Age-Related Disparities in the Quality of Stroke Care and Outcomes in Rehabilitation Hospitals: The Australian National Audit.

INTRODUCTION: Stroke affects all ages. Despite increased incidence in those <65 years, little is known about age-based differences in inpatient rehabilitation management and outcomes. OBJECTIVES: To investigate management and outcomes, comparing younger (<65 years) and older (≥65 years) patients with stroke, who received inpatient rehabilitation. METHODS: Multicentre, cross-sectional study using data from Australian hospitals who participated in the Stroke Foundation national stroke rehabilitation audit (2016-2018). Chi-square tests compared characteristics and care by age. Multivariable regression models were used to compare outcomes by age (e.g. length of stay). Models were adjusted for sex, stroke type and severity factors. RESULTS: 7,165 audited cases from 127 hospitals; 23% <65 years (66% male; 72% ischaemic stroke). When compared to older patients, younger patients were more likely male (66% vs 52%); identify as Aboriginal or Torres Strait Islander (6% vs 1%); be less disabled on admission; receive psychology (46% vs 34%) input, and community reintegration support, including return to work (OR 1.47, 95% CI 1.03, 2.11), sexuality (OR 1.60, 95% CI 1.39, 1.84) and self-management (OR 1.39, 95% CI 1.23, 1.57) advice. Following adjustment, younger patients had longer lengths of stay (coeff 3.54, 95% CI 2.27, 4.81); were more likely to be independent on discharge (aOR 1.96, 95% CI 1.68, 2.28); be discharged to previous residences (aOR 1.64, 95% CI 1.41, 1.91) and receive community rehabilitation (aOR: 2.27, 95% CI 1.91, 2.70). CONCLUSIONS: Age-related differences exist in characteristics, management and outcomes for inpatients with stroke accessing rehabilitation in Australia.

Development of an evaluation tool for geriatric rehabilitation care.

BACKGROUND: Geriatric rehabilitation care (GRC) is short-term and multidisciplinary rehabilitation care for older vulnerable clients. Studies were conducted about its effects. However, elements that influence the quality of GRC have not been studied previously. METHODS: In this study realist evaluation is used to find out which are the mechanisms and outcomes and which (groups of) persons are the context for GRC, according to GRC professionals. The mechanisms, outcomes and context of GRC were explored in three consecutive phases of qualitative data gathering, i.e. individual interviews, expert meeting, and focus groups. RESULTS: Eight mechanisms - client centeredness, client satisfaction during rehabilitation, therapeutic climate, information provision to client and informal care givers, consultation about the rehabilitation (process), cooperation within the MultiDisciplinary Team (MDT), professionalism of GRC professionals, and organizational aspects - were found. Four context groups-the client, his family and/or informal care giver(s), the individual GRC professional, and the MDT-were mentioned by the respondents. Last, two outcome factors were determined, i.e. client satisfaction at discharge and rehabilitation goals accomplished. CONCLUSIONS: In order to translate these insights into a practical tool that can be used by MDTs in the practice of GRC, identified mechanisms, contexts, and outcomes were visualized in a GRC evaluation tool. A graphic designer developed an interactive PDF which is the GRC evaluation tool. This tool may enable MDTs to discuss, prioritize, evaluate, and improve the quality of their GRC practice.

Association of sleep with neurobehavioral impairments during inpatient rehabilitation after traumatic brain injury.

BACKGROUND: Sleep disturbance is a common sequela after traumatic brain injury (TBI). Many of the impairments following TBI may be exacerbated by impaired sleep-wake cycle regulation. OBJECTIVES: To investigate the relationship between total sleep time (TST), measured by wrist actigraphy and observational sleep logs, and neurobehavioral impairments during inpatient rehabilitation after TBI. METHODS: Twenty-five subjects undergoing inpatient rehabilitation for traumatic brain injury were included. TST was measured using wrist actigraphy and observational sleep logs. Neurobehavioral impairments were assessed using the Neurobehavioral Rating Scale-Revised (NRS-R), a multidimensional clinician-based assessment. RESULTS: Of 25 subjects enrolled, 23 subjects completed the study. A significant negative correlation was found between total NRS-R and TST calculated by observational sleep logs (r = -0.28, p = 0.007). The association between total NRS-R and TST, as calculated by actigraphy, was not significantly correlated (R = -0.01, p = 0.921). CONCLUSIONS: Sleep disturbance during inpatient rehabilitation is associated with neurobehavioral impairments after TBI. TST measured by actigraphy may be limited by sleep detection algorithms that have not been validated in certain patient populations. Considerations should be made regarding the feasibility of using wearable sensors in patients with cognitive and behavioral impairments. Challenges regarding actigraphy for sleep monitoring in the brain injury population are discussed.

