5) for women. The mean age of women in the study sample was higher than that of men (73.2 vs 71.6). Patients who were less than 70 years of age stayed shorter periods in hospital than older subjects. Other factors associated with shorter hospitalization were a stroke type other than total anterior circulation infarct, a Barthel score of 12 or more on admission or at the time of discharge and a frequency of consultants' ward rounds of more than one per week. A delay in the provision of equipment and home adaptations and waiting for placement in a private nursing home were the best predictors of long hospital stays of stroke patients.

CONCLUSIONS

Early liaison of rehabilitation staff with Social Services in order to secure the quick provision of environmental aids and adaptations or placement in residential care of stroke patients with a poor prognosis for functional recovery would probably reduce the unnecessary hospitalization of these patients.