Relation of Aerobic Activity to Cognition and Well-being in Chronic Mild Traumatic Brain Injury: A LIMBIC-CENC Study.

INTRODUCTION: Because chronic difficulties with cognition and well-being are common after mild traumatic brain injury (mTBI) and aerobic physical activity and exercise (PAE) is a potential treatment and mitigation strategy, we sought to determine their relationship in a large sample with remote mTBI. MATERIALS AND METHODS: The Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study is a national multicenter observational study of combat-exposed service members and veterans. Study participants with positive mTBI histories (n = 1,087) were classified as "inactive" (23%), "insufficiently active" (46%), "active" (19%), or "highly active" (13%) based on the aerobic PAE level. The design was a cross-sectional analysis with multivariable regression. PAE was reported on the Behavioral Risk Factor Surveillance System. Preselected primary outcomes were seven well-validated cognitive performance tests of executive function, learning, and memory: The California Verbal Learning Test-Second Edition Long-Delay Free Recall and Total Recall, Brief Visuospatial Memory Test-Revised Total Recall, Trail-Making Test-Part B, and NIH Toolbox for the Assessment of Neurological Behavior and Function Cognition Battery Picture Sequence Memory, Flanker, and Dimensional Change Card Sort tests. Preselected secondary outcomes were standardized self-report questionnaires of cognitive functioning, life satisfaction, and well-being. RESULTS: Across the aerobic activity groups, cognitive performance tests were not significantly different. Life satisfaction and overall health status scores were higher for those engaging in regular aerobic activity. Exploratory analyses also showed better working memory and verbal fluency with higher aerobic activity levels. CONCLUSIONS: An association between the aerobic activity level and the preselected primary cognitive performance outcome was not demonstrated using this study sample and methods. However, higher aerobic activity levels were associated with better subjective well-being. This supports a clinical recommendation for regular aerobic exercise among persons with chronic or remote mTBI. Future longitudinal analyses of the exercise-cognition relationship in chronic mTBI populations are recommended.

Association Between Hospital Participation in Value-Based Programs and Timely Initiation of Post-Acute Home Health Care, Functional Recovery, and Hospital Readmission After Joint Replacement.

OBJECTIVES: This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission. METHOD: This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016 to 2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A 2-staged generalized boosted model was used to examine the association between delay in home health initiation and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission. RESULTS: Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20-1.26), mobility (OR = 1.15; 95% CI = 1.13-1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15-1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13-1.20) and mobility (OR = 1.26; 95% CI = 1.22-1.30) for hip replacement. CONCLUSION: Hospital participation in BPCI or comprehensive CJR was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission. IMPACT: Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models.

Assessing functional recovery for individuals with spinal cord injury post-discharge from inpatient rehabilitation.

OBJECTIVE: To determine the associations between trauma variables, acute phase-related variables, and patient-level characteristics with functional recovery during the first-year post-discharge from inpatient rehabilitation facilities (IRF) for individuals with spinal cord injury (SCI). DESIGN: Retrospective cohort analysis. SETTING: Two SCI Model Centers in Pennsylvania, United States. METHODS: We were able to link 378 individuals with traumatic SCI between the Pennsylvania Trauma Systems Outcomes Study and the National SCI Model Systems databases. Nineteen individuals with SCI were excluded due to missing data. We estimated functional recovery based on changes in functional independence measure (FIM) total motor score during the first-year post-discharge from IRF in 359 individuals with SCI, who did not have any missing data, using ordinary least squares regression (OLS). RESULTS: After discharge from IRF the majority of individuals with SCI improved over the first-year post-injury. Individuals with cervical A-C (injury severity group) who were older had a slight decrease in motor FIM at 1-year post-injury. Regression analysis indicated that lower functional recovery was associated with being of Black and Hispanic race and ethnicity, higher injury severity group, occurrence of non-pulmonary infection during acute care, and longer length of stay at IRF (R2 = 0.36). CONCLUSIONS: Patient-level characteristics, trauma variables, and acute phase-related variables were associated with functional recovery post-discharge from IRF. Further research is necessary to collect and assess post-rehabilitation and socio-economic factors that play a critical role in continued functional recovery in the community.

