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1.
Artículo en Inglés | MEDLINE | ID: mdl-35007549

RESUMEN

OBJECTIVE: To investigate whether a direct measure of need for PT, mobility status, was associated with acute care PT utilization and whether this relationship differs across sociodemographic factors and insurance type. DESIGN: In a secondary analysis of electronic health records data, we estimated logistic regression models to determine whether mobility status was associated with acute care PT utilization. Interactions between mobility and both sociodemographic factors (sex; age; significant other; minority status) and insurance type were included to investigate whether the relationship between mobility and PT utilization varied across patient characteristics. SETTING: Five regional hospitals from one health system. PARTICIPANTS: 60,459 adults admitted between 2014 and 2018 who received a PT evaluation. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Received acute care PT; Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measure of mobility. RESULTS: Half of patients who received a PT evaluation received subsequent treatment. Patients with mobility limitations were more likely to receive PT. Interaction terms indicated that among patients with mobility limitations, those who 1) were younger; 2) had significant others; and 3) had private insurance (vs. public) were more likely to receive PT. Among patients with greater mobility status, older patients and those without a significant other were more likely to receive PT. CONCLUSIONS: The relationship between acute care PT need and utilization differed across sociodemographic factors and insurance type. We offer potential explanations for these findings to guide studies targeting equitable distribution of beneficial PT services.

2.
Ann Phys Rehabil Med ; 65(1): 101503, 2022 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33667720

RESUMEN

BACKGROUND: Relying solely on null hypothesis significance testing to investigate rehabilitation interventions may result in researchers erroneously concluding the presence of a treatment effect. OBJECTIVE: We sought to quantify the strength of evidence in favour of rehabilitation treatment effects by calculating Bayes factors (BF10s) for significant findings. Additionally, we sought to examine associations between BF10s, P-values, and Cohen's d effect sizes. METHODS: We searched the Cochrane Database of Systematic Reviews for meta-analyses with "rehabilitation" as a keyword that evaluated a rehabilitation intervention. We extracted means, standard deviations, and sample sizes for treatment and comparison groups from individual findings within 175 meta-analyses. Investigators independently classified the interventions according to the Rehabilitation Treatment Specification System. We calculated t-statistics, P-values, effect sizes, and BF10s for each finding. We isolated statistically significant findings (P≤0.05); applied evidential categories to BF10s, P-values, and effect sizes; and examined relationships descriptively. RESULTS: We analysed 1935 rehabilitation findings. Across intervention types, 25% of significant findings offered only anecdotal evidence in favour of a treatment effect; only 48% indicated strong evidence. This pattern persisted within intervention types and when conducting robustness analyses. Smaller P-values and larger effect sizes were associated with stronger evidence in favour of a treatment effect. However, a notable portion of findings with P-value 0.01 to 0.05 (63%) or a large effect size (18%) offered anecdotal evidence in favour of an effect. CONCLUSIONS: For a substantial portion of statistically significant rehabilitation findings, the data neither support nor refute the presence of a treatment effect. This was the case among a notable portion of large treatment effects and for most findings with P-value>0.01. Rehabilitation evidence would be improved by researchers adopting more conservative levels of significance, complementing the use of null hypothesis significance testing with Bayesian techniques and reporting effect sizes.


Asunto(s)
Proyectos de Investigación , Teorema de Bayes , Humanos , Revisiones Sistemáticas como Asunto
3.
Am J Occup Ther ; 76(1)2022 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-34964838

RESUMEN

IMPORTANCE: Hospital readmissions are associated with poor patient outcomes, including higher risk for mortality, nutritional concerns, deconditioning, and higher costs. OBJECTIVE: To evaluate how acute occupational therapy service delivery factors affect readmission risk. DESIGN: Cross-sectional, retrospective study. SETTING: Single academic medical center. PARTICIPANTS: Medicare inpatients with a diagnosis included in the Hospital Readmissions Reduction Program (HRRP; N = 17,618). Data were collected from medical records at a large urban hospital in southeastern Wisconsin. Outcomes and Measures: Logistic regression models were estimated to examine the association between acute occupational therapy service delivery factors and odds of readmission. In addition, the types of acute occupational therapy services for readmitted versus not-readmitted patients were compared. RESULTS: Patients had significantly higher odds of readmission if they received occupational therapy services while hospitalized (odds ratio [OR] = 1.18, 95% confidence interval [CI] [1.07, 1.31]). However, patshients who received acute occupational therapy services had significantly lower odds of readmission if they received a higher frequency (OR = 0.99, 95% CI [0.99,1.00]) of acute occupational therapy services. A significantly higher proportion of patients who were not readmitted, compared with patients who were readmitted, received activities of daily living (ADL) or self-care training (p < .01). CONCLUSIONS AND RELEVANCE: For patients with HRRP-qualifying diagnoses who received acute occupational therapy services, higher frequency of acute occupational therapy services was linked with lower odds of readmission. Readmitted patients were less likely to have received ADL or self-care training while hospitalized. What This Article Adds: Identifying factors of acute occupational therapy services that reduce the odds of readmission for Medicare patients may help to improve patient outcomes and further define occupational therapy's role in the U.S. quality-focused health care system.


