Appropriateness of admission to rehabilitation: definition of a set of criteria and rules through the application of the Delphi method.

BACKGROUND: Controlling inappropriateness of care is an essential issue, especially in rehabilitation medicine. In fact, admitting a patient to a rehabilitation hospital or unit is a complex decision also due to the absence of shared and objective admission criteria. AIM: The aim was to define clinical admission criteria and rules in rehabilitation medicine. DESIGN: Survey based on the application of the Delphi method on a sample of rehabilitation medicine experts. SETTING: Administration of electronic online questionnaires concerning appropriateness of admission to intensive rehabilitation. POPULATION: Volunteer sample of 53 experts with the following inclusion criteria: being members of the Italian Society of Physical and Rehabilitation Medicine, having practical experience in the research field, agreeing to the confidentiality of the information and being skilled in both rehabilitation and healthcare organization. METHODS: A three-round Delphi survey was conducted according to international guidelines. The two initial rounds consisted of an electronic online questionnaire while in the third one a report of the results was provided to the participants. The experts had to score their agreement with each item in the questionnaires, based on either a Likert scale or a dichotomous statement. Consensus between the experts was assessed. RESULTS: A total of 53 health professionals completed the Delphi survey. 19 out of 20 Italian regions were represented. The first round consisted of 8 multiple-choice questions. The second round was designed according to the suggestions provided by the panelists in the previous one and consisted of a twelve items questionnaire. At the end of the survey, seven criteria of appropriateness of admission to rehabilitation were identified and five rules defining an appropriate admission to a rehabilitation facility were elaborated. CONCLUSIONS: This study represents an attempt to create a worthwhile and reliable tool for a more conscious clinical practice in admission to rehabilitation, based on a set of shared criteria and rules. CLINICAL REHABILITATION IMPACT: To increase appropriateness of admission to rehabilitation. Improving appropriateness in healthcare delivery must be a primary goal in order to improve healthcare quality, save money and ensure system sustainability.

Psychometric validation of the Italian Rehabilitation Complexity Scale-Extended version 13.

In Italy, at present, a well-known problem is inhomogeneous provision of rehabilitative services, as stressed by MoH, requiring appropriate criteria and parameters to plan rehabilitation actions. According to the Italian National Rehabilitation Plan, Comorbidity, Disability and Clinical Complexity should be assessed to define the patient's real needs. However, to date, clinical complexity is still difficult to measure with shared and validated tools. The study aims to psychometrically validate the Italian Rehabilitation Complexity Scale-Extended v13 (RCS-E v13), in order to meet the guidelines requirements. An observational multicentre prospective cohort study, involving 8 intensive rehabilitation facilities of the Emilia-Romagna Region and 1712 in-patients, [823 male (48%) and 889 female (52%), mean age 68.34 years (95% CI 67.69-69.00 years)] showing neurological, orthopaedic and cardiological problems, was carried out. The construct and concurrent validity of the RCS-E v13 was confirmed through its correlation to Barthel Index (disability) and Cumulative Illness Rating Scale (comorbidity) and appropriate admission criteria (not yet published), respectively. Furthermore, the factor analysis indicated two different components ("Basic Care or Risk-Equipment" and "Medical-Nursing Needs and Therapy Disciplines") of the RCS-E v13. In conclusion, the Italian RCS-E v13 appears to be a useful tool to assess clinical complexity in the Italian rehab scenario case-mix and its psychometric validation may have an important clinical rehabilitation impact allowing the assessment of the rehabilitation needs considering all three dimensions (disability, comorbidity and clinical complexity) as required by the Guidelines and the inhomogeneity could be reduced.

Motor and sensory rehabilitation after lower limb amputation: state of art and perspective of change.

The rehabilitation of the amputated patient is based on a coordinated sequence of diagnostic, prognostic and therapeutic procedures carried out by an interdisciplinary rehabilitation team, that works globally on all patient problems. The objectives of the different phases of the rehabilitation treatment were reviewed. Due to their relevance in conditioning the final outcome of the treatment, aspects requiring further studies and remarks, were also reviewed. Among these the psychological aspects, the alterations of all sensory inputs, the secondary alterations at the bone, articular and muscular level, pain of the residual limb and the phantom limb. Finally, the basic criteria to be used to choose the kind of prosthesis in relation to the characteristics and expectations of the amputated person, and the results of the recovery of the autonomy and walking ability, will be schematically described.

[Measuring change in rehabilitative cardiology: reliability of a short questionnaire to assess an outcome]. / Valutazione psicologica del cambiamento in cardiologia riabilitativa: validazione di un questionario a forma breve per la valutazione di esito.

UNLABELLED: The present Italian health planning demands the use of tools, care and treatments useful for the National Health Service, but with empirical effectiveness scientifically sustained. Aim of the present paper is to verify the validity, the reliability and the responsiveness of the factor "Perception of positive change" (named Schedule C) in cardiovascular rehabilitation. METHOD: The reliability of the Schedule C of the CBA VE has been examined comparing the mean scores obtained from each item at the entry and just before the discharge through the t-Student for paired sample. To assess the concurrent validity we used the AD Short Scale to measure anxiety and depression. 100 patients who underwent cardiac surgery were enrolled during hospitalization for a Cardiac Rehabilitation Programme. Cronbach's alpha was used to assess internal consistency of each item. RESULTS: Each item of the Schedule C demonstrated good internal consistency (Cronbach Alpha > .88) and elevated correlations item-total for each item. The strong correlation of anxiety and depression scores with the Schedule C points out appropriate concurrent validation. CONCLUSIONS: We believe that the Schedule C of the CBA VE is endowed with suitable metric validity and then useful as outcome evaluation in cardiovascular rehabilitation settings.

Peripheral muscle strength training in bed-bound patients with COPD receiving mechanical ventilation: effect of electrical stimulation.

STUDY OBJECTIVE: To compare the effects of active limb mobilization (ALM) with or without electrical stimulation (ES) on muscle strength, respiratory rate (RR), heart rate, oxygen saturation, and time needed to transfer from bed to chair in two groups of patients with COPD. DESIGN: Randomized, controlled study. SETTING: Respiratory high-dependency care unit. PATIENTS: Twenty-four bed-bound patients with chronic hypercapnic respiratory failure due to COPD who were receiving mechanical ventilation, with marked peripheral muscle hypotonia and atrophy. METHODS: Patients were randomly assigned either to ALM alone or to ALM plus ES (ALM/ES). ES was applied using square-wave alternate, symmetric, and compensated impulses for 30 min bid. The duration of treatment was 28 days for all patients. RESULTS: Muscle strength improved significantly in the overall group of patients (from 1.75 +/- 0.73 to 3.44 +/- 0.65, p < 0.05). Comparing the change (end minus beginning) of the analyzed variables, ALM/ES significantly improved muscle strength (2.16 +/- 1.02 vs 1.25 +/- 0.75, p = 0.02) and RR (- 1.91 +/- 1.72 vs 0.41 +/- 1.88, p = 0.004), and decreased the number of days needed to transfer from bed to chair (10.75 +/- 2.41 days vs 14.33 +/- 2.53 days, p = 0.001). CONCLUSION: In bed-bound patients with COPD receiving mechanical ventilation, with marked peripheral muscle hypotonia and atrophy, application of ES in addition to classical ALM significantly improved muscle strength and decreased the number of days needed to transfer from bed to chair.