Home health services for minorities in urban and rural areas with Alzheimer's and related dementia.

Timely access and continuum of care in older adults with Alzheimer's Disease and Related Dementia (ADRD) is critical. This is a retrospective study on Medicare fee-for-service beneficiaries with ADRD diagnosis discharged to home with home health care following an episode of acute hospitalization. Our sample included 262,525 patients. White patients in rural areas have significantly higher odds of delay (odds ratio [OR], 1.03; 95% CI, 1.01-1.06). Black patients in urban areas (OR, 1.15; 95% CI, 1.12-1.19) and Hispanic patients in urban areas also were more likely to have a delay (OR, 1.07; 95% CI, 1.03-1.11). Black and Hispanic patients residing in urban areas had a higher likelihood of delay in home healthcare initiation following hospitalization compared to Whites residing in urban areas.

Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD).

INTRODUCTION: We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer's disease and related dementias (ADRD). METHODS: Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge. RESULTS: Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA. DISCUSSION: Black patients are more likely to experience a delay in home health care initiation than White patients.

Effect of Variation in Early Rehabilitation on Hospital Readmission After Hip Fracture.

OBJECTIVE: Provision of early rehabilitation services during acute hospitalization after a hip fracture is vital for improving patient outcomes. The purpose of this study was to examine the association between the amount of rehabilitation services received during the acute care stay and hospital readmission in older patients after a hip fracture. METHODS: Medicare claims data (2016-2017) for older adults admitted to acute hospitals for a hip fracture (n = 131,127) were used. Hospital-based rehabilitation (physical therapy, occupational therapy, or both) was categorized into tertiles by minutes per day as low (median = 17.5), middle (median = 30.0), and high (median = 48.8). The study outcome was risk-adjusted 7-day and 30-day all-cause hospital readmission. RESULTS: The median hospital stay was 5 days (interquartile range [IQR] = 4-6 days). The median rehabilitation minutes per day was 30 (IQR = 21-42.5 minutes), with 17 (IQR = 12.6-20.6 minutes) in the low tertile, 30 (IQR = 12.6-20.6 minutes) in the middle tertile, and 48.8 (IQR = 42.8-60.0 minutes) in the high tertile. Compared with high therapy minutes groups, those in the low and middle tertiles had higher odds of a 30-day readmission (low tertile: odds ratio [OR] = 1.11, 95% CI = 1.06-1.17; middle tertile: OR = 1.07, 95% CI = 1.02-1.12). In addition, patients who received low rehabilitation volume had higher odds of a 7-day readmission (OR = 1.20; 95% CI = 1.10-1.30) compared with high volume. CONCLUSION: Elderly patients with hip fractures who received less rehabilitation were at higher risk of readmission within 7 and 30 days. IMPACT: These findings confirm the need to update clinical guidelines in the provision of early rehabilitation services to improve patient outcomes during acute hospital stays for individuals with hip fracture. LAY SUMMARY: There is significant individual- and hospital-level variation in the amount of hospital-based rehabilitation delivered to older adults during hip fracture hospitalization. Higher intensity of hospital-based rehabilitation care was associated with a lower risk of hospital readmission within 7 and 30 days.

Reliability and Validity of the Inpatient Rehabilitation Facility Discharge Mobility and Self-Care Quality Measures.

