Associations between comorbidity and quality of life outcomes after total joint replacement.

PURPOSE: We examined associations between self-reported and clinician-assessed comorbidity and quality of life (QOL) outcomes after hip and knee replacement. METHODS: This is a cross-sectional, questionnaire-based national survey. Participants aged 45 years or older (n = 409) were recruited from the New Zealand Joint Registry six months after a total hip (THR), total knee (TKR) or unicompartmental knee replacement (UKR). The main outcome QOL was measured using an 8-item short form of the World Health Organisation Quality of Life (WHOQOL-Bref) questionnaire six months following joint replacement surgery. The WHOQOL is a generic and non-health condition specific measure of QOL. RESULTS: Participants were on average 68 years of age, with more men (54%) than women (46%). Number of coexisting conditions and body mass index were correlated with age, pain and function scores, and QOL (p < 0.01), but not with each other. Linear regression analyses showed that comorbidities such as number of comorbid conditions and BMI had moderate associations with QOL outcomes. CONCLUSION: This study showed that general QOL outcomes following hip and knee joint replacement, while generally high, were associated with comorbidity burden and BMI. Future prospective research examining change in QOL before and following surgery would help to advance understandings of the various factors that contribute to patient satisfaction with their joint replacement.

Effect of Outpatient Rehabilitation on Functional Mobility After Single Total Knee Arthroplasty: A Randomized Clinical Trial.

Importance: Even without evidence, rehabilitation practitioners continue to introduce new interventions to enhance the mobility outcomes for the increasing population with a recent total knee arthroplasty (TKA). Objective: To compare post-TKA functional mobility outcomes among 3 newly developed physical therapy protocols with a standard-of-care post-TKA rehabilitation protocol. Design, Setting, and Participants: This randomized clinical trial included 4 study arms implemented in 15 outpatient clinics within a single health system in the Baltimore, Maryland, and Washington, District of Columbia, region from October 2013 to April 2017. Participants included patients who underwent elective unilateral TKA, were aged 40 years and older, and began outpatient physical therapy within 24 days after TKA. A total of 505 patients were screened and 386 participants were enrolled. Patients provided informed consent and were randomly assigned to 1 of 4 groups. Blinding patients and treating therapists was not feasible owing to the nature of the intervention. Analysis was conducted under the modified intent-to-treat principle from October 2017 to May 2019. Interventions: The control group used a standard recumbent bike for 15 to 20 minutes each session. Interventions used 1 of 3 modalities for 15 to 20 minutes each session: (1) a body weight-adjustable treadmill, (2) a patterned electrical neuromuscular stimulation device, or (3) a combination of the treadmill and electrical neuromuscular stimulation. Main Outcomes and Measures: Outcomes included the Activity Measure for Post-acute Care basic mobility score, a patient-reported outcome measure, and the 6-minute walk test. Outcomes were measured at baseline, monthly, and on discharge from outpatient therapy. Results: Data from 363 patients (mean [SD] age, 63.4 [7.9] years; 222 [61.2%] women) were included in the final analysis, including 92 participants randomized to the control group, 91 participants randomized to the treadmill group, 90 participants randomized to the neuromuscular stimulation device group, and 90 participants randomized to the combination intervention group. Activity Measure for Post-acute Care scores at discharge were similar across groups, ranging from 61.1 to 61.3 (P = .99) with at least 9.0 points improvement (P = .80) since baseline. The distances as measured by the 6-minute walking test were not statistically different across groups (range, 382.9-404.5 m; P = .60). Conclusions and Relevance: This randomized clinical trial found no statistically or clinically significant differences in outcomes across the 4 arms. Because outcomes were similar among arms, clinicians should instead consider relative cost in tailoring TKA rehabilitation. Trial Registration: ClinicalTrials.gov Identifier: NCT02426190.

Innovative Devices Did Not Provide Superior Total Knee Arthroplasty Outcomes in Post-Operative Rehabilitation: Results From a Four-Arm Randomized Clinical Trial.