Asunto(s)
Terapia Ocupacional , Readmisión del Paciente , Actividades Cotidianas , Anciano , Estudios Transversales , Humanos , Medicare , Estudios Retrospectivos , Estados Unidos
4.
Am J Occup Ther ; 76(1)2022 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-34964839

RESUMEN

IMPORTANCE: Readmissions are costly for Medicare and are associated with poor patient outcomes. OBJECTIVE: To determine whether two domains relevant to acute occupational therapy practice-self-care status and social factors-were associated with readmissions for Medicare patients in the Medicare Hospital Readmissions Reduction Program (HRRP). DESIGN: Cross-sectional, retrospective study. SETTING: Single academic medical center. PARTICIPANTS: Medicare inpatients with a diagnosis included in the HRRP (N = 17,618). Outcomes and Measures: Three logistic regression models were estimated to examine the associations among (1) self-care status and 30-day readmission, (2) social support and 30-day readmission, and (3) housing situation and 30-day readmission. Subgroup analyses were conducted for the individual HRRP diagnoses. RESULTS: No associations were found between acute self-care status, social support, or housing situation and 30-day readmission when all HRRP diagnoses were examined together. However, higher levels of independence with self-care were significantly associated with reduced odds of readmission for patients with pneumonia. CONCLUSIONS AND RELEVANCE: The findings for patients with pneumonia are consistent with those of other studies done in the acute care setting. Deficiencies in acute occupational therapy documentation may have affected the findings for the other HRRP diagnoses. What This Article Adds: This study is the first to examine the association between acute self-care status (as documented by acute care occupational therapy practitioners) and readmission.


Asunto(s)
Pacientes Internos , Readmisión del Paciente , Anciano , Estudios Transversales , Humanos , Medicare , Estudios Retrospectivos , Autocuidado , Factores Sociales , Estados Unidos
5.
Behav Neurol ; 2021: 3010555, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34804258

RESUMEN

BACKGROUND: Structural integrity of the ipsilesional corticospinal tract (CST) is important for upper limb motor recovery after stroke. However, additional neuromechanisms associated with motor function poststroke are less well understood, especially regarding the lower limb. OBJECTIVE: To investigate the neural basis of upper/lower limb motor deficits poststroke by correlating measures of motor function with diffusion tensor imaging-derived indices of white matter integrity (fractional anisotropy (FA), mean diffusivity (MD)) in primary and secondary motor tracts/structures. METHODS: Forty-three individuals with chronic stroke (time poststroke, 64.4 ± 58.8 months) underwent a comprehensive motor assessment and MRI scanning. Correlation and multiple regression analyses were performed to examine relationships between FA/MD in a priori motor tracts/structures and motor function. RESULTS: FA in the ipsilesional CST and red nucleus (RN) was positively correlated with motor function of both the affected upper and lower limb (r = 0.36-0.55, p ≤ 0.01), while only ipsilesional RN FA was associated with gait speed (r = 0.50). Ipsilesional CST FA explained 37.3% of the variance in grip strength (p < 0.001) and 31.5% of the variance in Arm Motricity Index (p = 0.004). Measures of MD were not predictors of motor performance. CONCLUSIONS: Microstructural integrity of the ipsilesional CST is associated with both upper and lower limb motor function poststroke, but appears less important for gait speed. Integrity of the ipsilesional RN was also associated with motor performance, suggesting increased contributions from secondary motor areas may play a role in supporting chronic motor function and could become a target for interventions.


