Physical Therapy Provider Continuity Predicts Functional Improvements in Inpatient Rehabilitation.

BACKGROUND AND PURPOSE: Health care continuity has been linked to improved patient outcomes in a variety of professions and settings. Patients in inpatient rehabilitation receive a consistent dosage of physical therapy (PT) treatment; however, the providing physical therapist may vary. Despite the potential influence of PT provider continuity on functional outcomes in the inpatient rehabilitation setting, this association has not yet been studied. METHODS: An observational retrospective chart review was conducted on 555 discharged inpatient rehabilitation patients. The relationship between the number of PT providers from whom a patient received care and Quality Indicator (QI) Mobility discharge scores was examined with Pearson product-moment correlation coefficients, initially with the entire patient group and secondarily with distinct diagnostic groups. Data from subgroups for whom a significant relationship was established were then included in a hierarchical linear regression analysis accounting for relevant covariates. RESULTS: The number of PT providers correlated negatively with QI Mobility discharge scores ( r = -0.41, P ≤ 0.001). When controlling for QI Mobility admission scores, the "Stroke" (partial r = -0.17, P = 0.02), "Spinal Cord Injury" (partial r = -0.28, P = 0.002), and "Other Neuromuscular" (partial r = -0.35, P = 0.03) groups demonstrated significant inverse relationships. A hierarchical linear regression incorporating these 3 diagnostic groups revealed that the number of PT providers remained a significant predictor of QI Mobility discharge scores ( B = -1.50, P ≤ 0.001) when accounting for covariates. DISCUSSION AND CONCLUSIONS: PT provider continuity is related to the functional improvement of neurologically impaired patients in inpatient rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A405 , which discusses the findings of this work in a narrative format).

Comparing adaptive fractal and detrended fluctuation analyses of stride time variability: Tests of equivalence.

BACKGROUND: Fractal analyses quantify self-similarities in stride-to-stride fluctuations over different time scales. Fractal exponents can be measured with adaptive fractal analysis (AFA) or detrended fluctuation analysis (DFA), though measurements obtained with the algorithms have not been directly compared. RESEARCH QUESTION: Are stride time fractal exponents measured with AFA and DFA algorithms equivalent? METHODS: Data from 50 participants with Parkinson's Disease (n = 15), age-similar healthy adults (n = 15) and healthy young adults (n = 20) were analyzed in this cross-sectional, observational study. Participants completed 6-min walks at self-selected speeds overground on a straight walkway and on a treadmill. Stride times were measured with inertial measurement units. Fractal exponents in stride time data were processed using AFA and DFA algorithms and compared with two one-sided tests of equivalence. Mixed ANOVAs were used to compare exponents between groups and conditions. RESULTS: Fractal exponents computed with AFA and DFA were equivalent neither in the overground (0.796 & 0.830, respectively, p = .587) nor treadmill conditions (0.806 & 0.882, respectively, p = .122). Fractal exponents measured with DFA were higher than when measured with AFA. Standard errors were 22% lower when measured with AFA. Additionally, a group × condition interaction was statistically significant when fractal exponents were processed with the AFA algorithm (F(2,47) = 11.696, p < .001), whereas the group × condition interaction was not statistically significant when DFA exponents were compared (F(2, 47) = 2.144, p = .129). SIGNIFICANCE: AFA and DFA do not produce equivalent estimates of the fractal exponent α in stride time dynamics. Estimates of the fractal exponent α obtained with AFA or DFA algorithms therefore should not be used interchangeably. Standard errors were lower when derived with AFA. Fractal exponents calculated with AFA may be more sensitive to conditions that influence stride time fractal dynamics than are measures calculated with DFA.

The Caregiver Experience After Stroke in a COVID-19 Environment: A Qualitative Study in Inpatient Rehabilitation.

BACKGROUND AND PURPOSE: Stroke is the leading cause of disability in the United States. Two-thirds of stroke survivors will require caregiver assistance. Evidence suggests the mental health of caregivers is closely related to patients' health outcomes. The timing of this study intersected with the beginning of the coronavirus disease-2019 (COVID-19) pandemic that required strict social distancing and hospital visitor policy changes. This study aims to answer the primary research question: What is the level and nature of stress experienced by caregivers of persons with newly-acquired stroke in the inpatient rehabilitation setting and how has the COVID-19 pandemic impacted the caregiver experience? METHODS: Recruitment occurred from a single inpatient rehabilitation facility. Participants were administered the Perceived Stress Scale and then completed qualitative semistructured interviews. The investigators used a phenomenological, iterative approach to collect and analyze qualitative data. The data were independently coded and categorized before consolidated into primary themes and subthemes. RESULTS: Eleven informal caregivers' perspectives generated 13 subthemes across 4 primary thematic categories: COVID-19 impact, concerns of the caregiver, coping strategies, and important aspects of the caregiver experience. COVID-19 social distancing necessitated new visitor policies, which presented additional challenges for caregivers. DISCUSSION AND CONCLUSIONS: Caregiver attendance at therapy sessions and frequent, direct communication between staff and caregivers improved caregiver readiness for family member discharge following inpatient rehabilitation. This study shared perspectives from a distinctive time during the COVID-19 pandemic. If visitation for multiple therapy sessions is prohibited, we recommend taking alternative measures to keep the caregiver involved in the plan of care.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A326).