OBJECTIVE: To describe the reliability and validity of the publicly reported facility-level quality measures Inpatient Rehabilitation Facility (IRF) Discharge Mobility Score for Medical Rehabilitation Patients ("Discharge mobility score") and IRF Discharge Self-Care Score for Medical Rehabilitation Patients ("Discharge self-care score"). DESIGN: Observational study using standardized patient assessment data to examine facility-level split-half reliability and construct validity of quality measure scores. SETTING AND PARTICIPANTS: All IRFs (n = 1117) in the United States with at least 20 Medicare stays. Facility-level quality measure scores were calculated from 2017 data on 428,192 Medicare (fee-for-service and Medicare Advantage) IRF patient stays. METHODS: Using clinician-reported assessment data, we calculated facility-level mobility and self-care quality measure scores and examined reliability of these scores using split-half analysis and Pearson product-moment correlations, Spearman rank correlations, and intraclass correlation coefficients (ICC2,1). We examined construct validity of these scores by comparing facility-level quality measure scores by facility stroke disease-specific certification status. RESULTS: Reported as percentages meeting or exceeding expectations, IRF quality measure scores ranged from 8.3% to 90.1% for mobility and 9.0% to 90.3% for self-care. IRF scores, when split in half to examine reliability, showed strong, positive correlations for the mobility (Pearson = 0.898, Spearman = 0.898, ICC = 0.898) and self-care (Pearson = 0.886, Spearman = 0.874, ICC = 0.886) scores. When stratified by provider volume, ICCs remained strong. Construct validity analyses showed IRFs with stroke disease-specific certification had higher mean and median scores than IRFs without certification, and a greater proportion of IRFs that were certified had higher scores. CONCLUSION AND IMPLICATIONS: Our results support the reliability and construct validity of the IRF quality measures Discharge mobility and Discharge self-care scores. Reported as percentages meeting or exceeding expectations, these quality measures are designed to be more consumer-friendly compared to change scores.

Association of Caregiver Availability and Training With Patient Community Discharge After Stroke.

Objective: To examine the association between committed caregivers and caregiver training with community discharge from inpatient rehabilitation after a stroke. Design: Secondary analysis of data extracted from electronic health records linked with the Uniform Data System for Medical Rehabilitation. Setting: Three hospital-based inpatient rehabilitation facilities (IRF) in a major metropolitan area. Participants: 1397 adult patients (mean ± SD age: 69.4 [13.5]; 724 men) transferred from an acute care setting to inpatient rehabilitation after an ischemic or hemorrhagic stroke (N=1397). Intervention: None. Main Outcome Measure: Community discharge from IRF. Results: 82.4% of patients had caregivers, 63.4% of patient caregivers received training at the IRF, and 79.5% had community discharge. After adjusting for age, stroke severity, functional status, and other social risk factors, having a committed caregiver and caregiver training were significantly associated with community discharge (odds ratio [OR]=7.80, 95% confidence interval [CI]: 5.03-12.10 and OR=4.89, 95% CI: 3.16-7.57, respectively). Conclusion: Caregivers increase a patient's likelihood of discharge from IRF; the added benefit of caregiver training needs to be further assessed, with essential elements prioritized prior to patients' IRF discharge.

Evaluating associations between trauma-related characteristics and functional recovery in individuals with spinal cord injury.

OBJECTIVE: To determine the associations between trauma variables, acute phase-related variables, and patient-level characteristics with functional recovery during inpatient rehabilitation for individuals with spinal cord injury (SCI). The associations were evaluated by linking individuals' records between the Pennsylvania Trauma Systems Outcomes Study and the National SCI Model Systems databases. DESIGN: Retrospective cohort analysis. SETTING: Two SCI Model Centers in Pennsylvania, United States. METHODS: We used a record linkage toolkit in Python to link 735 individuals with traumatic SCI between the databases. The percentage for true-match and error were 92.0% and 0.1%, respectively. The functional recovery during inpatient rehabilitation was determined in 604 individuals with SCI by ordinary least squares regression (OLS) and gradient boosting regression (GBR) analyses. RESULTS: The OLS and GBR analyses indicated older age, greater impairment (SCI level combined with American Spinal Injury Association impairment scale), presence of diabetes mellitus, pulmonary complications during acute care, and longer length of stay at an inpatient rehabilitation facility were associated with lower functional recovery (OLS R2 = 0.56 and GBR R2 = 0.58). CONCLUSIONS: Trauma and acute care variables in addition to patient characteristics were associated with functional recovery during inpatient rehabilitation in individuals with SCI. Further investigation is needed to understand the role of diabetes mellitus and pulmonary complications, which have not been previously associated with functional recovery in individuals with SCI.

Feasibility and thematic analysis of narrative visualization materials with physical activity monitoring among breast cancer survivors.

