Comparison of subacute rehabilitative care with outpatient primary medical care.

PURPOSE: Prior rehabilitation outcome studies have had many weaknesses. but they gradually observe a lack of long-term benefits from inpatient care alone. The goal of this study was to measure the additive effect of outpatient, subacute rehabilitation (compared with usual outpatient primary medical care) for adults diagnosed with a disabling disorder in four major diagnostic groups (nervous, circulatory, musculoskeletal and injury). METHOD: A randomized clinical trial was conducted to determine the effects of outpatient, subacute rehabilitative care on: (1) physical function; (2) health; (3) well being; (4) family function; and (5) social support. Patients hospitalized for the first time with a disabling condition (n = 180) were provided inpatient rehabilitation and then were randomly assigned to either outpatient, subacute rehabilitation at home (n = 90) or to usual outpatient follow-up (n = 90) in which only primary care medical services were provided. To compare the two groups, univariate analyses of covariance were conducted for the outcome variables. RESULTS: The major finding of this study was that of no significant effect of the intervention on any outcome variable. CONCLUSIONS: Based on current study results, we conclude that any long term additive benefit of outpatient, subacute rehabilitation may not be detectable across disability categories and may require closer evaluation in studies with a more homogeneous population than in the current study. Providing complex follow-up case management services to all clients is apparently not beneficial and might better be provided using selection criteria based on need. Future studies should determine if services are more effective when provided to those with the most unmet rehabilitative needs. Further outpatient, subacute care rehabilitation studies should address the specific needs of the patients and be adapted individually to those needs.

Department of Veterans Affairs Quality Enhancement Research Initiative for spinal cord injury.

Spinal cord injury (SCI) is a lifelong condition, requiring ongoing efforts by multiple disciplines to stabilize, diminish, or prevent impairments; avoid or limit secondary complications; and improve or maintain social role functioning and quality of life for the individual throughout his or her life. There are approximately 200,000 persons with SCI in the United States, of whom roughly 22% are veterans. The estimated national economic impact of SCI is approximately $9.73 billion per year. These figures illustrate why SCI is an important topic for the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI). The SCI QUERI will identify gaps in knowledge of SCI treatment and management, develop research efforts to address these gaps, identify best practices for care and management of SCI, and assess whether best practices lead to improved outcomes, including health-related quality of life.

Meta-analysis with longitudinal studies: controlling for analytical bias.

A recent study published in an international medical journal presented an opportunity to demonstrate the difficulties of interpreting meta-analysis results with longitudinal data. We conducted a new meta-analysis using identical data from the published study and showed contradictory results.

Multidisciplinary rehabilitation versus medical care: a meta-analysis.

Research studies in physical medicine have not demonstrated the effectiveness of inpatient rehabilitation services, primarily due to differences in methodological approaches which have led to inconsistent findings. Because of differing inclusion and outcome criteria, even meta-analyses have been inconclusive. To address this problem, research literature comparing the clinical effectiveness of rehabilitation programs with medical care was evaluated for three uniformly available outcome criteria: survival; functional ability; and discharge location. Published trials were obtained from citations in Index Medicus (Medicine) and Nursing and Allied Health Abstracts covering the recent 20 year period from 1974 to 1994. We used meta-analyses to test the hypotheses that specialized rehabilitative care (vs conventional medical care) improves health outcomes. Results of our meta-analyses indicated that rehabilitation services were significantly associated with better rates of survival and improved function during hospital stay (P < 0.01), but significance was not observed at follow-up. Also, rehabilitation patients returned to their homes and remained there more frequently than controls (P < 0.001). We concluded that patients who participate in inpatient rehabilitation programs function better at hospital discharge, have a better chance of short term survival, and return home more frequently than non-participants. However, long term survival and function were the same for experimental and control subjects. The sustaining benefit of returning home may suffice to justify the provision of inpatient rehabilitation. However, the lack of other long term benefits suggests that services may need to be continued at home or in subacute care settings to optimize their effectiveness.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke: a family dilemma.

Research studying the clinical effectiveness of stroke rehabilitation has focused on managing acute stages and on evaluating short-term treatment programmes. However, many studies suggest that stroke affects long-term quality of life and the well-being of the family. This article reviews the stroke literature relative to aging, disability, and rehabilitation. The social effects of stroke in terms of clinical problems which make rehabilitation a family dilemma are discussed. Issues identified include the need for family assessment, education, advocacy, and counselling to foster treatment compliance and social support.

Quality of life after spinal cord injury: a literature critique and meta-analysis (1983-1992).

