Mandated Quality of Care Metrics for Medicare Patients: Examining New or Worsened Pressure Ulcers and Rehabilitation Outcomes in United States Inpatient Rehabilitation Facilities.

OBJECTIVE: To examine the association between the Medicare pressure ulcer quality indicator (the development of new or worsened pressure ulcers) and rehabilitation outcomes among Medicare patients seen in an inpatient rehabilitation facility (IRF). DESIGN: Retrospective descriptive study. SETTING: IRFs subscribed to the Uniform Data System for Medical Rehabilitation. PARTICIPANTS: Nearly 500,000 IRF Medicare patients who were discharged between January 2013 and September 2014 were examined. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional independence, functional change (gain), and discharge destination. RESULTS: The pressure ulcer quality indicator was associated with poorer rehabilitation outcomes; patients were less likely to achieve functional independence (odds ratio [OR], .47; 95% confidence interval [CI], .44-.51), were less likely to be discharged to a community setting (OR, .88; 95% CI, .82-.95), and made less functional gain during their IRF stay (a difference of 6 FIM points). CONCLUSIONS: These results support that the pressure ulcer quality indicator is associated with lower quality of rehabilitation outcomes; however, given that those patients with a new or worsened pressure injury still made functional gains and most were discharged to the community, the risk of pressure injury development should not preclude the admission of these cases to an IRF.

Trajectories of Functional Change After Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To examine trajectories of functional recovery after rehabilitation for traumatic brain injury (TBI). DESIGN: Prospective study. SETTING: Inpatient rehabilitation hospitals in the Uniform Data System for Medical Rehabilitation. PARTICIPANTS: A subset of individuals receiving inpatient rehabilitation services for TBI from 2002 to 2010 who also had postdischarge measurement of functional independence (N=16,583). INTERVENTIONS: Inpatient rehabilitation. MAIN OUTCOMES MEASURES: Admission, discharge, and follow-up data were obtained from the Uniform Data System for Medical Rehabilitation. We used latent class mixture models to examine recovery trajectories for both cognitive and motor functioning as measured by the FIM instrument. RESULTS: Latent class models identified 3 trajectories (low, medium, high) for both cognitive and motor FIM subscales. Factors associated with membership in the low cognition trajectory group included younger age, male sex, racial/ethnic minority, Medicare or Medicaid (vs commercial or other insurance), comorbid conditions, and greater duration from injury date to rehabilitation admission date. Factors associated with membership in the low motor trajectory group included older age, racial/ethnic minority, Medicare or Medicaid coverage, comorbid conditions, open head injury, and greater duration to admission. CONCLUSIONS: Standard approaches to assessing recovery patterns after TBI obscure differences between subgroups with trajectories that differ from the overall mean. Select demographic and clinical characteristics can help classify patients with TBI into distinct functional recovery trajectories, which can enhance both patient-centered care and quality improvement efforts.

Characterization of Cancer Patients in Inpatient Rehabilitation Facilities: A Retrospective Cohort Study.

OBJECTIVES: To identify the types of cancer patients admitted to inpatient medical rehabilitation and to describe their rehabilitation outcomes. DESIGN: Retrospective cohort study. SETTING: U.S. inpatient rehabilitation facilities (IRFs). PARTICIPANTS: Adult patients (N=27,952) with a malignant cancer diagnosis admitted to an IRF with a cancer-related impairment between October 2010 and September 2012 were identified from the Uniform Data System for Medical Rehabilitation database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic, medical, and rehabilitation characteristics for patients with various cancer tumor types were summarized using data collected from the Inpatient Rehabilitation Facility-Patient Assessment Instrument. Rehabilitation outcomes included the percentage of patients discharged to the community and acute care settings, and functional change from admission to discharge. Functional status was measured using the FIM instrument. RESULTS: Cancer patients constituted about 2.4% of the total IRF patient population. Cancer types included brain and nervous system (52.9%), digestive (12.0%), bone and joint (8.7%), blood and lymphatic (7.6%), respiratory (7.1%), and other (11.7%). Overall, 72% were discharged to a community setting, and 16.5% were discharged back to acute care. Patients with blood and lymphatic cancers had the highest frequency of discharge back to acute care (28%). On average, all cancer patient groups made significant functional gains during their IRF stay (mean FIM total change ± SD, 23.5±16.2). CONCLUSIONS: In a database representing approximately 70% of all U.S. patients in IRFs, we found that patients with a variety of cancer types are admitted to inpatient rehabilitation. Most cancer patients admitted to IRFs were discharged to a community setting and, on average, improved their function. Future research is warranted to understand the referral patterns of admission to postacute care rehabilitation and to identify factors that are associated with rehabilitation benefit in order to inform the establishment of appropriate care protocols.

Hospital Readmission Following Discharge From Inpatient Rehabilitation for Older Adults With Debility.