BACKGROUND: Orthopedic surgeons face an increasing array of post-TKA (total knee arthroplasty) rehabilitation interventions that entail innovative equipment and devices, but their relative effectiveness remains unknown. The study compared patient outcomes among primary unilateral TKA patients participating in one of 4 post-TKA rehabilitation interventions-a standard-of-care intervention and 3 more recently developed physical therapy interventions. METHODS: The Knee Arthroplasty Rehabilitation Outcomes Study is a 4-arm randomized clinical trial conducted across 15 outpatient rehabilitation clinics. The trial evaluated 4 alternative interventions: (1) a stationary recumbent bike (control intervention); (2) a body weight-adjustable treadmill; (3) a recumbent bike and use of a patterned electrical neuromuscular stimulation device; and (4) a body weight-adjustable treadmill and a patterned electrical neuromuscular stimulation device. The study's outcome measures were patient walking speed and the Knee injury and Osteoarthritis Outcome Score (KOOS) measured at therapy discharge and at follow-up. RESULTS: The study enrolled 363 TKA patients with 90-92 patients in each of the 4 study arms. Participants were similar across the 4 groups: They were about 63 years old, 61% female, 67% white, living at home, overweight (mean body mass index = 31.6), with mostly private insurance (61%) or Medicare (32%). Walking speed was similar at admission and discharge; KOOS scores were similar at admission, discharge, and follow-up across the 4 intervention groups. CONCLUSION: The study found no statistical or clinically meaningful differences across the 4 study arms in walking speed or KOOS outcomes. Clinicians, payers, and policy makers will want to encourage providers and patients to use the least expensive intervention since each provide similar outcomes. TRIAL REGISTRATION: NCT02426190; https://clinicaltrials.gov/ct2/show/NCT02426190?term=NCT02426190&cntry=US&rank=1.

Use of rehabilitation after hip and knee replacement in New Zealand: a national survey.

AIMS: Our objective was to describe rehabilitation used before and after joint replacement in New Zealand and evaluate variation based on geography and ethnicity. METHODS: In this descriptive cross-sectional questionnaire-based study we recruited participants 45 years or older (n=608) from the New Zealand Joint Registry six months after primary total hip, total knee or uni-compartmental knee replacement. RESULTS: The cohort was predominantly New Zealand European (89.9%). The average age of participants was 68.2 years. Less rehabilitation was used pre-operatively (31.0%) than post-operatively (79.6%) and total hip replacement participants reported using less rehabilitation (63.3%) than those after total knee (90.7%) or uni-compartmental knee (80.3%) replacement (p<0.01). There were trends towards more pre-operative rehabilitation for participants living in larger urban areas, most evident for total hip replacement (p<0.05). CONCLUSIONS: Participants reported generally positive outcomes six months after primary total hip, knee and uni-compartmental knee replacement. However, differences in use of rehabilitation services before and after joint replacement were evident depending on joint replaced. Broadening setting options for rehabilitation might improve use of rehabilitation resources.

Rehabilitation after total joint replacement: a scoping study.

PURPOSE: The evidence supporting rehabilitation after joint replacement, while vast, is of variable quality making it difficult for clinicians to apply the best evidence to their practice. We aimed to map key issues for rehabilitation following joint replacement, highlighting potential avenues for new research. MATERIALS AND METHODS: We conducted a scoping study including research published between January 2013 and December 2016, evaluating effectiveness of rehabilitation following hip and knee total joint replacement. We reviewed this work in the context of outcomes described from previously published research. RESULTS: Thirty individual studies and seven systematic reviews were included, with most research examining the effectiveness of physiotherapy-based exercise rehabilitation after total knee replacement using randomized control trial methods. Rehabilitation after hip and knee replacement whether carried out at the clinic or monitored at home, appears beneficial but type, intensity and duration of interventions were not consistently associated with outcomes. The burden of comorbidities rather than specific rehabilitation approach may better predict rehabilitation outcome. Monitoring of recovery and therapeutic attention appear important but little is known about optimal levels and methods required to maximize outcomes. CONCLUSIONS: More work exploring the role of comorbidities and key components of therapeutic attention and the therapy relationship, using a wider range of study methods may help to advance the field. Implications for Rehabilitation Physiotherapy-based exercise rehabilitation after total hip replacement and total knee replacement, whether carried out at the clinic or monitored at home, appears beneficial. Type, intensity, and duration of interventions do not appear consistently associated with outcomes. Monitoring a patient's recovery appears to be an important component. The available research provides limited guidance regarding optimal levels of monitoring needed to achieve gains following hip and knee replacement and more work is required to clarify these aspects. The burden of comorbidities appears to better predict outcomes regardless of rehabilitation approach.

