Poststroke Rehabilitation and Restorative Care Utilization: A Comparison Between VA Community Living Centers and VA-contracted Community Nursing Homes.

BACKGROUND: Effective poststroke rehabilitation care can speed patient recovery and minimize patient functional disabilities. Veterans affairs (VA) community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the 2 major sources of institutional long-term care for Veterans with stroke receiving care under VA auspices. OBJECTIVES: This study compares rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus those Veterans in VA-contracted CNHs. RESEARCH DESIGN: Retrospective observational. SUBJECTS: All Veterans diagnosed with stroke, newly admitted to the CLCs or CNHs during the study period who completed at least 2 Minimum Data Set assessments postadmission. MEASURES: The outcomes were numbers of days for rehabilitation therapy and restorative nursing care received by the Veterans during their stays in CLCs or CNHs as documented in the Minimum Data Set databases. RESULTS: For rehabilitation therapy, the CLC Veterans had lower user rates (75.2% vs. 76.4%, P=0.078) and fewer observed therapy days (4.9 vs. 6.4, P<0.001) than CNH Veterans. However, the CLC Veterans had higher adjusted odds for therapy (odds ratio=1.16, P=0.033), although they had fewer average therapy days (coefficient=-1.53±0.11, P<0.001). For restorative nursing care, CLC Veterans had higher user rates (33.5% vs. 30.6%, P<0.001), more observed average care days (9.4 vs. 5.9, P<0.001), higher adjusted odds (odds ratio=2.28, P<0.001), and more adjusted days for restorative nursing care (coefficient=5.48±0.37, P<0.001). CONCLUSION: Compared with their counterparts at VA-contracted CNHs, Veterans at VA CLCs had fewer average rehabilitation therapy days (both unadjusted and adjusted), but they were significantly more likely to receive restorative nursing care both before and after risk adjustment.

Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War Veteran V.A. users.

BACKGROUND: Traumatic brain injury (TBI) is the "signature injury" in the Afghanistan and Iraq wars [Operation Enduring Freedom in Afghanistan (OEF)/Operation Iraqi Freedom (OIF)]. Patients with combat-related TBI also have high rates of psychiatric disturbances and pain. OBJECTIVES: To determine the prevalence of TBI alone and TBI with other conditions and the average cost of medical care for veterans with these diagnoses. METHODS: Observational study using national inpatient, outpatient, and pharmacy data from Veterans Health Administration (VHA) datasets. Costs are estimated from utilization related to care within the VHA system. Participants were all OEF/OIF VHA users in 2009. RESULTS: Among 327,388 OEF/OIF veterans using VHA services in 2009, 6.7% were diagnosed with TBI. Among those with TBI diagnoses, 89% were diagnosed with a psychiatric diagnosis [the most frequent being posttraumatic stress disorder (PTSD) at 73%], and 70% had a diagnosis of head, back, or neck pain. The rate of comorbid PTSD and pain among those with and without TBI was 54% and 11%, respectively. The median annual cost per patient was nearly 4-times higher for TBI-diagnosed veterans as compared with those without TBI ($5831 vs. $1547). Within the TBI group, cost increased as diagnostic complexity increased, such that those with TBI, pain, and PTSD demonstrated the highest median cost per patient ($7974). CONCLUSIONS: The vast majority of VHA patients diagnosed with TBI also have a diagnosed mental disorder and more than half have both PTSD and pain. Patients with these comorbidities incur substantial medical costs and represent a target population for future research aimed at improving health care efficiency.

Analysis of US Veterans Health Administration comprehensive evaluations for traumatic brain injury in Operation Enduring Freedom and Operation Iraqi Freedom Veterans.

OBJECTIVE: To describe neurobehavioural symptoms in Iraq and Afghanistan war veterans evaluated for traumatic brain injury (TBI) through the Veterans Health Administration (VHA) TBI screening and evaluation programme. DESIGN: An observational study based on VHA administrative data for all veterans who underwent TBI Comprehensive Evaluation between October 2007 and June 2010. RESULTS: 55,070 predominantly white, non-Hispanic, male Veterans with a positive TBI screen had comprehensive TBI evaluations completed during the study period. Moderate-to-severe symptoms were common in the entire sample, both in those with and without a clinician-diagnosed TBI. However, the odds of reporting symptoms of this severity were significantly higher in those diagnosed with TBI compared to those without a TBI diagnosis, with odds ratios ranging from 1.35-2.21. TBI-specialty clinicians believed that in the majority of diagnosed TBI cases both behavioural health conditions and TBI contributed to patients' symptom presentation. CONCLUSIONS: The VHAs TBI screening and evaluation process is identifying individuals with ongoing neurobehavioural symptoms. Moderate-to-severe symptoms were more prevalent in veterans with TBI-specialty clinician determined TBI. However, the high rate of symptom reporting also present in individuals without a confirmed TBI suggest that symptom aetiology may be multi-factorial in nature.