Research articles cross-indexed in Index Medicus under the subject headings "quality of life" (QOL) and "spinal cord injury" (SCI) were examined in order to compare their relative merits in terms of research design, sampling techniques and the type of QOL criteria included. Of 3,710 citations indexed for the ten year period 1983 through 1992 under "quality of life," thirty-two research articles (< 1 percent) were cross-indexed with the subject heading "spinal cord injury." The modal design was a descriptive survey or case study (n = 23 or 72 percent). None of them were randomized clinical trials. Because of limited rigor of research design and poor validity of measurements, conclusions about the ability of rehabilitative care to improve the QOL for SCI persons could not be drawn from the studies reviewed. Meta-analysis indicated that severity of injury is associated with QOL, with more severe injury being correlated with poorer quality. The critique concludes that QOL research with SCI persons needs to be better designed and should include more uniform and valid criteria.

Evaluating hospital discharge planning: a randomized clinical trial.

To select patients for early discharge planning, a randomized clinical trial evaluated a protocol that used risk factors identified upon hospital admission. The goal of the study was to determine if intervention with high-risk patients could reduce the need for hospital admission or skilled care. Of 13,255 patients screened, 835 study participants were identified as "at risk" for frequent health care resource use. Half of the high-risk patients were randomly assigned to the experimental group (n = 417) and received discharge planning from day 3 of their hospital stay, while the control group (n = 418) received discharge planning only if there was a written physician request. Those patients receiving early, systematic discharge planning experienced an increased likelihood of successful return to home after hospital admission and a decreased chance of unscheduled readmission for the 9-month study period. Length of the index hospital stay was not affected by early planning, however. The major clinical implication is the potential for discharge planners to decrease the need for, and use of, health care resources after hospital admission.

The family's role in stroke rehabilitation. A review of the literature.

Clinical and research attention in stroke care has been on managing the acute stage of stroke recovery and on evaluating the effectiveness of relatively short-term rehabilitation programs. However, studies suggest that stroke can diminish quality of life and the well-being of patients' families. This article reviews the literature pertaining to the effects of stroke on family functioning and discusses stroke in terms of clinical problems that make rehabilitation a family dilemma. Issues identified in the literature include the need for family assessment, education, advocacy and counseling to foster treatment compliance and social support after stroke.

Poststroke family function: an evaluation of the family's role in rehabilitation.

Stroke affects long-term quality of life and well-being for not only the patients themselves but also their families. However, the focus of most rehabilitation programs has been on managing the acute stage of stroke and evaluating the effectiveness of short-term treatments. Families usually share in treatment, especially in the long term, and they are ultimately responsible for the patient's welfare. This article reviews the literature as it relates to the clinical problems that make rehabilitation a family issue.

Characteristics of hospital patients receiving medical rehabilitation: an exploratory outcome comparison.

This study classified consecutive hospital admissions to acute medical and surgical wards (n = 3,170) into clinical subgroups based on diagnostic, prognostic, and functional criteria. The groups were (1) independent, (2) terminal, (3) medical, (4) dementia, and (5) rehabilitation candidate. Medical record data from hospital admission, discharge, and nine-month follow-up were collected. The groups had unique patterns of survival, residence, and use of health care services during follow-up. Rehabilitation participants were compared with a group similar in age, major diagnostic category, and functional ability, who did not receive rehabilitation. Only 21% of persons meeting the study criteria for rehabilitation actually received rehabilitation services. At follow-up, participants in rehabilitation had lower mortality, spent less time in skilled nursing care, and were less frequently hospitalized. Although exploratory in nature, this study supports previously observed benefits of rehabilitation. In combination with clinical assessment, the process of identifying patient subgroups may be useful in planning interventions more uniformly and in developing measures to reduce selection bias in rehabilitation admission decisions.

Factors influencing the decision to rehabilitate: an initial comparison of rehabilitation candidates.

This study classified consecutive admissions to a U.S. Department of Veteran Affairs Medical Center. Patients on acute medical and surgical wards (n = 3170) were divided into clinical subgroups based on diagnostic, prognostic and functional criteria. The groups were: (1) independent; (2) terminal; (3) medical; (4) dementia; and (5) rehabilitation candidate. Medical record data from hospital admission, discharge and 9 month follow-up were collected. The groups had unique patterns of survival, residence and use of health care services during follow-up. Subsequently, rehabilitation participants were compared with a group similar in age, major diagnostic category and functional ability, who did not receive rehabilitation. Twenty-one percent of persons meeting study criteria for rehabilitation received rehabilitation services. At follow-up, participants in rehabilitation had lower mortality, spent less time in skilled care and were less frequently hospitalized. Although exploratory in nature, this study supports previously observed benefits of rehabilitation. In combination with clinical assessment, the process of identifying patient subgroups may be useful in planning interventions more uniformly and in developing measures to reduce selection bias in rehabilitation admission decisions.