Asunto(s)
Tractos Piramidales , Accidente Cerebrovascular , Estudios Transversales , Imagen de Difusión Tensora , Humanos , Extremidad Inferior/diagnóstico por imagen , Imagen por Resonancia Magnética , Tractos Piramidales/diagnóstico por imagen , Núcleo Rojo/diagnóstico por imagen , Accidente Cerebrovascular/diagnóstico por imagen
6.
Ann Phys Rehabil Med ; 64(4): 101425, 2021 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-32805456

RESUMEN

BACKGROUND: Relying solely on null hypothesis significance testing (NHST) to investigate rehabilitation interventions may result in researchers erroneously concluding the absence of a treatment effect. OBJECTIVE: We aimed to distinguish between truly null treatment effects and data that are insensitive to detecting treatment effects by calculating Bayes factors (BF01s) for non-significant findings in the rehabilitation literature. Additionally, to examine associations between BF01, sample size, and observed P-values. METHOD: We searched the Cochrane Database of Systematic Reviews for meta-analyses with "rehabilitation" as a keyword that clearly evaluated a rehabilitation intervention. We extracted means, standard deviations, and sample sizes for treatment and comparison groups for individual findings within 175 meta-analyses. Two independent investigators classified the interventions into 4 categories using the Rehabilitation Treatment Specification System. We calculated t-statistics and associated P-values for each finding in order to extract non-significant results (P>0.05). We calculated BF01s for 5790 non-significant results and classified BF01s based on the strength of evidence in favour of the null hypothesis (i.e., anecdotal, moderate, and strong) across and within intervention types. We examined correlations between BF01, sample size, and P-values across and within intervention types. RESULTS: Across all intervention types, most (71.9%) findings were deemed anecdotal, and this pattern remained within distinct intervention types (58.4-76.0%). Larger sample sizes tended to be associated with greater strength in favour of the null hypothesis, both across and within intervention types. Larger P-values were not associated with greater strength in favour of the null hypothesis; this finding was present both across and within intervention types. CONCLUSION: Our findings indicate that most non-significant rehabilitation findings are unable to distinguish between the true absence of a treatment effect and data that are merely insensitive to detecting a treatment effect. Findings also suggest that rehabilitation researchers may improve the strength of their statistical conclusions by increasing sample size and that Bayes factors may offer unique benefits relative to P-values.


Asunto(s)
Rehabilitación , Proyectos de Investigación , Teorema de Bayes , Humanos , Metaanálisis como Asunto , Revisiones Sistemáticas como Asunto
7.
J Allied Health ; 49(4): 279-284, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33259574

RESUMEN

BACKGROUND: Admission committees have the difficult task of selecting candidates with the greatest likelihood of success for their programs and the profession. Because of limitations in defining the successful candidate, we attempted to predict who will become a "student with perceived difficulty" within a doctor of physical therapy (DPT) program using data available during the time of application. METHODS: A retrospective analysis of 479 students from three entry-level DPT programs. The dependent variable was student with perceived difficulty status. Student characteristics were compared using unpaired t-tests (or non-parametric equivalent) and chi-squared tests. Receiver operating characteristic curves were constructed for variables significantly associated with student status to compare the predictive capabilities of the student characteristics and identify cutpoints that maximized sensitivity and specificity. We examined the predictive capabilities of clusters of characteristics that differed significantly between groups by calculating likelihood ratios and estimating odds ratios from logistic regression. RESULTS: The cluster of characteristics that best identified students with perceived difficulty was prerequisite GPA <3.7, Analytical Writing GRE <4, and attended >2 undergraduate institutions. Twenty students met these criteria and 8 (40%) were identified as students with perceived difficulty. The positive likelihood ratio for this cluster of characteristics was 6.9 and the odds ratio was 8.7 (95% CI: 3.2, 23.0). CONCLUSIONS: These results suggest that this cluster of variables, available at the time of admission, can be used to identify students whose progress in the program may need to be more closely monitored and who may benefit from additional services to minimize difficulties for the student and faculty.


Asunto(s)
Criterios de Admisión Escolar , Estudiantes , Demografía , Humanos , Modalidades de Fisioterapia , Estudios Retrospectivos
8.
BMC Musculoskelet Disord ; 21(1): 776, 2020 Nov 25.
Artículo en Inglés | MEDLINE | ID: mdl-33238964