Virtual Physical Therapy and Telerehabilitation.

Telerehabilitation is now a mainstay in health care delivery, with recent trends pointed to continued expansion in the future. Physical therapy (PT) being provided via telehealth, also known as virtual PT, has been demonstrated to provide functional improvements and satisfaction for the consumer and provider, and is applicable in various physical therapy treatment diagnostic areas. Research and technology enhancements will continue to offer new and innovative means to provide physical therapy. This article further provides points to make virtual PT successful and highlights some recommended equipment and outcome recommendations. The future is bright for providing virtual PT.

Possible incremental benefits of specialized rehabilitation bed units among veterans after lower extremity amputation.

BACKGROUND: Little is known about the effect of different types of inpatient rehabilitation on outcomes of patients undergoing lower extremity amputation for nontraumatic reasons. OBJECTIVE: To compare outcomes between patients who received inpatient rehabilitation on specific rehabilitation bed units (specialized) to patients who received rehabilitation on general medical/surgical units (generalized) during the acute postoperative period. METHODS: This was an observational study including 1339 veterans who underwent lower extremity amputation between October 1, 2002 and September 30, 2004. Data were compiled from 9 administrative databases from the Veterans Health Administration. Propensity score risk adjustment methodology was used to reduce selection bias in looking at the effect of type of rehabilitation on outcomes (1-year survival, home discharge from the hospital, prescription of a prosthetic limb within 1 year post surgery, and improvement in physical functioning at rehabilitation discharge). RESULTS: After applying propensity score risk adjustment, there was strong evidence that patients who received specialized versus generalized rehabilitation were more likely to be discharged home (risk difference = 0.10), receive a prescription for a prosthetic limb (risk difference = 0.13), and improve physical functioning (gains on average 6.2 points higher). Specialized patients had higher 1-year survival (risk difference = 0.05), but the difference was not statistically significant. The sensitivity analysis demonstrated our findings to be unaffected by a moderately strong amount of unmeasured confounding. CONCLUSIONS: Receipt of specialized compared with generalized rehabilitation during the acute postoperative inpatient period was associated with better outcomes. Future studies will need to look at different intensity, timing, and location of rehabilitation services.

Short- and long-term prognosis among veterans with neurological disorders and subsequent lower-extremity amputation.

BACKGROUND: Although comorbid neurological conditions are not uncommon for individuals undergoing lower-extremity (LE) amputation, short- and long-term prognosis is unclear. METHODS: This cohort study on the survival of United States veterans with LE amputations examined the association between different preexisting neurological conditions and short- and long-term (in-hospital and within 1-year of surgical amputation) mortality. Chi(2) and t test statistics compared baseline characteristics for patients with and without neurological disorders. Multiple logistic regression and Cox proportional hazard models were used to examine short- and long-term survival and identify predictors limited to the subset of those with neurological conditions adjusting for age, amputation level and etiology, and co-morbidities. RESULTS: Of 4,720 patients, 43.3% had neurological disorders documented. Most prevalent were stroke or hemiparesis (18.3%) and peripheral nervous system (PNS) disorders (20.3%). Among patients with neurological conditions, those with a PNS disorder or spinal cord injury (or paralysis) were significantly less likely to die in hospital and within 1 year (p < 0.05) when compared to the other types of neurological condition groups including stroke (or hemiparesis), cerebral degenerative diseases, movement disorders and autonomic disorders. CONCLUSIONS: The high prevalence of preexisting neurological disorders among LE amputees and the varying effect of different conditions on risk of mortality highlights the need to further characterize the diverseness of this understudied subpopulation. While preexisting spinal cord injury and PNS disorders appear to carry a decreased risk among amputees, those with central nervous system disorders have comparatively greater mortalities.

Factors influencing decisions to admit patients to veterans affairs specialized rehabilitation units after lower-extremity amputation.

UNLABELLED: Bates BE, Kwong PL, Kurichi JE, Bidelspach DE, Reker DM, Maislin G, Xie D, Stineman M. Factors influencing decisions to admit patients to Veterans Affairs specialized rehabilitation units after lower-extremity amputation. OBJECTIVE: To understand patient- and facility-level characteristics that influence decisions to admit veterans to a specialized rehabilitation unit (SRU) after a lower-extremity amputation. DESIGN: Database study. SETTING: All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS: Veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Admission to an SRU. RESULTS: There were a total of 2922 veterans with lower-extremity amputations; 616 patients were admitted to an SRU, whereas 2306 received consultative rehabilitation services only. Patients admitted to an SRU waited longer to have their first rehabilitation assessment after surgery and had middle-range physical and cognitive disabilities. Patients who received consultative rehabilitation services only tended to have greater illness burden. They were more likely to have previous amputation complication, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities. CONCLUSIONS: The selection of veterans with new lower-extremity amputations for admission to an SRU appears clinically reasonable and based on the likelihood of successful outcomes.