BACKGROUND: Debility accounts for 10% of inpatient rehabilitation cases among Medicare beneficiaries. Debility has the highest 30-day readmission rate among 6 impairment groups most commonly admitted to inpatient rehabilitation. OBJECTIVE: The purpose of this study was to examine rates, temporal distribution, and factors associated with hospital readmission for patients with debility up to 90 days following discharge from inpatient rehabilitation. DESIGN: A retrospective cohort study was conducted using records for 45,424 Medicare fee-for-service beneficiaries with debility discharged to community from 1,199 facilities during 2006-2009. METHODS: Cox proportional hazard regression models were used to estimate hazard ratios for readmission. Schoenfeld residuals were examined to identify covariate-time interactions. Factor-time interactions were included in the full model for Functional Independence Measure (FIM) discharge motor functional status, comorbidity tier, and chronic pulmonary disease. Most prevalent reasons for readmission were summarized by Medicare severity diagnosis related groups. RESULTS: Hospital readmission rates for patients with debility were 19% for 30 days and 34% for 90 days. The highest readmission count occurred on day 3 after discharge, and 56% of readmissions occurred within 30 days. A higher FIM discharge motor rating was associated with lower hazard for readmissions prior to 60 days (30-day hazard ratio=0.987; 95% confidence interval=0.986, 0.989). Comorbidities with hazard ratios >1.0 included comorbidity tier and 11 Elixhauser conditions, 3 of which (heart failure, renal failure, and chronic pulmonary disease) were among the most prevalent reasons for readmission. LIMITATIONS: Analysis of Medicare data permitted only use of variables reported for administrative purposes. Comorbidity data were analyzed only for inpatient diagnoses. CONCLUSIONS: One-third of patients were readmitted to acute hospitals within 90 days following rehabilitation for debility. Protective effect of greater motor function was diminished by 60 days after discharge from inpatient rehabilitation.

Measure of functional independence dominates discharge outcome prediction after inpatient rehabilitation for stroke.

BACKGROUND AND PURPOSE: Identifying clinical data acquired at inpatient rehabilitation admission for stroke that accurately predict key outcomes at discharge could inform the development of customized plans of care to achieve favorable outcomes. The purpose of this analysis was to use a large comprehensive national data set to consider a wide range of clinical elements known at admission to identify those that predict key outcomes at rehabilitation discharge. METHODS: Sample data were obtained from the Uniform Data System for Medical Rehabilitation data set with the diagnosis of stroke for the years 2005 through 2007. This data set includes demographic, administrative, and medical variables collected at admission and discharge and uses the FIM (functional independence measure) instrument to assess functional independence. Primary outcomes of interest were functional independence measure gain, length of stay, and discharge to home. RESULTS: The sample included 148,367 people (75% white; mean age, 70.6±13.1 years; 97% with ischemic stroke) admitted to inpatient rehabilitation a mean of 8.2±12 days after symptom onset. The total functional independence measure score, the functional independence measure motor subscore, and the case-mix group were equally the strongest predictors for any of the primary outcomes. The most clinically relevant 3-variable model used the functional independence measure motor subscore, age, and walking distance at admission (r(2)=0.107). No important additional effect for any other variable was detected when added to this model. CONCLUSIONS: This analysis shows that a measure of functional independence in motor performance and age at rehabilitation hospital admission for stroke are predominant predictors of outcome at discharge in a uniquely large US national data set.

Risk Factors for Development of New or Worsened Pressure Ulcers Among Patients in Inpatient Rehabilitation Facilities in the United States: Data From the Uniform Data System for Medical Rehabilitation.

BACKGROUND: Documentation of a new or worsened pressure ulcer is a new, required quality indicator for all inpatient rehabilitation facilities (IRFs) in the United States; however, there is little research regarding risk factors for pressure ulcers among patients seen in IRFs. OBJECTIVE: To examine the risk factors for development of a new or worsened pressure ulcer among patients seen in IRFs. DESIGN: A retrospective cohort study. SETTING: IRFs in the United States. PARTICIPANTS: IRF patients more than 18 years of age, with documented new or worsened pressure ulcer during their rehabilitation stay (n = 2766) and IRF patients with no new or worsened pressure ulcer documented from admission to discharge (n = 190,996) discharged October 2008 to September 2011, included in the Uniform Data System for Medical Rehabilitation database. METHODS: Multiple logistic regression analysis was used to estimate risk factors for the development of a new or worsened pressure ulcer utilizing data captured in the Centers for Medicare and Medicaid Services (CMS) payment document. Examined were demographic variables, including age and gender, medical variables, including impairment type and presence of comorbidities, and functional status, as measured through the Functional Independence Measure (FIM) instrument. MAIN OUTCOME MEASURES: Development of a new or worsened pressure ulcer in patients during the rehabilitation stay compared to patients with no documented pressure ulcer or no worsened ulcer. RESULTS: Admission FIM total was strongly associated with development of a new or worsened pressure ulcer, P <.001 in analyses of all patients and for each of the 3 impairment-specific groups with the highest rate of ulcer development among spinal cord injury, orthopedic, and amputation cases. CMS comorbidity tier was also significantly associated with ulcers in all models. Other variables that entered one or more models included increased age, male gender, and use of a wheelchair. CONCLUSIONS: Admission FIM total and CMS comorbidity tier may be useful in the identification of patients at risk for development of new or worsened pressure ulcers in IRFs. Identification of pressure ulcer risk factors has important implications for individual plan-of-care decisions as well as for resource provisions during the rehabilitation stay.