Treadmill walking alters stride time dynamics in Parkinson's disease.

BACKGROUND: Treadmill training may be used to improve gait rhythmicity in people with Parkinson's disease. Treadmills, however, alter dynamical stride time fluctuations in healthy adults in a manner that mimics pathologic states, indicating the stride-to-stride fluctuations that characterize healthy gait are constrained. It is unclear if treadmills similarly alter dynamic gait properties in Parkinson's disease. RESEARCH QUESTION: Do stride time fractal dynamics in individuals with Parkinson's disease differ between treadmill and overground walking? METHODS: Fifteen participants with Parkinson's disease and 15 healthy age-similar adults walked for 6 min in a conventional overground condition and on a treadmill while wearing inertial measurement units. Gait speed, stride times and stride time variability were measured. Fractal exponents (α) were computed with adaptive fractal analysis. Inferential statistics were analyzed with mixed model analyses of variance and post hoc simple effects tests. RESULTS: Mean gait speeds decreased and stride times increased on the treadmill but did not differ between the Parkinson's and control groups. Stride time variability was greater in the Parkinson's than control group in both conditions. Most relevant to our research question, stride time fractal exponents were greater on the treadmill (mean α = .910) than overground (mean α = .797) in individuals with Parkinson's disease, but not in healthy controls. SIGNIFICANCE: The fractal scaling exponent α emanating from stride time fluctuations during treadmill walking increased toward a 1/f signal of α = 1.0 that has been interpreted as an optimal structural variability for gait. The clinical implication is that treadmill training may promote more efficient walking dynamics in people with Parkinson's disease than conventional overground training.

Consensus Guidelines for Facilities Performing Outpatient Procedures: Evidence Over Ideology.

In policy and law, regulation of abortion is frequently treated differently from other health services. The safety of abortion is similar to that of other types of office- and clinic-based procedures, and facility requirements should be based on assuring high-quality, safe performance of all such procedures. False concerns for patient safety are being used as a justification for promoting regulations that specifically target abortion. The Project on Facility Guidelines for the Safe Performance of Primary Care and Gynecology Procedures in Offices and Clinics was undertaken by clinicians, consumers, and representatives from accrediting bodies to review the available evidence and guidelines that inform safe delivery of outpatient care. Our overall objective was to develop evidence-informed consensus guidelines to promote health care quality, safety, and accessibility. Our consensus determined that requiring facilities performing office-based procedures, including abortion, to meet standards beyond those currently in effect for all general medical offices and clinics is unjustified based on an analysis of available evidence. No safety concerns were identified.

Complexity, fractal dynamics and determinism in treadmill ambulation: Implications for clinical biomechanists.

BACKGROUND: Reduced inter-stride complexity during ambulation may represent a pathologic state. Evidence is emerging that treadmill training for rehabilitative purposes may constrain the locomotor system and alter gait dynamics in a way that mimics pathological states. The purpose of this study was to examine the dynamical system components of gait complexity, fractal dynamics and determinism during treadmill ambulation. METHODS: Twenty healthy participants aged 23.8 (1.2) years walked at preferred walking speeds for 6min on a motorized treadmill and overground while wearing APDM 6 Opal inertial monitors. Stride times, stride lengths and peak sagittal plane trunk velocities were measured. Mean values and estimates of complexity, fractal dynamics and determinism were calculated for each parameter. Data were compared between overground and treadmill walking conditions. FINDINGS: Mean values for each gait parameter were statistically equivalent between overground and treadmill ambulation (P>0.05). Through nonlinear analyses, however, we found that complexity in stride time signals (P<0.001), and long-range correlations in stride time and stride length signals (P=0.005 and P=0.024, respectively), were reduced on the treadmill. INTERPRETATION: Treadmill ambulation induces more predictable inter-stride time dynamics and constrains fluctuations in stride times and stride lengths, which may alter feedback from destabilizing perturbations normally experienced by the locomotor control system during overground ambulation. Treadmill ambulation, therefore, may provide less opportunity for experiencing the adaptability necessary to successfully ambulate overground. Investigators and clinicians should be aware that treadmill ambulation will alter dynamic gait characteristics.