Coming to Terms With the IMPACT Act of 2014.

The Improving Medicare Post-Acute Transformation (IMPACT) Act of 2014 will set the course for much of postacute care well into the next decade. It (1) authorizes a uniform method of patient assessment in postacute care; (2) sets a timetable for developing, implementing, and reporting quality measures; and (3) lays the groundwork for future payment reform in postacute care. This article places the IMPACT Act into the larger arc of health care reform and change. It summarizes the law's key provisions and presents a contrarian analysis of this much-heralded bipartisan legislation. The Affordable Care Act (ACA) of 2010 already gives the Centers for Medicare and Medicaid Services the authority to implement what the IMPACT Act requires. The IMPACT Act may even slow down the changes envisioned in the ACA. The article concludes by noting the implications for occupational therapy both as a practice and a profession.

Advancing SCI health care to avert rehospitalization.

This commentary reflects on the high rate of health care utilization among individuals with traumatic spinal cord injury (SCI) in the first year of injury as reported by Skelton et al. in the current issue of this journal. Commentary argues that the variation in risk-adjusted rehospitalization rates suggests that there is considerable opportunity for improvement. Authors note that we need better strategies to prevent the onset of the 3 conditions that drive most of the rehospitalization, namely, urinary tract infections, pneumonia, and pressure ulcers. Commentary also urges providers to rethink and reinvent the process of care in acute, rehabilitation, and post-discharge phases of care. It recommends that SCI centers take greater advantage data resources already available such as the National Spinal Cord Injury Database to openly share and compare center-to-center differences in practice and outcomes. It also urges SCI centers to reinvent their systems of care in ways being made possible under health care reform, especially systems that make all providers in a given episode of care-from acute to rehabilitation to post-discharge care, mutually and financially accountable for both outcomes and costs including emergency room use and rehospitalization.

Attending to biographical disruption: the experience of rehabilitation following tetraplegia due to spinal cord injury.

PURPOSE: To explore the experience of rehabilitation from the perspective of individuals with tetraplegia. METHODS: Semi-structured interviews of between 40 and 60 min were conducted with three men and one woman, with spinal injuries at C7 or higher, within 6 months of discharge from inpatient spinal cord injury (SCI) rehabilitation. Data were subject to an Interpretive Phenomenological Analysis (IPA). RESULTS: Participants described their injuries as more than a biological impairment that limited certain functional abilities. For them, SCI was a sudden event that also disrupted one's "life biography". Interviews uncovered three key themes essential to an individual's ability to restore feelings of self-agency and biographical continuity: The importance of information, regaining control, and restoring a sense of personal narrative. CONCLUSION: Findings from studies using IPA have much to contribute to discussion and debate at the level of rehabilitation theory and can guide future research directions. The findings of the present study support a growing body of literature that argues that rehabilitation research needs to focus more intensely on the biographical disruption caused by SCI. Implications for Rehabilitation Participants in the present study experienced a significant disruption to their biographical narratives following a SCI as they entered an unknown and uncertain world. The findings from the present study provide an evidence-base that is best applied to discussion regarding psychosocial adjustment at the level rehabilitation theory. The concepts of identity and biographical disruption are appearing more frequently in qualitative literature and both merit further investigation to assess their prevalence among the wider SCI populations.