RESUMEN

BACKGROUND: Although risk-stratifying patients with acute lower back pain is a promising approach for improving long-term outcomes, efforts to implement stratified care in the US healthcare system have had limited success. The objectives of this process evaluation were to 1) examine variation in two essential processes, risk stratification of patients with low back pain and referral of high-risk patients to psychologically informed physical therapy and 2) identify barriers and facilitators related to the risk stratification and referral processes. METHODS: We used a sequential mixed methods study design to evaluate implementation of stratified care at 33 primary care clinics (17 intervention, 16 control) participating in a larger pragmatic trial. We used electronic health record data to calculate: 1) clinic-level risk stratification rates (proportion of patients with back pain seen in the clinic over the study period who completed risk stratification questionnaires), 2) rates of risk stratification across different points in the clinical workflow (front desk, rooming, and time with clinician), and 3) rates of referral of high-risk patients to psychologically informed physical therapy among intervention clinics. We purposively sampled 13 clinics for onsite observations, which occurred in month 24 of the 26-month study. RESULTS: The overall risk stratification rate across the 33 clinics was 37.8% (range: 14.7-64.7%). Rates were highest when patients were identified as having back pain by front desk staff (overall: 91.9%, range: 80.6-100%). Rates decreased as the patient moved further into the visit (rooming, 29.3% [range: 0-83.3%]; and time with clinician, 11.3% [range: 0-49.3%]. The overall rate of referrals of high-risk patients to psychologically informed physical therapy across the 17 intervention clinics was 42.1% (range: 8.3-70.8%). Barriers included staffs' knowledge and beliefs about the intervention, patients' needs, technology issues, lack of physician engagement, and lack of time. Adaptability of the processes was a facilitator. CONCLUSIONS: Adherence to key stratified care processes varied across primary care clinics and across points in the workflow. The observed variation suggests room for improvement. Future research is needed to build on this work and more rigorously test strategies for implementing stratified care for patients with low back pain in the US healthcare system. TRIAL REGISTRATION: Trial registration: ClinicalTrials.gov ( NCT02647658 ). Registered January 6, 2016.


Asunto(s)
Dolor Agudo , Dolor de la Región Lumbar , Dolor de Espalda , Humanos , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/epidemiología , Dolor de la Región Lumbar/terapia , Modalidades de Fisioterapia , Atención Primaria de Salud
9.
J Bone Joint Surg Am ; 102(24): 2157-2165, 2020 Dec 16.
Artículo en Inglés | MEDLINE | ID: mdl-33093299

RESUMEN

BACKGROUND: In an effort to improve quality and reduce costs, reimbursement for total knee arthroplasty (TKA) and total hip arthroplasty (THA) in the United States is being based on the value of care provided, with adjustments for some qualifying comorbidities, including diabetes in its most severe form and excluding many diabetes codes. The aims of this study were to examine the effects of diabetes on elective TKA or THA complications and readmission risks among Medicare beneficiaries. METHODS: Complication (n = 521,230) and readmission (n = 515,691) data were extracted from Medicare files in 2013 and 2014. Diabetes status (no diabetes, controlled-uncomplicated diabetes, controlled-complicated diabetes, and uncontrolled diabetes) was identified with ICD-9 (International Classification of Diseases, 9th Revision) codes. TKA or THA complications and readmission odds based on diabetes status were estimated using logistic regression and adjusted for sociodemographic and clinical characteristics, including comorbidities. RESULTS: Compared with no diabetes, the odds ratio (OR) of TKA complications was significantly higher for uncontrolled diabetes (1.29, 95% confidence interval [CI] = 1.06 to 1.57). The OR of THA complications was significantly higher for controlled-complicated diabetes (1.45, 95% CI = 1.17 to 1.80). The OR of readmission was significantly higher for all diabetes groups (1.21 to 1.48 for TKA, 1.20 to 1.70 for THA). CONCLUSIONS: Readmission odds were higher in all diabetes categories. The uncontrolled-diabetes group had the greatest TKA readmission and complication odds. The controlled-complicated diabetes group had the greatest THA readmission and complication odds. The findings suggest that including diabetes and associated systemic complications in cost adjustments in alternative payment models for arthroplasty should be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.


Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Complicaciones de la Diabetes/epidemiología , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Medicare/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Factores de Riesgo , Estados Unidos
10.
Phys Ther ; 100(8): 1278-1288, 2020 08 12.
Artículo en Inglés | MEDLINE | ID: mdl-32372072

RESUMEN

OBJECTIVE: The purpose of this study was to describe the process and cost of delivering a physical therapist-guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline. METHODS: Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant. RESULTS: A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the "value proposition" of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved. CONCLUSIONS: The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a "blue print" for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine. IMPACT: As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study's experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.


Asunto(s)
Infecciones por Coronavirus , Personas con Discapacidad/rehabilitación , Terapia por Ejercicio/economía , Servicios de Atención de Salud a Domicilio/economía , Pandemias , Modalidades de Fisioterapia/economía , Neumonía Viral , Telemedicina/economía , Actividades Cotidianas , Anciano , COVID-19 , Dolor Crónico/terapia , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Proyectos Piloto , Telemedicina/métodos
11.
Arch Phys Med Rehabil ; 101(6): 1009-1016, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32035139