Promoting Patient and Family Partnerships in Ambulatory Care Improvement: A Narrative Review and Focus Group Findings.

INTRODUCTION: Ambulatory practices that actively partner with patients and families in quality improvement (QI) report benefits such as better patient/family interactions with physicians and staff, and patient empowerment. However, creating effective patient/family partnerships for ambulatory care improvement is not yet routine. The objective of this paper is to provide practices with concrete evidence about meaningfully involving patients and families in QI activities. METHODS: Review of literature published from 2000-2015 and a focus group conducted in 2014 with practice advisors. RESULTS: Thirty articles discussed 26 studies or examples of patient/family partnerships in ambulatory care QI. Patient and family partnership mechanisms included QI committees and advisory councils. Facilitators included process transparency, mechanisms for acting on patient/family input, and compensation. Challenges for practices included uncertainty about how best to involve patients and families in QI. Several studies found that patient/family partnership was a catalyst for improvement and reported that partnerships resulted in process improvements. Focus group results were concordant. CONCLUSION: This paper describes emergent mechanisms and processes that ambulatory care practices use to partner with patients and families in QI including outcomes, facilitators, and challenges. FUNDING: Gordon and Betty Moore Foundation.

A comparison of variability in spatiotemporal gait parameters between treadmill and overground walking conditions.

Motorized treadmills are commonly used in biomechanical and clinical studies of human walking. Whether treadmill walking induces identical motor responses to overground walking, however, is equivocal. The purpose of this study was to examine differences in the spatiotemporal gait parameters of the lower extremities and trunk during treadmill and overground walking using comparison of mean and variability values. Twenty healthy participants (age 23.8±1.2 years) walked for 6min on a treadmill and overground while wearing APDM 6 Opal inertial monitors. Stride length, stride time, stride velocity, cadence, stance phase percentage, and peak sagittal and frontal plane trunk velocities were measured. Mean values were calculated for each parameter as well as estimates of short- (SD1) and long-term variability (SD2) using Poincaré analyses. The mean, SD1, and SD2 values were compared between overground and treadmill walking conditions with paired t-tests (α=0.05) and with effect size estimates using Cohen's d statistic. Mean values for each of the gait parameters were statistically equivalent between treadmill and overground walking (p>0.05). The SD1 and SD2 values representing short- and long-term variability were considerably reduced (p<0.05) on the treadmill as compared to overground walking. This demonstrates the importance of consideration of gait variability when using treadmills for research or clinical purposes. Treadmill training may induce invariant gait patterns, posing difficulty in translating locomotor skills gained on a treadmill to overground walking conditions.

The National Cardiovascular Data Registry Voluntary Public Reporting Program: An Interim Report From the NCDR Public Reporting Advisory Group.

Public reporting of health care data continues to proliferate as consumers and other stakeholders seek information on the quality and outcomes of care. Medicare's Hospital Compare website, the U.S. News & World Report hospital rankings, and several state-level programs are well known. Many rely heavily on administrative data as a surrogate to reflect clinical reality. Clinical data are traditionally more difficult and costly to collect, but more accurately reflect patients' clinical status, thus enhancing the validity of quality metrics. We describe the public reporting effort being launched by the American College of Cardiology and partnering professional organizations using clinical data from the National Cardiovascular Data Registry (NCDR) programs. This hospital-level voluntary effort will initially report process of care measures from the percutaneous coronary intervention (CathPCI) and implantable cardioverter-defibrillator (ICD) registries of the NCDR. Over time, additional process, outcomes, and composite performance metrics will be reported.

If you build it, will they come? Designing truly patient-centered health care.

As the United States debates how to reorganize its health care system, policy makers must ask what patients really want and need from their primary care providers. There is often a disconnect between what patients say they want and what other providers or payers think patients want. Our research at the National Partnership for Women and Families suggests that a truly patient-centered health care system must be designed to incorporate features that matter to patients--including "whole person" care, comprehensive communication and coordination, patient support and empowerment, and ready access. Without these features, and without consumer input into the design, ongoing practice, and evaluation of new models, patients may reject new approaches such as medical homes and accountable care organizations.

Blueprint for action: steps toward a high-quality, high-value maternity care system.

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The "Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System", issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, "Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?" Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term "2020 Vision for a High Quality, High Value Maternity Care System", also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the "Blueprint for Action" presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

Crossroads in quality.

Expanding insurance coverage is a critical step in health reform, but we argue that to be successful, reforms must also address the underlying problems of quality and cost. We identify five fundamental building blocks for a high-performance health system and urge action to create a national center for effectiveness research, develop models of accountable health care entities capable of providing integrated and coordinated care, develop payment models to reward high-value care, develop a national strategy for performance measurement, and pursue a multistakeholder approach to improving population health.