BACKGROUND: Breast cancer survivors have a unique risk for negative health outcomes. Engaging in routine physical activity (PA) can reduce these risks. However, PA levels are low among this population. Narrative visualization (NV) is a technique that uses drawings, photographs, and text to contextualize data, which may increase integrated regulation, or motivation related to personal values and identity. A PA intervention targeting breast cancer survivors using an NV strategy may improve PA behavior. The purpose of this study was to determine whether scrapbooking activities could successfully be used as an NV strategy for older (55+) breast cancer survivors. METHODS: Breast cancer survivors were given workbooks, wearable electronic activity monitors, instant cameras, and art supplies including a variety of stickers (e.g., emojis, affirmations). Participants were instructed to use these materials for 7 days. The workbook pages prompted participants to re-draw their daily activity graphs from the wearable's mobile app, then annotate them with text, photographs, stickers, etc. to reflect what the data meant to them. Hybrid thematic analysis was used to analyze the photographs, drawings, and written content to identify emergent themes. Content analysis was also used to investigate use of stickers and photographs. RESULTS: Of the 20 consented women (mean age 67 ± 5 years, 45% non-Hispanic white), 3 participants were lost to follow-up or unable to complete the procedures. The NV procedures were successfully utilized by the remaining 17 participants, who collectively used 945 stickers over 7 days, most of which were emojis. Emojis were both positively and negatively valanced. Participants took a mean of 9 photos over 7 days and completed workbook questions regarding current PA and PA goals. Themes within the photos included family, specific locations, everyday objects, religion, and friends. Themes within the written portions of the workbook included family, chores and obligations, health, personal reflection, hobbies, and shopping. CONCLUSIONS: The materials provided allowed breast cancer survivors to successfully use NV techniques to reflect on their PA data and behavior. These techniques show promise for promoting integrated regulation in activity monitoring interventions. TRIAL REGISTRATION: This study was funded by the National Cancer Institute ( R21CA218543 ) beginning July 1, 2018.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity.

Importance: Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. Objective: To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. Design, Setting, and Participants: This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. Exposures: Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. Main Outcomes and Measures: Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. Results: Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. Conclusions and Relevance: In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.

Identifying factors associated with acute hospital discharge dispositions in patients with moderate-to-severe traumatic brain injury.

OBJECTIVE: Identify sociodemographic, injury, and hospital-level factors associated with acute hospital discharge dispositions following acute hospitalization for moderate-to-severe traumatic brain injury (TBI) in the United States. METHODS: The 2011-2014 National Trauma Data Bank data was used, including 466 acute care hospitals and 114,736 patients ≥16 years old who survived moderate-to-severe TBI. Outcome was acute hospital discharge dispositions: home with/without care (HC), skilled nursing home/other care facility (SNF/ICF) and inpatient rehabilitation/long-term care facility (IRF). Independent variables were patients' sociodemographic, injury, and hospital-level factors. Multilevel modeling was used to assess associations and compare likelihood of discharges. RESULTS: Of all patients, 74.5%, 14.6% ,and 10.9% were discharged to HC, SNF/ICF ,and IRF, respectively. Intraclass correlation coefficients indicated that hospitals explained 14.3% and 14.8% of variations in probabilities of institution dispositions. Sociodemographic factors including older age, females, Non-Hispanic Whites, recipients of commercial insurance, and Medicare/Medicaid were significantly associated with higher institution discharges. Hospital-related factors including bed size, teaching status, trauma accreditations, and hospital locations were significantly associated with discharge dispositions. CONCLUSION: Identifying factors associated with discharge dispositions after acute hospitalization of TBI is pertinent to ensure quality of care and optimal patient outcomes. Further research into hospital-related variations in acute care discharge dispositions is recommended.

Inpatient Rehabilitation Facility Change in Self-Care and Change in Mobility Quality Measures: Development and Reliability and Validity Testing.