Three Year Trends in Veterans Health Administration Utilization and Costs after Traumatic Brain Injury Screening among Veterans with Mild Traumatic Brain Injury.

Examination of trends in Veterans Health Administration (VHA) healthcare utilization and costs among veterans with mild traumatic brain injury (mTBI) is needed to inform policy, resource allocation, and treatment planning. The objective of this study was to assess the patterns of VHA healthcare utilization and costs in the 3 years following TBI screening among veterans with mTBI, compared with veterans without TBI. A retrospective cohort study of veterans who underwent TBI screening in fiscal year 2010 was conducted. We used VHA healthcare utilization and associated costs by categories of care to compare veterans diagnosed with mTBI (n = 7318) with those who screened negative (n = 75,294) and those who screened positive but had TBI ruled out (n = 3324). Utilization and costs were greatest in year 1, dropped in year 2, and then leveled off. mTBI diagnosis was associated with high rates of utilization. Each year, healthcare costs for those with mTBI were two to three times higher than for those who screened negative, and 20-25% higher than for those who screened positive but had TBI ruled out. A significant proportion of healthcare use and costs for veterans with mTBI were associated with mental health service utilization. The relatively high rate of VHA utilization and costs associated with mTBI over time demonstrates the importance of long-term planning to meet these veterans' needs. Identifying and engaging patients with mTBI in effective mental health treatments should be considered a critical component of treatment planning.

Regional variation in post-stroke multidisciplinary rehabilitation care among veteran residents in community nursing homes.

INTRODUCTION: Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors' functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans' health services as well as the geographic variation of the service utilization. AIM: The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care. METHODS: This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans' inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays. RESULTS: The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p<0.001) more likely to receive rehabilitation therapies than veterans from other regions. However, veterans in Southeast CNHs were significantly (p<0.001) less likely to receive restorative nursing care compared with veterans in all other regions, before and after risk adjustment. CONCLUSION: The majority of veterans with stroke received rehabilitation therapy, and about one-third had restorative nursing care during their stay at VA-contracted CNHs. Significant regional variations in weekly days for rehabilitation therapy and restorative nursing care utilization were observed even after adjusting for potential risk factors.

Prognostic differences for functional recovery after major lower limb amputation: effects of the timing and type of inpatient rehabilitation services in the Veterans Health Administration.

OBJECTIVE: To compare the recovery of mobility and self-care functions among veteran amputees according to the timing and type of rehabilitation services received. DESIGN: Observational study of inpatient rehabilitation care patterns of 2 types (specialized and consultative) with 2 timings (early and late). SETTING: Data from inpatient specialized rehabilitation units (SRUs) and consultative services within 95 Veterans Affairs Medical Centers across the United States during fiscal years 2003 to 2004. PATIENTS: Medical records of 1502 patients who received early or late consultative or specialized rehabilitation. ASSESSMENT OF RISK FACTORS: Hypotheses were established and general categories of negative and positive risk factors specified a priori from available clinical characteristics. Linear mixed effects models were used to model motor Functional Independence Measure (FIM) gain scores on patient-level variables accounting for the correlation within the same facility. MAIN OUTCOME MEASURES: Recovery of activities of daily living (ADLs) and mobility (physical functioning) expressed as the magnitudes of gains in motor FIM scores achieved by rehabilitation discharge. RESULTS: After adjustment, amputees who received specialized rehabilitation had motor FIM gains that were on average 8.0 points greater than those for amputees who received consultative rehabilitation. Although patients whose rehabilitation was delayed until after discharge from the index surgical stay tended to be more clinically complex, they had gains comparable to those of patients who received early rehabilitation. Advanced age, transfemoral amputation, paralysis, serious nutritional compromise, and psychosis were associated with lower motor FIM gains. The variance for the random effect for facility was statistically significant, suggesting extraneous variation within facility that was not explainable by observed patient-level variables. CONCLUSION: On the basis of this analysis, those patients who receive specialized rehabilitation can be expected to make comparatively greater gains than patients who receive consultative services, regardless of timing and clinical complexity. Findings highlight the need for clinicians to adjust prognostic expectations to both clinical severity and the type of rehabilitation that patients receive.

Survival analysis in amputees based on physical independence grade achievement.

BACKGROUND: Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. OBJECTIVES: To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. DESIGN: Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. SETTING: Ninety-nine US Department of Veterans Affairs Medical Centers. PATIENTS: Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. MAIN OUTCOME MEASURE: Cumulative 6-month survival after rehabilitation discharge. RESULTS: The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. CONCLUSIONS: Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.