Factors influencing general practice follow-up attendances of patients with complex medical problems after hospitalization.

BACKGROUND: Supported discharge care of patients with complex medical problems is associated with improved health outcomes. GPs are ideally placed to provide post-discharge care in the community. Knowledge of factors that influence patients' decisions to attend such follow-up is thus important to improve health care outcomes of these patients. OBJECTIVES: To explore factors that influence complex medical patients' decision to attend GP follow-up after discharge and factors affecting their level of satisfaction with such follow-up. METHODS: Qualitative investigation using semi-structured telephone interviews of 26 patients with complex medical issues conducted 2 weeks after hospital discharge. RESULTS: Complex medical patients experienced varying degrees of concern and information needs after discharge from hospital. Patients' understanding of the role of the GP and experiences of continuity of care also influence patients' decisions to attend follow-up with their GP. In addition, practical factors such as GP availability, presence of discharge instructions, access to transport and level of social support also affect patients' ability to attend early GP follow-up after hospital discharge. Patients' satisfaction with GP follow-up was influenced by perceived competence and personal continuity with the GP. CONCLUSIONS: Patients' decisions to attend GP follow-up after hospitalization are influenced by a number of factors. Interventions to support post-hospital care that address these issues need to be developed and tested. Key issues are patients' understanding of their condition, understanding of the role of the GP in follow-up and continuity of care.

Interrater reliability of functional status scores for patients transferred from one rehabilitation setting to another.

OBJECTIVE: To report the interrater reliability of FIM total score, FIM motor subscore, and FIM cognitive subscore from scoring that occurred in routine clinical practice in 2 closely linked inpatient rehabilitation services in Sydney, Australia. DESIGN: A natural-experiment blind clinical interrater reliability cohort study of the FIM across 2 rehabilitation units. SETTING: This study is set in 2 inpatient rehabilitation units immediately adjacent to each other in southwestern Sydney, New South Wales, Australia. PARTICIPANTS: All patients (N=143) who were transferred between the 2 rehabilitation units between August 2006 and October 2007 were included in the study. INTERVENTION: Discharge FIMs were scored by the first unit and an admission FIM was scored independently by the second unit within a few days. The FIM scores were analyzed for agreement and systematic bias. MAIN OUTCOME MEASURE: Intraclass correlation coefficients, kappa statistic, weighted kappa statistic, and Bland-Altman plots were used. RESULTS: There were 143 sets of scores identified. The range of differences between the 2 FIM totals was -32 to 50, between the FIM motor subscores was -22 to 43, and between the FIM cognitive subscores was -14 to 21. Bland-Altman plots demonstrated poor agreement. Few FIM totals were perfectly matched. The intraclass correlation coefficients ranged from .872 for the FIM total to .830 for the cognitive subscales. Values for kappa ranged from -.007 (FIM motor subscore) to .123 (FIM cognitive subscore). Values for weighted kappa ranged from .465 (FIM cognitive subscore) to .521 (FIM total). CONCLUSIONS: There was no systematic scoring bias evident. Intraclass correlation coefficients were high, but tests of agreement demonstrated poor agreement. These findings have implications for the use of the FIM and any patient classification or funding system based on the FIM, especially if poor levels of agreement were found in the presence of all staff being FIM credentialed and standardization of methods of assessment. This study indicates that further investigation of agreement of both FIM totals and FIM item scores in the clinical setting is warranted.

Health service management study for stroke: a randomized controlled trial to evaluate two models of stroke care.

BACKGROUND: The most effective and efficient model for providing organized stroke care remains uncertain. This study aimed to compare the effect of two models in a randomized controlled trial. METHODS: Patients with acute stroke were randomized on day one of admission to combined, co-located acute/rehabilitation stroke care or traditionally separated acute/rehabilitation stroke care. Outcomes measured at baseline and 90 days postdischarge included functional independence measure, length of hospital stay, and functional independence measure efficiency (change in functional independence measure score ÷ total length of hospital stay). RESULTS: Among 41 patients randomized, 20 were allocated co-located acute/rehabilitation stroke care and 21 traditionally separated acute/rehabilitation stroke care. Baseline measurements showed no significant difference. There was no significant difference in functional independence measure scores between the two groups at discharge and again at 90 days postdischarge (co-located acute/rehabilitation stroke care: 103.6 ± 22.2 vs. traditionally separated acute/rehabilitation stroke care: 99.5 ± 27.7; P = 0.77 at discharge; co-located acute/rehabilitation stroke care: 109.5 ± 21.7 vs. traditionally separated acute/rehabilitation stroke care: 104.4 ± 27.9; P = 0.8875 at 90 days post-discharge). Total length of hospital stay was 5.28 days less in co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (24.15 ± 3.18 vs. 29.42 ± 4.5, P = 0.35). There was significant improvement in functional independence measure efficiency score among participants assigned to co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (co-located acute/rehabilitation stroke care: median 1.60, interquartile range: 0.87-2.81; traditionally separated acute/rehabilitation stroke care: median 0.82, interquartile range: 0.27-1.57, P = 0.0393). Linear regression analysis revealed a high inverse correlation (R(2) = 0.89) between functional independence measure efficiency and time spent in the acute stroke unit. CONCLUSION: This proof-of-concept study has shown that co-located acute/rehabilitation stroke care was just as effective as traditionally separated acute/rehabilitation stroke care as reflected in functional independence measure scores, but significantly more efficient as shown in greater functional independence measure efficiency. Co-located acute/rehabilitation stroke care has potential for significantly improved hospital bed utilization with no patient disadvantage.