Factors associated with pressure ulcer risk in spinal cord injury rehabilitation.

OBJECTIVE: The aim of this study was to identify patient and clinical factors most strongly associated with a spinal cord injury patient's risk for developing a pressure ulcer (PU) during rehabilitation. DESIGN: This is a prospective observational cohort study conducted at an urban rehabilitation hospital-based specialized spinal cord injury center. The main outcome measure was the onset of a stage 2 or higher PU. RESULTS: Study patients (N = 159) with new (n = 66) and patients with earlier (n = 99) spinal injuries had identical rates at which they acquired a new PU (stage ≥2) in rehabilitation--13.1%. The patients who came to rehabilitation with a PU or myocutaneous flap exhibited a higher rate of developing yet another PU while in rehabilitation (30.2%) than those who came to rehabilitation without an existing PU or flap (6.9%). Logistic regression analysis identified two variables that best predicted a patient's risk at admission for developing a PU during rehabilitation (c = 0.77)--entering rehabilitation with a PU and admission Functional Independence Measure transfers score of less than 3.5. CONCLUSIONS: The greatest risk of developing a new PU in rehabilitation is being admitted with an existing PU followed by admission Functional Independence Measure transfers score of less than 3.5. Using these two variables, one can develop a patient PU risk algorithm at admission that can alert clinicians for the need to enhance vigilance, skin monitoring, and early patient education.

Site-neutral payment for postacute care: framing the issue.

This commentary evaluates the merits of proposals in the United States to create a site-neutral payment system for postacute care for patients with select rehabilitation-related conditions. Under a site-neutral payment system, Medicare would pay providers based on patients' clinical needs, not on the peculiarities of individual postacute settings such as skilled nursing facilities and inpatient rehabilitation facilities. This commentary frames the policy choices by taking into account the research evidence on setting costs and outcomes, the policy tools and preconditions needed for an effective site-neutral payment system, and the overall direction of American health and postacute policy.

Are we asking the right question about postacute settings of care?

This issue of Archives includes an article by Mallinson et al that compares the outcomes of patients with hip fracture who received rehabilitation services in 3 different postacute settings: skilled nursing facilities, inpatient rehabilitation facilities, or home health. Except in 1 instance, Mallinson found no setting-specific effects and noted that the issue of defining an optimum postacute rehabilitation program is complex and requires more investigation. Mallinson's findings are interesting in their own right but raise a more fundamental issue. This commentary observes that rehabilitation patients typically use multiple postacute settings, not just 1 setting of care, for the same episode of care. This commentary asks whether we should be examining episode outcomes and not just setting-specific outcomes, especially in the face of bundled payment and value-based payment reforms in the Affordable Care Act.

Role of body weight in therapy participation and rehabilitation outcomes among individuals with traumatic spinal cord injury.

OBJECTIVE: To examine the association between body weight, therapy participation, and functional outcomes among people with spinal cord injury (SCI). DESIGN: Multisite prospective observational cohort study. SETTING: Six acute rehabilitation facilities. PARTICIPANTS: Patients (N=1017) aged ≥ 12 years admitted for their initial rehabilitation after SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Motor FIM at inpatient rehabilitation discharge and 1 year postinjury. RESULTS: Underweight and overweight/obese patients consisted of 2 different clusters of SCI patients. Underweight patients were more likely to be younger, black, less educated, single, have Medicaid as a primary payer, and more likely to have had a cervical level injury because of violence and vehicular-related events than their overweight and obese counterparts. We found few significant differences in hours of therapy during inpatient rehabilitation across weight groups. Among patients with C5-8 ASIA Impairment Scale (AIS) grades A, B, and C injuries, underweight patients received fewer hours of physical therapy per week than patients with a healthy weight (P=.028). Obese patients with paraplegia AIS grades A, B, and C received more hours of occupational therapy during their rehabilitation stay (P<.001) than other weight groups. A higher percentage of underweight patients had pressure ulcers during inpatient rehabilitation in C5-8 AIS grades A, B, and C and paraplegia AIS grades A, B, and C groups. Only in the paraplegia AIS grades A, B, and C group did we find a significant association between weight groups and discharge motor FIM score. Regression models showed that among C1-4 AIS grades A, B, and C patients, the overweight group had better 1-year follow-up motor FIM scores than other weight groups. CONCLUSIONS: Patients who had an unhealthy body weight, that is, being underweight or obese, often have therapy participation and profiles different from those deemed healthy, or just overweight. For patients with paraplegia AIS grades A, B, and C, being overweight or obese was associated with diminished motor FIM outcomes at discharge from rehabilitation. The relation between body weight status, therapy participation, and outcomes are not consistent among study group participants.