RESUMEN

OBJECTIVE: The purpose of this study was to determine the association between mobility, self-care, cognition, and caregiver support and 30-day potentially preventable readmissions (PPR) for individuals with dementia. DESIGN: This retrospective study derived data from 100% national Centers for Medicare and Medicaid Services data files from July 1, 2013, through June 1, 2015. PARTICIPANTS: Criteria from the Home Health Claims-Based Rehospitalization Measure and the Potentially Preventable 30-Day Post Discharge Readmission Measure for the Home Health Quality Reporting Program were used to identify a cohort of 118,171 Medicare beneficiaries. MAIN OUTCOME MEASURE: The 30-day PPR rates with associated 95% CIs were calculated for each patient characteristic. Multilevel logistic regression was used to study the relationship between mobility, self-care, caregiver support, and cognition domains and 30-day PPR during home health, adjusting for patient demographics and clinical characteristics. RESULTS: The overall rate of 30-day PPR was 7.6%. In the fully adjusted models, patients who were most dependent in mobility (odds ratio [OR], 1.59; 95% CI, 1.47-1.71) and self-care (OR, 1.73; 95% CI, 1.61-1.87) had higher odds for 30-day PPR. Patients with unmet caregiving needs had 1.11 (95% CI, 1.05-1.17) higher odds for 30-day PPR than patients whose caregiving needs were met. Patients with cognitive impairment had 1.23 (95% CI, 1.16-1.30) higher odds of readmission than those with minimal to no cognitive impairment. CONCLUSIONS: Decreased independence in mobility and self-care tasks, unmet caregiver needs, and impaired cognitive processing at admission to home health are associated with risk of 30-day PPR during home health for individuals with dementia. Our findings indicate that deficits in mobility and self-care tasks have the greatest effect on the risk for PPR.


Asunto(s)
Cuidadores/psicología , Demencia/enfermería , Servicios de Atención de Salud a Domicilio , Readmisión del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Medicare , Estudios Retrospectivos , Estados Unidos
12.
J Am Med Dir Assoc ; 21(4): 519-524.e3, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-31734120

RESUMEN

OBJECTIVES: Approximately 14% of Medicare beneficiaries are readmitted to a hospital within 30 days of home health care admission. Individuals with dementia account for 30% of all home health care admissions and are at high risk for readmission. Our primary objective was to determine the association between dementia severity at admission to home health care and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity scale from Outcome and Assessment Information Set (OASIS) items based on the Functional Assessment Staging Tool (FAST). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Home health care; 126,292 Medicare beneficiaries receiving home health care (July 1, 2013-June 1, 2015) diagnosed with dementia (ICD-9 codes). MEASURES: 30-day PPR during home health care. Dementia severity categorized into 6 levels (nonaffected to severe). RESULTS: The overall rate of 30-day PPR was 7.6% [95% confidence interval (CI) 7.4, 7.7] but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratio (OR) for dementia severity category 6 was 1.37 (95% CI 1.29, 1.46) and the OR for category 7 was 1.94 (95% CI 1.64, 2.31) as compared to dementia severity category 1/2. CONCLUSIONS AND IMPLICATIONS: Dementia severity in the later stages is associated with increased risk for potentially preventable readmissions. Our findings suggest that individuals admitted to home health during the later stages of Alzheimer's disease and related dementias may require greater supports and specialized care to minimize negative outcomes such as readmissions. Development of a dementia severity scale based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing potentially preventable readmissions of individuals with severe dementia who receive home health care. Future research is also needed to validate the proposed dementia severity categories used in this study.


Asunto(s)
Demencia , Servicios de Atención de Salud a Domicilio , Anciano , Demencia/epidemiología , Humanos , Medicare , Readmisión del Paciente , Estudios Retrospectivos , Estados Unidos
13.
Top Stroke Rehabil ; 27(2): 118-126, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31622172

RESUMEN

Background and Purpose: Persons with stroke have increased risk for recurrent stroke. Group exercise programs like cardiac rehabilitation might reduce this risk. These programs commonly use the six-minute walk test to measure aerobic capacity. However, failure to assess fall risk may compromise safety for persons with stroke. The study aim was to determine the association between the six-minute walk test and fall risk in persons with stroke.Methods: Cross-sectional analysis measured the association between the six-minute walk test and fall risk in 66 persons with stroke with a mean age of 66 years (SD 12) and median stroke chronicity of 60.9 months (range 6.0-272.1). The six-minute walk test was evaluated using logistic regression. The best fit model was used in Receiver Operating Characteristic analysis. Likelihood ratios and post-test probabilities were calculated.Results: Lower six-minute walk test distance was associated with increased fall risk in logistic regression (p = .002). The area under the curve for the univariate six-minute walk test model (best fit) was 0.701 (p = .006). The cutoff for increased fall risk was six-minute walk test <331.65 m. The post-test probability of fall risk increased to 74.3% from a pre-test probability of 59.1%.Discussion: The moderate association between fall risk and six-minute walk test suggests that in addition to assessing capacity, the six-minute walk test provides insight into fall risk/balance confidence.Conclusion: Using the six-minute walk test cutoff to screen fall risk in community exercise programs may enhance safety for persons with stroke without additional testing required.