Causes and correlates of 30 day and 180 day readmission following discharge from a Medicine for the Elderly Rehabilitation unit.

BACKGROUND: Recently hospitalized patients experience a period of generalized risk of adverse health events. This study examined reasons for, and predictors of, readmission to acute care facilities within 30 and 180 days of discharge from an inpatient rehabilitation unit for older people. METHODS: Routinely collected, linked clinical data on admissions to a single inpatient rehabilitation facility over a 13-year period were analysed. Data were available regarding demographics, comorbid disease, admission and discharge Barthel scores, length of hospital stay, and number of medications on discharge. Discharge diagnoses for the index admission and readmissions were available from hospital episode statistics. Univariate and multivariate Cox regression analyses were performed to identify baseline factors that predicted 30 and 180-day readmission. RESULTS: A total of 3984 patients were included in the analysis. The cohort had a mean age of 84.1 years (SD 7.4), and 39.7% were male. Overall, 5.6% (n = 222) and 23.2% (n = 926) of the patients were readmitted within 30 days and 180 days of discharge respectively. For patients readmitted to hospital, 26.6% and 21.1% of patients were readmitted with the same condition as their initial admission at 30 days and 180 respectively. For patients readmitted within 30 days, 13.5% (n = 30) were readmitted with the same condition with the most common diagnoses associated with readmission being chest infection, falls/immobility and stroke. For patients readmitted within 180 days, 12.4% (n = 115) of patients were readmitted with the same condition as the index condition with the most common diagnoses associated with readmission being falls/immobility, cancer and chest infections. In multivariable Cox regression analyses, older age, male sex, length of stay and heart failure predicted 30 or 180-day readmission. In addition, discharge from hospital to patients own home predicted 30-day readmission, whereas diagnoses of cancer, previous myocardial infarction or chronic obstructive pulmonary disease predicted 180-day readmission. CONCLUSION: Most readmissions of older people after discharge from inpatient rehabilitation occurred for different reasons to the original hospital admission. Patterns of predictors for early and late readmission differed, suggesting the need for different mitigation strategies.

The effectiveness of inpatient rehabilitation after uncomplicated total hip arthroplasty: a propensity score matched cohort.

BACKGROUND: Inpatient rehabilitation is an expensive option following total hip arthroplasty (THA). We aimed to determine if THA patients who receive inpatient rehabilitation report better hip and quality of life scores post-surgery compared to those discharged directly home. METHODS: Prospective, propensity score matched cohort involving 12 private hospitals across five Australian States. Patients undergoing THA secondary to osteoarthritis were included. Those receiving inpatient rehabilitation for reasons other than choice or who experienced significant health events within 90-days post-surgery were excluded. Comparisons were made between those who did and did not receive inpatient rehabilitation for patient-reported hip pain and function (Oxford Hip Score, OHS) and 'today' health rating (EuroQol 0-100 scale). Rehabilitation provider charges were also estimated and compared. RESULTS: Two hundred forty-six patients (123 pairs, mean age 67 (10) yr., 66% female) were matched on 19 covariates for their propensity to receive inpatient rehabilitation. No statistically nor clinically significant between-group differences were observed [OHS median difference (IQR): 0 (- 3, 3), P = 0.60; 0 (- 1 to 1), P = 0.91, at 90 and 365-days, respectively; EuroQol scale median difference 0 (- 10, 12), P = 0.24; 0 (- 10, 10), P = 0.49; 5 (- 10, 15), P = 0.09, at 35-, 90- and 365-days, respectively]. Median rehabilitation provider charges were 10-fold higher for those who received inpatient rehabilitation [median difference $7582 (5649, 10,249), P <  0.001]. Sensitivity analyses corroborated the results of the primary analyses. CONCLUSION: Utilization of inpatient rehabilitation pathways following THA appears to be low value healthcare. Sustainability of inpatient rehabilitation models may be enhanced if inpatient rehabilitation is reserved for those most impaired or who have limited social supports. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01899443 .

Decannulation of tracheotomized patients after long-term mechanical ventilation - results of a prospective multicentric study in German neurological early rehabilitation hospitals.

BACKGROUND: In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation. METHODS: From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge. RESULTS: Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated. CONCLUSIONS: This study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.