Relation between inpatient and postdischarge services and outcomes 1 year postinjury in people with traumatic spinal cord injury.

OBJECTIVE: To examine the association between inpatient and postdischarge rehabilitation services and function, life satisfaction, and community participation 1 year after spinal cord injury (SCI). DESIGN: Prospective, observational. SETTING: Six rehabilitation facilities. PARTICIPANTS: Patients with SCI (N=1376). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART), motor FIM (mFIM), and return to work/school at 1 year post-SCI. RESULTS: Demographic and injury characteristics explained 49% of the variance in mFIM and 9% to 25% of the variance in SWLS and CHART social integration, mobility, and occupation scores. Inpatient rehabilitation services explained an additional 2% of the variance for mFIM and 1% to 3% of the variance for SWLS and CHART scores. More time in inpatient physical therapy (PT) was associated with higher mFIM scores; more time in inpatient therapeutic recreation (TR) and social work and more postdischarge nursing (NSG) were associated with lower mFIM scores. More inpatient PT and TR and more postdischarge PT were associated with higher mobility scores; more inpatient psychology (PSY) was associated with lower mobility scores. More postdischarge TR was associated with higher SWLS; more postdischarge PSY services was associated with lower SWLS. Inpatient TR was positively associated with social integration scores; postdischarge PSY was negatively associated with social integration scores. More postdischarge vocational counseling was associated with higher occupation scores. Differences between centers did not explain additional variability in the outcomes studied. CONCLUSIONS: Inpatient and postdischarge rehabilitation services are weakly associated with life satisfaction and societal participation 1 year after SCI. Further study of the type and intensity of postdischarge services, and the association with outcomes, is needed to ascertain the most effective use of therapy services after SCI.

Comparing rehabilitation services and outcomes between older and younger people with spinal cord injury.

OBJECTIVE: To compare patient and injury characteristics, rehabilitation services, and outcomes between people incurring traumatic spinal cord injury (SCI) at younger and older ages. DESIGN: Multisite prospective observational cohort study. SETTING: Six acute rehabilitation facilities. PARTICIPANTS: Patients (N=866) aged ≥ 16 years admitted to participating centers for their initial rehabilitation after SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Motor FIM scores at discharge and 1 year postinjury, discharge location, and postacute clinical pathways. RESULTS: Patients were divided into 4 age-at-injury groups: 16 to 29, 30 to 44, 45 to 60, and >60 years of age. Older adults (>60 y) incurring SCI were more likely to be married, retired/unemployed, on Medicare, and to have attained more education. Their injuries mostly resulted from falls and were incomplete in nature. The oldest group had the highest severity of illness, lowest admission and discharge motor FIM scores, and longer rehabilitation stay. They received relatively less rehabilitation than younger groups. They spent proportionately more time in occupational therapy working on preparatory activities and less time on self-care activities during inpatient rehabilitation. In the aged >60 years group, 80% went home at discharge; 17.2% were discharged to a nursing home. Younger groups were less likely to go to a nursing home. Admission motor FIM was the most significant predictor of motor FIM at discharge and 1-year anniversary across age groups. But the age groups differed significantly in patient and treatment factors that explained their respective outcomes. CONCLUSIONS: Older injured individuals experienced a different clinical pathway from younger patients. The present study suggests the need for development of a rehabilitation program tailored specifically to older adults.