Asunto(s)
Accidentes por Caídas , Rehabilitación de Accidente Cerebrovascular/métodos , Accidente Cerebrovascular/fisiopatología , Prueba de Paso , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Modelos Logísticos , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Equilibrio Postural , Valor Predictivo de las Pruebas , Curva ROC , Medición de Riesgo , Accidente Cerebrovascular/complicaciones
14.
Arch Rehabil Res Clin Transl ; 2(2): 100052, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-33543079

RESUMEN

OBJECTIVE: The objective of this study was to determine the feasibility of a rehabilitation approach focusing on cardiovascular, strength, and gait training intensity in the inpatient rehabilitation setting after a new onset of stroke. We additionally aimed to determine the efficacy of this intensity-based program on rehabilitation outcomes compared with usual care. DESIGN: Participants were pseudo-randomized to an intensity-based program focusing on gait, cardiovascular, and strength training or to usual care. Outcomes included FIM, 10-meter walk, 2-minute walk, timed Up and Go test, 5-time sit-to-stand test, and Tinetti balance assessment. INTERVENTION: The intervention consisted of 6 20-minute sessions per week dedicated to intensity of activity: 2 each for walking, cardiovascular training, and strength training. PARTICIPANTS: Patients (N=49) with new onset stroke admitted to inpatient rehabilitation over the course of 1 year. SETTING: Four inpatient rehabilitation facilities with comprehensive neurologic rehabilitation teams. RESULTS: Thirty-five individuals (16 intervention, 19 controls) completed all testing. Subject compliance to the intensity intervention demonstrated completion of approximately half the prescribed sessions. All outcomes improved significantly from admission to discharge, and a significant interaction between treatment group and time was observed for the 2-minute walk and the Tinetti balance assessment. The 2-minute walk, Tinetti balance assessment, 10-meter walk, and FIM demonstrated between-group effect sizes greater than 0.60 in favor of the intervention group. CONCLUSIONS: The intensity-based protocol was safe, and several measures demonstrated efficacy when compared with usual care. Results may have been limited by poor program compliance, showing a need to identify and ameliorate obstacles to integration of comprehensive intensity-based programs addressing endurance, strength, and gait training. Applying physiological principles of exercise to acute stroke rehabilitation demonstrates great promise for improving independent physical function.

15.
J Allied Health ; 48(4): e113-e116, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31800665

RESUMEN

Physical therapists (PTs) routinely participate in continuing education (CE) courses with the goal of increasing their knowledge and skills in order to improve quality of care and ultimately patient outcomes. Little has been done to investigate the effect that CE courses have on PT practice. This study assessed whether a CE course series that included review sessions, between-course assignments, and a practical and written examination changed clinician 1) attitudes (i.e., comfort and confidence in working with patients with spinal dysfunctions) and 2) behaviors (i.e., utilization of outcome measures). PTs (n=24) employed by the same hospital system and who enrolled in a CE course series were administered anonymous and voluntary pre-course (n=14) and post-course surveys (n=14). Data on the PTs' use of standardized outcomes for 6 months prior to and after the course series were collected. The number of PTs tracking outcomes went from 6 to 19 of the 24 PTs in the course series, and 14 of the 24 PTs had an overall increase in their comfort and confidence. This pilot study demonstrated a change in clinician behaviors and self-perceived attitudes after a course series that included review sessions, assignments, and examinations.


Asunto(s)
Modalidades de Fisioterapia/educación , Especialidad de Fisioterapia/educación , Curriculum , Humanos , Proyectos Piloto , Factores de Tiempo
16.
JAMA Netw Open ; 2(12): e1917559, 2019 12 02.
Artículo en Inglés | MEDLINE | ID: mdl-31834398