OBJECTIVE: To describe the development, implementation and reliability and validity testing of the inpatient rehabilitation facility (IRF) Change in Self-Care and Change in Mobility quality measures. DESIGN: We describe the activities involved in developing and implementing the 2 facility-level quality measures, including public comment opportunities. We examined facility-level reliability using split-half testing and Pearson product-moment correlations, Spearman rank correlations, and intraclass correlation coefficients (ICC2,1). We examined validity by comparing facility-level quality measure scores and facility disease-specific certification status. SETTING: All 1117 IRFs in the United States with at least 20 Medicare stays that ended in 2017. PARTICIPANTS: Facility-level quality measure scores (N=1117) were derived from data from 427,517 (self-care) and 427,956 (mobility) Medicare fee-for-service and Medicare Advantage IRF patient stays in 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Facility-level Change in Self-Care and Change in Mobility quality measure scores and facility Disease-Specific Certification for Stroke Rehabilitation from The Joint Commission were used in validity analysis. RESULTS: The split-half quality measure scores showed strong, positive correlations for the facility-level self-care (Pearson=0.903, Spearman=0.884, ICC=0.903, P<.0001) and mobility (Pearson=0.903, Spearman=0.884, ICC= 0.903, P<.0001) quality measure scores, providing evidence of reliability. ICCs remained strong when stratifying by provider volume. IRFs with stroke certification had slightly higher mean and median quality measure scores than IRFs without certification, and IRFs with the higher quality measure scores tended to have a higher percentage of certified IRFs. CONCLUSIONS: Our analyses support the reliability and validity of the Change in Self-Care and Change in Mobility quality measure scores in IRFs.

Clinical features of dementia cases ascertained by ICD coding in LIMBIC-CENC multicenter study of mild traumatic brain injury.

OBJECTIVE: Describe dementia cases identified through International Classification of Diseases (ICD) coding in the Long-term Impact of Military-relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter prospective longitudinal study (PLS) of mild traumatic brain injury (mTBI). DESIGN: Descriptive case series using cross-sectional data. METHODS: Veterans Affairs (VA) health system data including ICD codes were obtained for 1563 PLS participants through the VA Informatics and Computing Infrastructure (VINCI). Demographic, injury, and clinical characteristics of Dementia positive and negative cases are described. RESULTS: Five cases of dementia were identified, all under 65 years old. The dementia cases all had a history of blast-related mTBI and all had self-reported functional problems and four had PTSD symptomatology at the clinical disorder range. Cognitive testing revealed some deficits especially in the visual memory and verbal learning and memory domains, and that two of the cases might be false positives. CONCLUSIONS: ICD codes for early dementia in the VA system have specificity concerns, but could be indicative of cognitive performance and self-reported cognitive function. Further research is needed to better determine links to blast exposure, blast-related mTBI, and PTSD to early dementia in the military population.

Economic impact of comorbid TBI-dementia on VA facility and non-VA facility costs, 2000-2020.

OBJECTIVE: There is evidence Traumatic Brain Injury (TBI) is associated with increased risk of dementia (D). We compared VA and non-VA facility costs associated with TBI+D and each diagnosis alone, relative to neither diagnosis, annually and over time, 2000-2020. METHODS: We estimated adjusted panel models of annual VHA costs in VA and non-VA facilities, stratified by age, and by TBI-dementia status. We also estimated cost for the TBI+D cohort by time since TBI and dementia diagnoses. All costs were 2021 inflation adjusted. RESULTS: Veterans <65 ($30,736) and ≥65 ($15,650) with TBI+D, while veterans <65 ($3,379) and ≥65 ($4,252) with TBI-only had higher annual total VHA costs, relative to neither diagnosis. Veterans with TBI+D < 65 ($42,864) and ≥65 ($72,424) had higher costs in years≥15 after TBI diagnosis, while <65 ($36,431) and ≥65 ($37,589) had higher costs in years ≥10 after dementia diagnosis. CONCLUSIONS: The main cost driver was inpatient non-VA facility costs. Veterans had continuously increasing inpatient care costs in non-VA facilities over time since their TBI and dementia diagnoses. Given budget constraints on the VA system, quality of care in non-VA facilities warrants comparison with VA facilities to make informed decisions regarding referrals to non-VA facilities.

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries.