Association of various comorbidity measures with spinal cord injury rehabilitation outcomes.

OBJECTIVE: To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status. DESIGN: Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury. SETTING: Inpatient rehabilitation and community follow-up at 6 SCI treatment centers. PARTICIPANTS: Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI). RESULTS: Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school. CONCLUSIONS: Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account.

Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation.

OBJECTIVE: To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization. DESIGN: Prospective observational cohort study. SETTING: Six geographically dispersed rehabilitation centers in the U.S. PARTICIPANTS: Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations. RESULTS: More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered. CONCLUSIONS: Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

Acute rehospitalizations during inpatient rehabilitation for spinal cord injury.

OBJECTIVES: To investigate frequency of and reasons for readmission to acute care (RTAC) during inpatient rehabilitation after traumatic spinal cord injury (SCI), and to identify factors associated with RTAC. DESIGN: Prospective observational cohort. SETTING: Inpatient rehabilitation. PARTICIPANTS: Individuals with SCI (N=1376) consecutively admitted for inpatient rehabilitation; 1032 randomly selected for model development; 344 selected for model cross-validation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: RTAC, RTAC reasons, rehabilitation length of stay (LOS), discharge location and FIM, rehospitalization between discharge and year 1, and 1-year outcomes: FIM, Craig Handicap Assessment and Reporting Technique, and Patient Health Questionnaire-9. RESULTS: Participants (n=116; 11%) experienced RTAC with a total 143 episodes--96 patients experienced only 1 RTAC, while 14 had 2 RTACs, 5 had 3 RTACs, and 1 had 4 RTACs. The most common RTAC reasons were surgery (36%), infection (22%), noninfectious respiratory (14%), and gastrointestinal (8%). Mean days ± SD from rehabilitation admission to first RTAC was 27 ± 30 days. Seventy-four (7%) patients had at least 1 RTAC for medical reasons and 46 (4%) for surgical reasons. Regression analyses indicated several variables were associated with RTACs: greater admission medical severity, lower admission cognitive FIM, pressure ulcer acquired in acute care, and study site. Medical RTACs were associated with higher body mass index, lower admission cognitive and motor FIM, payer, and study site. Predictors of surgical RTAC were longer time from injury to rehabilitation admission and study site. After controlling for the other variables, the only outcome RTAC influenced was longer rehabilitation LOS. CONCLUSIONS: Approximately 11% of SCI patients experience RTAC during the course of rehabilitation for a variety of medical and surgical reasons. RTACs are associated with longer rehabilitation LOS.

Practice-based evidence research in rehabilitation: an alternative to randomized controlled trials and traditional observational studies.

Sound rigorous methods are needed by researchers and providers to address practical questions about risks, benefits, and costs of interventions as they occur in routine clinical practice such as: Are treatments used in daily practice associated with intended outcomes? For whom does an intervention work best? With limited clinical resources, what are the best interventions to use for specific types of patients? Answers to such questions can help clinicians, patients, researchers, and health care administrators learn from, and improve, real-world everyday clinical practice. In this article, we describe existing research designs to demonstrate clinical usefulness and comparative effectiveness of rehabilitation treatments. We compare randomized controlled trials and observational cohort studies of various types, including those that use instrumental variables or propensity scores to control for potential patient or treatment selection effects. We argue that practice-based evidence (PBE) study designs include features that address limitations inherent in both randomized trials and traditional observational studies, and also reduce the need for instrumental variables and propensity scores methods. We give examples of how PBE designs have been used in various rehabilitation areas to determine better treatments for specific types of patients.

Outcomes and weight-bearing status during rehabilitation after arthroplasty for hip fractures.

