Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research.

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Development of a 30-Day Readmission Risk Calculator for the Inpatient Rehabilitation Setting.

OBJECTIVES: Readmission to acute care from the inpatient rehabilitation facility (IRF) setting is potentially preventable and an important target of quality improvement and cost savings. The objective of this study was to develop a risk calculator to predict 30-day all-cause readmissions from the IRF setting. DESIGN: Retrospective database analysis using the Uniform Data System for Medical Rehabilitation (UDSMR) from 2015 through 2019. SETTING AND PARTICIPANTS: In total, 956 US inpatient rehabilitation facilities and 1,849,768 IRF discharges comprising patients from 14 impairment groups. METHODS: Logistic regression models were developed to calculate risk-standardized 30-day all-cause hospital readmission rates for patients admitted to an IRF. Models for each impairment group were assessed using 12 common clinical and demographic variables and all but 4 models included various special variables. Models were assessed for discrimination (c-statistics), calibration (calibration plots), and internal validation (bootstrapping). A readmission risk scoring system was created for each impairment group population and was graphically validated. RESULTS: The mean age of the cohort was 68.7 (15.2) years, 50.7% were women, and 78.3% were Caucasian. Medicare was the primary payer for 73.1% of the study population. The final models for each impairment group included between 4 and 13 total predictor variables. Model c-statistics ranged from 0.65 to 0.70. There was good calibration represented for most models up to a readmission risk of 30%. Internal validation of the models using bootstrap samples revealed little bias. Point systems for determining risk of 30-day readmission were developed for each impairment group. CONCLUSIONS AND IMPLICATIONS: Multivariable risk factor algorithms based upon administrative data were developed to assess 30-day readmission risk for patients admitted from IRF. This report represents the development of a readmission risk calculator for the IRF setting, which could be instrumental in identifying high risk populations for readmission and targeting resources towards a diverse group of IRF impairment groups.

For-Profit and Not-for-Profit Inpatient Rehabilitation in Traumatic Brain Injury: Analysis of Demographics and Outcomes.

OBJECTIVE: To describe differences in characteristics and outcomes of patients with traumatic brain injury by inpatient rehabilitation facility (IRF) profit status. DESIGN: Retrospective database review using the Uniform Data System for Medical Rehabilitation. SETTING: IRFs. PARTICIPANTS: Individual discharges (N=53,630) from 877 distinct rehabilitation facilities for calendar years 2016 through 2018. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Patient demographic data (age, race, primary payer source), admission and discharge FIM, FIM gain, length of stay efficiency, acute hospital readmission from for-profit and not-for-profit IRFs within 30 days, and community discharges by facility profit status. RESULTS: Patients at for-profit facilities were significantly older (69.69 vs 64.12 years), with lower admission FIM scores (52 vs 57), shorter lengths of stay (13 vs 15 days), and higher discharge FIM scores (88 vs 86); for-profit facilities had higher rates of community discharges (76.8% vs 74.6%) but also had higher rates of readmission (10.3% vs 9.9%). CONCLUSIONS: The finding that for-profit facilities admit older patients who are reportedly less functional on admission and more functional on discharge, with higher rates of community discharge but higher readmission rates than not-for-profit facilities is an unexpected and potentially anomalous finding. In general, older, less functional patients who stay for shorter periods of time would not necessarily be expected to make greater functional gains. These differences should be further studied to determine if differences in patient selection, coding and/or billing, or other unreported factors underlie these differences.

Variation in 30-Day Readmission Rates from Inpatient Rehabilitation Facilities to Acute Care Hospitals.

OBJECTIVES: To quantify the rate of readmission from inpatient rehabilitation facilities (IRFs) to acute care hospitals (ACHs) during the first 30 days of rehabilitation stay. To measure variation in 30-day readmission rate across IRFs, and the extent that patient and facility characteristics contribute to this variation. DESIGN: Retrospective analysis of an administrative database. SETTING AND PARTICIPANTS: Adult IRF discharges from 944 US IRFs captured in the Uniform Data System for Medical Rehabilitation database between October 1, 2015 and December 31, 2017. METHODS: Multilevel logistic regression was used to calculate adjusted rates of readmission within 30 days of IRF admission and examine variation in IRF readmission rates, using patient and facility-level variables as predictors. RESULTS: There were a total of 104,303 ACH readmissions out of a total of 1,102,785 IRFs discharges. The range of 30-day readmission rates to ACHs was 0.0%‒28.9% (mean = 8.7%, standard deviation = 4.4%). The adjusted readmission rate variation narrowed to 2.8%‒17.5% (mean = 8.7%, standard deviation = 1.8%). Twelve patient-level and 3 facility-level factors were significantly associated with 30-day readmission from IRF to ACH. A total of 82.4% of the variance in 30-day readmission rate was attributable to the model predictors. CONCLUSIONS AND IMPLICATIONS: Fifteen patient and facility factors were significantly associated with 30-day readmission from IRF to ACH and explained the majority of readmission variance. Most of these factors are nonmodifiable from the IRF perspective. These findings highlight that adjusting for these factors is important when comparing readmission rates between IRFs.

Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population.

OBJECTIVE: To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities. MAIN OUTCOME MEASURES: International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated. RESULTS: Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes. CONCLUSION: Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.

Utility of Functional Metrics Assessed During Acute Care on Hospital Outcomes: A Systematic Review.

OBJECTIVE: Traditionally, illness severity, social factors, and comorbid conditions have been examined as predictors of hospital outcomes. However, recent research in the rehabilitation setting demonstrated that physical function outperformed comorbidity indices as a predictor of 30-day readmission. The purpose of this study was to review the literature examining the association between acute hospital physical function and various hospital outcomes and health care utilization. TYPE: Systematic review. LITERATURE SURVEY: A review of the MEDLINE database was performed. Search terms included acute functional outcomes and frailty outcomes. Studies up to September 2017 were included if they were in English and examined how functional metrics collected at acute care hospitalization affected hospital outcomes. METHODOLOGY: Cohort characteristics and measures of associations were extracted from the studies. Outcomes include hospital readmission, length of stay, mortality, discharge location, and physical function post acute care. The studies were assessed for potential confounders as well as selection, attrition, and detection bias. SYNTHESIS: A total of 30 studies were identified (hospital readmissions: 6; discharge location: 11; length of stay: 4; mortality: 15; function: 6). Thirteen different metrics assessed function during acute care. Lower function during acute care was associated with statistically significant higher odds of hospital readmission, lower likelihood of discharge to home, longer hospital length of stay, increased mortality, and worse functional recovery when compared to patients with higher function during acute care, when adjusted for age and gender. The Barthel Index may be a useful marker for mortality in the elderly whereas the Functional Independence Measure instrument may be valuable for examining discharge location. CONCLUSIONS: There is increasing evidence that function measured during acute care predicts a broad array of meaningful clinical outcomes. Further research would help direct the use of practical, yet parsimonious functional metrics that effectively screen high-need, high-cost patients to deliver optimal care. LEVEL OF EVIDENCE: I.

Women physicians underrepresented in American Academy of Neurology recognition awards.

OBJECTIVE: To investigate representation by gender among recipients of physician recognition awards presented by the American Academy of Neurology (AAN). METHODS: We analyzed lists of individual recipients over the 63-year history of the AAN recognition awards. Included were awards intended primarily for physician recipients that recognized a body of work over the course of a career. The primary outcome measures were total numbers and proportions of men and women physician award recipients. RESULTS: During the period studied, the proportion of women increased from 18% (1996) to 31.5% (2016) among AAN US neurologist members and from 18.6% (1992) to 35% (2015) in academia, and the AAN presented 323 awards to physician recipients. Of these recipients, 264 (81.7%) were men and 59 (18.3%) were women. During the most recent 10-year period studied (2008-2017), the proportion of women increased from 24.7% (2008) to 31.5% (2016) among AAN US neurologist members and from 28% (2009) to 35% (2015) in academia, and the AAN presented 187 awards to physician recipients, comprising 146 men (78.1%) and 41 women (21.9%). Although it has been more than 2 decades since the proportion of women among US neurologist members of the AAN was lower than 18%, 1 in 4 AAN award categories demonstrated 0% to 18% representation of women among physician recipients during the most recent decade. Moreover, for highly prestigious awards, underrepresentation was more pronounced. CONCLUSION: Although the reasons why are not clear, women were often underrepresented among individual physician recognition award recipient lists, particularly for highly prestigious awards.

Women Physicians Are Underrepresented in Recognition Awards From the Association of Academic Physiatrists.

OBJECTIVE: Determine representation by gender for individual recognition awards presented to physicians by the Association of Academic Physiatrists (AAP). DESIGN: Cross-sectional survey was used. Lists of individual recognition award recipients for the 27-yr history of the AAP awards (1990-2016) were analyzed. The primary outcome measures were the total numbers of men versus women physician award recipients overall and for the past decade (2007-2016). RESULTS: No awards were given to women physicians for the past 4 yrs (2013-2016) or in half of the award categories for the past decade (2007-2016). No woman received the outstanding resident/fellow award since its inception (2010-2016). There was a decrease in the proportion of awards given to women in the past decade (2007-2016, 7 of 39 awards, 17.9%) as compared with the first 17 yrs (1990-2006, 10 of 46 awards, 21.7%). Furthermore, compared with their proportional membership within the specialty, women physicians were underrepresented for the entire 27-yr history of the AAP awards (1990-2016, 17 of 85 awards, 20%). According to the Association of American Medical Colleges, the proportion of full-time female physical medicine and rehabilitation faculty members was 38% in 1992 and 41% in 2013. CONCLUSIONS: Women physicians have been underrepresented by the AAP in recognition awards. Although the reasons are not clear, these findings should be further investigated.

Where Are the Women? The Underrepresentation of Women Physicians Among Recognition Award Recipients From Medical Specialty Societies.