OBJECTIVES: To examine Medicare health care spending and health services utilization among high-need population segments in older Mexican Americans, and to examine the association of frailty on health care spending and utilization. METHODS: Retrospective cohort study of the innovative linkage of Medicare data with the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) were used. There were 863 participants, which contributed 1,629 person years of information. Frailty, cognition, and social risk factors were identified from the H-EPESE, and chronic conditions were identified from the Medicare file. The Cost and Use file was used to calculate four categories of Medicare spending on: hospital services, physician services, post-acute care services, and other services. Generalized estimating equations (GEE) with a log link gamma distribution and first order autoregressive, correlation matrix was used to estimate cost ratios (CR) of population segments, and GEE with a logit link binomial distribution was applied to estimate odds ratios (OR) of healthcare use. RESULTS: Participants in the major complex chronic illness segment who were also pre-frail or frail had higher total costs and utilization compared to the healthy segment. The CR for total Medicare spending was 3.05 (95% CI, 2.48-3.75). Similarly, this group had higher odds of being classified in the high-cost category 5.86 (95% CI, 3.35-10.25), nursing home care utilization 11.32 (95% CI, 3.88-33.02), hospitalizations 4.12 (95% CI, 2.88-5.90) and emergency room admissions 4.24 (95% CI, 3.04-5.91). DISCUSSION: Our findings highlight that frailty assessment is an important consideration when identifying high-need and high-cost patients.

Impact of Hospital-Based Rehabilitation Services on Discharge to the Community by Value-Based Payment Programs After Joint Replacement Surgery.

OBJECTIVE: The purpose of this study was to examine the impact of hospital-based rehabilitation services on community discharge rates after hip and knee replacement surgery according to hospital participation in value-based care models: bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR). The secondary objective was to determine whether community discharge rates after hip and knee replacement surgery differed by participation in these models. METHODS: A secondary analysis of Medicare fee-for-service claims was conducted for beneficiaries 65 years of age or older who underwent hip and knee replacement surgery from 2016 to 2017. Independent variables were hospital participation in value-based programs categorized as: (1) BPCI, (2) CJR, and (3) non-BPCI/CJR; and total minutes per day of hospital-based rehabilitation services categorized into tertiles. The primary outcome variable was discharged to the community versus discharged to institutional post-acute care settings. The association between rehabilitation amount and community discharge among BPCI, CJR, and non-BPCI/CJR hospitals was adjusted for patient-level clinical and hospital characteristics. RESULTS: Participation in BPCI or CJR was not associated with community discharge. This analysis found a dose-response relationship between the amount of rehabilitation services and odds of community discharge. Among those who received a hip replacement, this relationship was most pronounced in the BPCI group; compared with the low rehabilitation category, the medium category had odds ratio (OR) = 1.28 (95% CI = 1.17 to 1.41), and the high category had OR = 1.90 (95% CI = 1.71 to 2.11). For those who received a knee replacement, there was a dose-response relationship in the CJR group only; compared with the low rehabilitation category, the medium category had OR = 1.21 (95% CI = 1.15 to 1.28), and the high category had OR = 1.56 (95% CI = 1.46 to 1.66). CONCLUSION: Regardless of hospital participation in BPCI or CJR models, higher amounts of rehabilitation services delivered during acute hospitalization is associated with a higher likelihood of discharge to community following hip and knee replacement surgery. IMPACT: In the era of value-based care, frontloading of rehabilitation care is vital for improving patient-centered health outcomes in acute phases of lower extremity joint replacement.

Making the Case for Patient-Reported Outcome Measures in Big-Data Rehabilitation Research: Implications for Optimizing Patient-Centered Care.

Advances in data science and timely access to health informatics provide a pathway to integrate patient-reported outcome measures (PROMs) into clinical workflows and optimize rehabilitation service delivery. With the shift toward value-based care in the United States health care system, as highlighted by the recent Centers for Medicare and Medicaid Services incentive and penalty programs, it is critical for rehabilitation providers to systematically collect and effectively use PROMs to facilitate evaluation of quality and outcomes within and across health systems. This editorial discusses the potential of PROMs to transform clinical practice, provides examples of health systems using PROMs to guide care, and identifies barriers to aggregating data from PROMs to conduct health services research. The article proposes 2 priority areas to help advance rehabilitation health services research: (1) standardization of collecting PROMs data in electronic health records to facilitate comparing health system performance and quality and (2) increased partnerships between rehabilitation providers, researchers, and payors to accelerate health system learning. As health care reform continues to emphasize value-based payment strategies, it is essential for the field of physical medicine and rehabilitation to be at the forefront of demonstrating its value in the care continuum.