RESUMEN

Importance: The Improving Medicare Post-Acute Care Transformation Act of 2014 mandated a quality measure of potentially preventable 30-day hospital readmission for inpatient rehabilitation facilities (IRFs). Examining IRF performance nationally may help inform health care quality initiatives for Medicare beneficiaries. Objective: To examine variation in Centers for Medicare & Medicaid Services Quality Reporting Program measures for US facility-level risk-adjusted all-cause and potentially preventable hospital readmission rates after inpatient rehabilitation. Design, Setting, and Participants: This cohort study of Medicare claims data included 454 378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. Data were analyzed March 23, 2018, through June 24, 2019. Main Outcomes and Measures: All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities and the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation. Specifications from the Centers for Medicare & Medicaid Services were followed to identify the cohort, define outcomes, and calculate risk-standardized facility-level rates. Results: Among a cohort of 454 378 patients, the mean (SD) age was 76.2 (10.6) years and 263 546 (58.0%) were women. The all-cause readmission rate was 12.3% (95% CI, 12.2%-12.4%), and the potentially preventable readmission rate was 5.3% (95% CI, 5.3%-5.4%). Across 1162 included IRFs, risk-standardized all-cause readmission rates ranged from 10.1% (95% CI, 8.9%-11.6%) to 15.9% (95% CI, 13.6-18.6%) and potentially preventable readmission rates ranged from 4.3% (95% CI, 3.7%-5.4%) to 7.3% (95% CI, 5.7%-8.3%). Using the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities, 16 IRFs (1.4%) had 95% CIs above the national mean rate, 1137 IRFs (97.9%) had 95% CIs containing the national mean rate, and 9 IRFs (0.8%) had 95% CIs below the national mean rate. Using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation, 8 IRFs (0.7%) had 95% CIs above the national mean rate, 1153 IRFs (99.2%) had 95% CIs containing the national mean rate, and 1 IRF (0.1%) had a 95% CI below the national mean rate. Conclusions and Relevance: This cohort study found that readmission rates were lower when using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation and further reduced discrimination between facilities compared with the recently discontinued All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities. This finding may indicate there is a lack of room for improvement in readmission rates. Given the rationale of the Centers for Medicare & Medicaid Services for removing measures that fail to discriminate quality performance, this suggests that the current readmission measure should not be implemented as part of the Inpatient Rehabilitation Quality Reporting Program.


Asunto(s)
Planes de Aranceles por Servicios , Medicare , Alta del Paciente/normas , Readmisión del Paciente/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Centros de Rehabilitación/normas , Atención Subaguda/normas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/normas , Disparidades en Atención de Salud/estadística & datos numéricos , Humanos , Masculino , Medicare/economía , Medicare/normas , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Alta del Paciente/economía , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/economía , Readmisión del Paciente/normas , Garantía de la Calidad de Atención de Salud/métodos , Indicadores de Calidad de la Atención de Salud/economía , Centros de Rehabilitación/economía , Centros de Rehabilitación/estadística & datos numéricos , Estudios Retrospectivos , Ajuste de Riesgo , Atención Subaguda/economía , Atención Subaguda/estadística & datos numéricos , Estados Unidos
17.
Med Care ; 57(2): 145-151, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30531524

RESUMEN

BACKGROUND: Beginning in 2019, home health agencies' rates of potentially preventable hospital readmissions over the 30 days following discharge will be publicly reported. OBJECTIVES: Our primary objective was to determine the association between patients' functional status at discharge from home health care and 30-day potentially preventable readmissions. A secondary objective was to identify the most common conditions resulting in potentially preventable readmissions. DESIGN: This was a retrospective cohort study. PARTICIPANTS: A total of 1,510,297 Medicare fee-for-service beneficiaries discharged from home health care in 2013-2015. Average age was 75.9 (SD, 10.9) years, 60.0% were female, and 84.2% non-Hispanic white. MEASUREMENTS: Thirty-day potentially preventable readmissions following home health discharge. Functional status measures included mobility, self-care, and impaired cognition. RESULTS: The overall rate of 30-day potentially preventable readmissions was 2.6% (N=39,452), which accounted for 40% of all 30-day readmissions. After adjusting for sociodemographic and clinical characteristics, the odds ratios for the most dependent score quartile versus the most independent was 1.58 [95% confidence interval (CI), 1.53-1.63] for mobility and 1.65 (95% CI, 1.59-1.69) for self-care. The odds ratios for impaired versus intact cognition was 1.21 (95% CI, 1.18-1.24). The 5 most common conditions resulting in a potentially preventable readmission were congestive heart failure (23.6%), septicemia (16.7%), bacterial pneumonia (9.8%), chronic obstructive pulmonary disease (9.4%), and renal failure (7.5%). CONCLUSIONS: Functional limitations at discharge from home health are associated with increased risk for potentially preventable readmissions. Future research is needed to determine whether improving functional independence decreases the risk for potentially preventable readmissions following home health care.