Membership in medical societies is associated with a number of benefits to members that may include professional education, opportunities to present research, scientific and/or leadership training, networking, and others. In this perspective article, the authors address the value that medical specialty society membership and inclusion have in the development of an academic physician's career and how underrepresentation of women may pose barriers to their career advancement. Because society membership itself is not likely sufficient to support the advancement of academic physicians, this report focuses on one key component of advancement that also can be used as a measure of inclusion in society activities-the representation of women physicians among recipients of recognition awards. Previous reports demonstrated underrepresentation of women physicians among recognition award recipients from 2 physical medicine and rehabilitation specialty organizations, including examples of zero or near-zero results. This report investigated whether zero or near-zero representation of women physicians among recognition award recipients from medical specialty societies extended beyond the field of physical medicine and rehabilitation. Examples of the underrepresentation of women physicians, as compared with their presence in the respective field, was found across a range of additional specialties, including dermatology, neurology, anesthesiology, orthopedic surgery, head and neck surgery, and plastic surgery. The authors propose a call for action across the entire spectrum of medical specialty societies to: (1) examine gender diversity and inclusion data through the lens of the organization's mission, values, and culture; (2) transparently report the results to members and other stakeholders including medical schools and academic medical centers; (3) investigate potential causes of less than proportionate representation of women; (4) implement strategies designed to improve inclusion; (5) track outcomes as a means to measure progress and inform future strategies; and (6) publish the results to engage community members in conversation about the equitable representation of women.

Female Physicians Are Underrepresented in Recognition Awards from the American Academy of Physical Medicine and Rehabilitation.

BACKGROUND: Medical specialty societies are important resources for physicians in advancing their careers. There is a gap in the literature regarding gender disparities within these societies. This study assesses one area where disparities may exist: recognition awards. OBJECTIVE: To determine whether female physicians are underrepresented among recognition award recipients by the American Academy of Physical Medicine and Rehabilitation (AAPM&R). DESIGN: Surveillance study. SETTING AND METHODS: A published online list of national award recipients from the AAPM&R was analyzed. Forty-eight years of data were included, as the list contained all major recognition award recipients from 1968 to 2015. All awards that were given exclusively to physicians were included. There were eight award categories listed online; seven met this criterion, with a total of 264 individual awards presented. One award category was excluded because it focused on distinguished public service and included both physician and nonphysician (eg, public official) recipients. Awards that were not published online were also excluded. MAIN OUTCOME MEASURES: Total awards given to female versus male physicians from 1968 to 2015, with awards given over the past decade (2006-2015) assessed independently. Lectureships were also analyzed as a set. For awards given to groups of physician recipients, analysis included gender composition of the group (eg, male only versus female only versus mixed-gender physician groups). To assess the proportion of female versus male physiatrists over time, physician gender and specialty data from 3 sources were used: the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), and the AAPM&R. RESULTS: Over the past 48 years, the AAPM&R presented 264 recognition awards to physicians. Award recipients were overwhelmingly male (n = 222; 84.1%). Females received 15.9% (n = 42) of the total awards, although there was an upward trend in female physician recipients to 26.8% (n = 26) from 2006 to 2015. Lectureships were given to 8 female physicians (n = 8 of 77, 10.4%). These results were lower than the proportion of female physicians in the field of physiatry (35% in 2013). Female physicians were more likely to receive awards if they were part of a group and less likely to be recognized if the award was given to only 1 recipient each year or involved a lectureship with a speaking opportunity at a national meeting. CONCLUSIONS: To our knowledge, this is the first study in medicine to assess whether female physicians are underrepresented among recipients of recognition awards presented by a national medical society. For nearly half a century, female physicians have been underrepresented in awards presented by the AAPM&R. Although it is encouraging that the proportion of female physicians receiving awards is increasing, further research is needed to understand why underrepresentation remains. LEVEL OF EVIDENCE: Not applicable.

Assessing the ability of comorbidity indexes to capture comorbid disease in the inpatient rehabilitation burn injury population.

OBJECTIVE: Burn patients exhibit comorbidities that influence outcomes. This study examines whether existing comorbidity measures capture comorbidities in the burn inpatient rehabilitation population. DESIGN: Data were obtained from the Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury. International Classification of Diseases, 9th Revision, codes were used to assess three comorbidity measures (Charlson Comorbidity Index, Elixhauser Comorbidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers). The number of subjects and unique comorbidity codes (>1% of frequency) captured by each comorbidity measure was calculated. RESULTS: The study included 5347 patients with a median total body surface area burn decile of 20%-29%, mean age of 51.6 yrs, and mean number of comorbidities of 7.6. There were 2809 unique International Classification of Diseases, 9th Revision, comorbidity codes. The Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Centers for Medicare and Medicaid Services Comorbidity Tiers did not capture 67%, 27%, and 58% of the subjects, respectively. There were 107 unique comorbidities that occurred with a frequency of greater than 1%. Of these, 67% were not captured in all three comorbidity measures. CONCLUSIONS: Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the burn rehabilitation population. Future work is needed to assess the need for comorbidity indexes specific to the inpatient rehabilitation setting.