Factors associated with post-acute functional status and discharge dispositions in individuals with spinal cord injury.

BACKGROUND: Research has evaluated the effect of surgical timing on patient functional recovery in individuals with spinal cord injury (SCI); however, there is a critical need to assess how demographics, clinical characteristics, and process of care affect functional outcomes. OBJECTIVE: We examined the association between demographic, clinical, and process of care factors with post-acute functional status (locomotion and transfer mobility scores) and discharge disposition (home vs. institution) in individuals with SCI. METHODS: This study was a retrospective cohort analysis of the Pennsylvania Trauma Systems Outcomes Study (PTOS) database for individuals with traumatic SCI (N = 2223). We conducted multinomial and binomial logistic regression analyses to examine post-acute functional status and discharge disposition, respectively. RESULTS: The results indicated that older age, longer length of stay, lower Glasgow Coma Scale (GCS), higher Injury Severity Score (ISS), and individuals with tetraplegia had significantly lower motor functional score at discharge from an acute hospital. In addition, older age, individuals with public-sponsored insurance, longer length of stay, lower GCS, and higher ISS had significantly higher odds of being discharged to an institution, as compared to home. Individuals of Hispanic ethnicity, as compared to White, had lower odds of being discharged to an institution. CONCLUSIONS: The regression models developed in this study were able to better classify discharge destinations compared to the functional outcomes at discharge from the acute hospital. Further research is necessary to determine how these factors and their associations vary nationally across the US, which have the potential to inform trauma and acute care post-SCI.

Medicare Claim-Based National Institutes of Health Stroke Scale to Predict 30-Day Mortality and Hospital Readmission.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) penalizes hospitals for higher than expected 30-day mortality rates using methods without accounting for condition severity risk adjustment. For patients with stroke, CMS claims did not quantify stroke severity until recently, when the National Institutes of Health Stroke Scale (NIHSS) reporting began. OBJECTIVE: Examine the predictive ability of claim-based NIHSS to predict 30-day mortality and 30-day hospital readmission in patients with ischemic stroke. DESIGN: Retrospective cohort study of Medicare claims data. PATIENTS: Medicare beneficiaries with ischemic stroke (N=43,241) acute hospitalization between October 2016 and November 2017. MEASUREMENTS: All-cause 30-day mortality and 30-day hospital readmission. NIHSS score was derived from ICD-10 codes and stratified into the following: minor to moderate, moderate, moderate to severe, and severe categories. RESULTS: Among 43,241 patients with ischemic stroke with NIHSS from 2,659 US hospitals, 64.6% had minor to moderate stroke, 14.3% had moderate, 12.7% had moderate to severe, and 8.5% had a severe stroke,10.1% died within 30 days, 12.1% were readmitted within 30 days. The NIHSS exhibited stronger discriminant property (C-statistic 0.83, 95% CI: 0.82-0.84) for 30-day mortality compared to Elixhauser (0.74, 95% CI: 0.73-0.75). A monotonic increase in the adjusted 30-day mortality risk occurred relative to minor to moderate stroke category: hazard ratio [HR]=2.92 (95% CI=2.59-3.29) for moderate stroke, HR=5.49 (95% CI=4.90-6.15) for moderate to severe stroke, and HR=7.82 (95% CI=6.95-8.80) for severe stroke. After accounting for competing risk of mortality, there was a significantly higher readmission risk in the moderate stroke (HR=1.11, 95% CI=1.03-1.20), but significantly lower readmission risk in the severe stroke (HR=0.84, 95% CI=0.74-0.95) categories. LIMITATION: Timing of NIHSS reporting during hospitalization is unknown. CONCLUSIONS: Medicare claim-based NIHSS is significantly associated with 30-day mortality in Medicare patients with ischemic stroke and significantly improves discriminant property relative to the Elixhauser comorbidity index.