OBJECTIVE: To examine the association of weight-bearing status with patient-related variables and outcomes of inpatient rehabilitation after hip arthroplasty for acute hip fracture. DESIGN: A multi-site prospective observational cohort study. SETTING: Eighteen skilled nursing and inpatient rehabilitation facilities. SUBJECTS: Patients with hip fractures (N = 224) treated with hip arthroplasty and admitted to either skilled nursing or inpatient rehabilitation facilities; a subset (N = 84) with telephone follow-up outcomes 8 months after rehabilitation discharge. METHODS: Measurements included demographic variables, medical severity using the Comprehensive Severity Index, and functional levels using the Functional Independence Measure. MAIN OUTCOMES MEASUREMENT: Cognitive, motor, and total Functional Independence Measure scores at rehabilitation discharge and at 8-month follow-up; living location at discharge and follow-up. RESULTS: Patients on average (standard deviation) were 76.8 ± 11.4 years old, mainly women (78%), and mainly white (87%). In unadjusted analysis, weight bearing as tolerated (WBAT) was associated with less osteoarthritis (P = .025) and lower admission medical severity (ACSI) (P = .014). One participating facility had a significant preponderance of restricted weight-bearing cases. WBAT had no bivariate association with cognitive or motor function at discharge. Therapists cited restricted weight bearing as a barrier to therapy in 11% of cases. In logistic regressions, lower medical admission severity, older age, and one specified site significantly predicted WBAT (c statistic = 0.714). Significant predictors for home discharge included lower maximum severity (P < .001), younger age (P < .001), higher cognition (P = .037), and WBAT (P = .051) (c statistic = 0.863). CONCLUSIONS: WBAT is associated with a greater likelihood of home discharge and had similar functional outcomes compared with restricted weight bearing. These findings add support for allowing WBAT after arthroplasty for hip fracture.

Initial recovery trajectories among patients with hip fracture: a conceptual approach to exploring comparative effectiveness in postacute care.

OBJECTIVE: To assess whether clusters of patients with hip fracture and with distinct initial recovery trajectories (IRT) could be identified by using practice-based evidence data and to examine the validity of these data. DESIGN: Analysis of multisite prospective observational cohort study database. SETTING: Eighteen skilled nursing and inpatient rehabilitation facilities. PATIENTS: Patients with hip fractures (N = 226) treated with joint replacement and admitted to skilled nursing or inpatient rehabilitation facilities, subset (n = 85), with telephone follow-up results approximately 8 months after rehabilitation discharge. Patients' ages were 76.8 ± 11.4 years; the majority were women (78%) and white (87%). METHODS: Measurements included medical severity by using the Comprehensive Severity Index and functional levels by using Functional Independence Measure (FIM). The IRT was calculated for each patient as the rate of change in function from the time of surgery to rehabilitation admission. We used cluster analysis to partition patients into subsets that shared common IRT scores. Validity was explored by comparing subgroups across patient characteristics and treatment patterns. Significance was defined as P ≤ .05. MAIN OUTCOMES MEASUREMENTS: IRT grouping, Comprehensive Severity Index, FIM, discharge location, living location at follow-up. RESULTS: We identified 3 patient clusters with differentiated IRT scores: group 1: 4.96 ± 2.45 (range, 0.4-8.6) FIM point change per day; group 2: 12.42 ± 2.51 (range, 8.9-17.0); group 3: 26.80 ± 13.78 (range, 17.5-70.0). Clinical group validation was established from statistically different Comprehensive Severity Index scores on admission; FIM scores at admission, discharge, and follow-up; and discharge and 8-month living settings. Calculation of IRT recovery curves by using FIM scores and associated time in days through logarithmic regression curves confirmed each group's IRT remained distinct through rehabilitation and follow-up. CONCLUSIONS: The IRT concept appears to be valid in patients with hip fracture who were treated with hip arthroplasty, and may assist in evaluating and comparing the effectiveness of postacute rehabilitation services.