Prospective payment for rehabilitation: effects on hospital readmission, home care, and placement.

Suspected benefits of a prospective payment system (PPS) in which hospitals are paid by diagnosis-related groups (DRGs) are that hospital lengths of stay and costs may be reduced. The US Department of Veterans Affairs is one of the first agencies to adopt PPS funding for rehabilitation; this early adoption of PPS provides a unique opportunity to test for both beneficial and adverse outcomes. This study compared hospital stay, readmission rate, and incidence of nursing home placement before and after introduction of PPS on a 22-bed rehabilitation service. Hospital stay decreased from 29.3 days to 26.4 days, but 64% more patients were discharged to nursing homes. Findings suggest that PPS may overlook home care in favor of placement, which neutralizes the cost benefits of the proposed reimbursement system. Further research on the effects of PPS is needed to determine (1) impact on clinical aspects of rehabilitation and (2) whether other funding mechanisms are more appropriate.

Effects of prospective payment financing on rehabilitation outcome.

A suspected benefit of paying hospitals per diagnostic related groups (DRGs), i.e. the prospective payment system (PPS), is that lengths of stay (LOS) and costs may be reduced. A potential adverse effect is that providers may discharge patients to reduce costs regardless of clinical consequence. The Veterans Administration (VA) is one of the first agencies to adopt PPS for rehabilitation. This study analyzed the effects of PPS on LOS, readmission rate, nursing home placement (NHP), and referral for Home Health Care (HHC) on a 22 bed rehabilitation unit. One hundred and eighty-seven patients discharged in 1987, prior to the program, were compared (using t-tests) with 215 discharges in 1988, after PPS was established. There were no significant differences in demographics, self-care ability, or in readmissions. Referrals for HHC decreased significantly. LOS decreased from 29.3 days (SD = 16.4) in 1987 to 26.4 days (SD = 14.1) in 1988 (t = 5.3, p less than 0.01). However, 24 more patients were discharged to nursing homes in 1988 (N = 54, 25%) than in 1987 (N = 30, 16%), which represents an increase of 64% (p less than 0.05). Findings suggest that PPS may defer home care in favor of placement. Clinicians need to assess whether reducing inpatient LOS justifies increased use of nursing homes. Further research on the effects of PPS is needed to determine: (a) impact on clinical aspects of rehabilitation; and (b) if other funding mechanisms are more appropriate.

Timing of social work intervention and medical patient's length of hospital stay.

Findings report that hospital inpatients who receive social work intervention present difficult problems and have longer-than-average lengths of stay and that the earlier in the hospitalization that intervention occurs, the shorter the stay will be. A total of 243 patients referred for social services at a 440-bed teaching hospital were evaluated. Paired t-tests indicated a significant difference in the mean length of stay based on normative data. Timing of the intervention accounted for a significant amount of variance (13 percent) in length of hospital stay. The major clinical implications of the study are that social work intervention has the potential to decrease length of hospitalization, and that this methodology may be used reliably to evaluate changes in discharge planning protocol.

Caregiver assessment of personal adjustment after stroke in a Veterans Administration Medical Center outpatient cohort.

We evaluated 80 stroke patients to examine the contributions of caregiver anxiety, self-care ability, age, time since onset, marital and residential status, and need for health care services on personal adjustment as reported by caregivers. Mean age of the patients was 65.4 years, and the average time from stroke onset to evaluation was 415 days. Multiple regression analyses indicated that a significant amount of variance in patient adjustment was accounted for by caregiver anxiety (R2 = 0.28, p less than 0.05) and patient self-care ability (R2 = 0.13, p less than 0.05). Compared with community norms, stroke patients were reported to be more depressed, confused, and anxious and they demonstrated fewer household management skills. Stroke patients were not different from a normative sample on measures of interpersonal involvement or social activity. Caregivers had high levels of anxiety compared with norms. Our results may aid in developing methods for identifying stroke patients and caregivers at risk for suboptimal adjustment.

Identifying factors associated with health care use: a hospital-based risk screening index.

The purpose of the current study was to identify variables near hospital admission that could effectively discriminate patients at risk for nursing home placement, long hospital stay, or readmission. Risk factors reported in the literature were used to predict hospital outcome for 532 admissions. Factors that discriminated type of outcome included: two or more chronic medical conditions, living alone or being admitted from a nursing home, dependent ambulation, poor mental status, psychiatric comorbidity, prior admission, age over 75, and being unmarried. Using these criteria, an index was developed to determine risk for placement, readmission, or lengthy stay. Use of cumulative risk scores can result in accurate prediction of outcome and may be useful in targeting patients for intervention. Performance characteristics of the risk index are discussed.