Asunto(s)
Actividades Cotidianas , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Anciano , Planes de Aranceles por Servicios , Femenino , Humanos , Masculino , Medicare , Estudios Retrospectivos , Factores de Riesgo , Autocuidado/estadística & datos numéricos , Estados Unidos
18.
Am J Phys Med Rehabil ; 97(12): 879-884, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-29952780

RESUMEN

OBJECTIVE: The aim of the study was to quantify the improvement in independence experienced by patients with the following diagnoses: Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke after inpatient rehabilitation. DESIGN: Subjects who were admitted to inpatient rehabilitation hospitals in 2012-2013 with an incident diagnosis of the following: Guillain-Barré syndrome (n = 1079), multiple sclerosis (n = 1438), Parkinson disease (n = 11,834), or stroke (n = 131,313), were included. The main outcome measure was improvement in Functional Independence Measure scores on self-care, mobility, and cognition during inpatient rehabilitation. We estimated percent improvement from a linear mixed-effects model adjusted for patients' age, sex, race/ethnicity, comorbidity count, diagnostic group (Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke), and admission score. RESULTS: All patient diagnostic groups receiving inpatient rehabilitation improved across all three domains. The largest adjusted percent improvements were observed in the mobility domain and the smallest in the cognition domain for all groups. Percent improvement in mobility ranged from 84.9% (multiple sclerosis) to 144.0% (Guillain-Barré syndrome), self-care from 49.5% (multiple sclerosis) to 84.1% (Guillain-Barré syndrome), and cognition from 34.0% (Parkinson disease) to 51.7% (Guillain-Barré syndrome). Patients with Guillain-Barré syndrome demonstrated the greatest percent improvement across all three domains. CONCLUSIONS: Patients with Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke should improve during inpatient rehabilitation but anticipated outcomes for patients with Guillain-Barré syndrome should be even higher.


Asunto(s)
Síndrome de Guillain-Barré/rehabilitación , Hospitalización , Esclerosis Múltiple/rehabilitación , Enfermedad de Parkinson/rehabilitación , Rehabilitación de Accidente Cerebrovascular , Anciano , Trastornos del Conocimiento/rehabilitación , Evaluación de la Discapacidad , Femenino , Trastornos Neurológicos de la Marcha/rehabilitación , Humanos , Masculino , Limitación de la Movilidad , Autocuidado
19.
J Am Geriatr Soc ; 66(10): 1880-1886, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-29656399

RESUMEN

OBJECTIVES: To determine how the risk of subsequent long-term care (LTC) placement varies between skilled nursing facilities (SNFs) and the SNF characteristics associated with this risk. DESIGN: Population-based national cohort study with participants nested in SNFs and hospitals in a cross-classified multilevel model. SETTING: SNFs (N=6,680). PARTICIPANTS: Fee-for-service Medicare beneficiaries (N=552,414) discharged from a hospital to a SNF in 2013. MEASUREMENTS: Participant characteristics from Medicare data and the Minimum Data Set. SNF characteristics from Medicare and Nursing Home Compare. Outcome was a stay of 90 days or longer in a LTC nursing home within 6 months of SNF admission. RESULTS: Within 6 months of SNF admission, 10.4% of participants resided in LTC. After adjustments for participant characteristics, the SNF where a participant received care explained 7.9% of the variance in risk of LTC, whereas the prior hospital explained 1.0%. Individuals in SNFs with excellent quality ratings had 22% lower odds of transitioning to LTC than those in SNFs with poor ratings (odds ratio=0.78, 95% confidence interval=0.74-0.84). Variation between SNFs and associations with quality markers were greater in sensitivity analyses limited to individuals least likely to require LTC. Results were essentially the same in a number of other sensitivity analyses designed to reduce potential confounding. CONCLUSION: Risk of subsequent LTC placement, an important and negatively viewed outcome for older adults, varies substantially between SNFs. Individuals in higher-quality SNFs are at lower risk.


Asunto(s)
Hogares para Ancianos/estadística & datos numéricos , Cuidados a Largo Plazo/estadística & datos numéricos , Medicare/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Planes de Aranceles por Servicios/estadística & datos numéricos , Femenino , Humanos , Masculino , Análisis Multinivel , Evaluación de Resultado en la Atención de Salud , Estados Unidos
20.
J Am Med Dir Assoc ; 19(10): 896-901, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-29691152

RESUMEN

OBJECTIVE: Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. DESIGN: Retrospective cohort study. SETTING: Acute care hospitals. PARTICIPANTS: Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. MEASUREMENTS: 90-day unplanned readmissions. RESULTS: The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. CONCLUSIONS: We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care.


Asunto(s)
Planes de Aranceles por Servicios , Alta del Paciente , Readmisión del Paciente/estadística & datos numéricos , Atención Subaguda , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo , Estudios de Cohortes , Episodio de Atención , Femenino , Fracturas de Cadera/epidemiología , Humanos , Masculino , Medicare , Estudios Retrospectivos , Instituciones de Cuidados Especializados de Enfermería , Accidente Cerebrovascular/epidemiología , Estados Unidos/epidemiología
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