Association between Functional Severity and Amputation Type with Rehabilitation Outcomes in Patients with Lower Limb Amputation.

The purpose of this study was to determine independent influences of functional level and lower limb amputation type on inpatient rehabilitation outcomes. We conducted a secondary data analysis for patients with lower limb amputation who received inpatient medical rehabilitation (N = 26,501). The study outcomes included length of stay, discharge functional status, and community discharge. Predictors included the 3-level case mix group variable and a 4-category amputation variable. Age of the sample was 64.5 years (13.4) and 64% were male. More than 75% of patients had a dysvascular-related amputation. Patients with bilateral transfemoral amputations and higher functional severity experienced longest lengths of stay (average 13.7 days) and lowest functional rating at discharge (average 79.4). Likelihood of community discharge was significantly lower for those in more functionally severe patients but did not differ between amputation categories. Functional levels and amputation type are associated with rehabilitation outcomes in inpatient rehabilitation settings. Patients with transfemoral amputations and those in case mix group 1003 (admission motor score less than 36.25) generally experience poorer outcomes than those in other case mix groups. These relationships may be associated with other demographic and/or health factors, which should be explored in future research.

Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.

IMPORTANCE: The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. OBJECTIVE: To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of records for 736,536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white. MAIN OUTCOMES AND MEASURES: Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. RESULTS: Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission. CONCLUSIONS AND RELEVANCE: Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.

Trajectories in functional recovery for patients receiving inpatient rehabilitation for unilateral hip or knee replacement.

The purpose of this study was to explore trajectories of recovery in patients with lower extremity joint replacements receiving post-acute rehabilitation. A retrospective cohort design was used to examine data from the Uniform Data System for Medical Rehabilitation (UDSMR®) for 7434 patients with total knee replacement (TKR) and 4765 patients with total hip replacement (THR) who received rehabilitation from 2008 to 2010. Functional Independence Measure (FIM)™ instrument ratings were obtained at admission, discharge, and 80-180 days after discharge. Random coefficient regression analyses using linear mixed models were used to estimate mean ratings for items within the four motor subscales (self-care, sphincter control, transfers, and locomotion) and the cognitive domain of the FIM instrument. Mean improvements at discharge for motor items ranged from 1.16 (95% confidence interval [CI]: 1.14, 1.19) to 2.69 (95% CI: 2.66, 2.71) points for sphincter control and locomotion, respectively. At follow-up mean motor improvements ranged from 2.17 (95% CI: 2.15, 2.20) to 4.06 (95% CI: 4.03, 4.06) points for sphincter control and locomotion, respectively. FIM cognition yielded smaller improvements: discharge=0.47 (95% CI: 0.46, 0.48); follow-up=0.83 (95% CI: 0.81, 0.84). Persons who were younger, female, non-Hispanic white, unmarried, with fewer comorbid conditions, and who received a TKR demonstrated slightly higher functional motor ratings. Overall, patients with unilateral knee or hip replacement experienced substantial improvement in motor functioning both during and up to six months following inpatient rehabilitation.

Perceptions of inpatient rehabilitation changes after the Centers for Medicare and Medicaid Service 2010 regulatory updates contrasted with actual performance.

OBJECTIVES: To compare and contrast subjective perceptions with objective compliance of the impact of the 2010 Centers for Medicare and Medicaid Service updates of the Medicare Benefit Policy Manual. DESIGN OR SETTING: Cross-sectional survey. PARTICIPANTS AND METHODS: An electronic survey was sent by the Uniform Data System for Medical Rehabilitation to all enrolled inpatient rehabilitation facility subscribers (n = 817). The survey was sent April 15, 2011, and responses were tabulated if they were received by May 15, 2011. MAIN OUTCOME MEASUREMENTS: Comparing and contrasting of the subjective perception to objective evaluation and/or compliance with the Medicare Benefit Policy Manual on case mix index, length of stay, admissions by diagnostic category as well as perception of preadmission screening, postadmission evaluation, plan of care, and interdisciplinary conferencing. RESULTS: Twenty-five percent of the 817 facilities responded, for a total of 209 responses. Complete data were present in 148 of the respondents. For most diagnostic categories, perception of change did not mirror reality of change; neither did the perception between change in case mix index and length of stay. Perception did match reality in stroke and multiple trauma cases; respondents perceived an increase in admissions for the 2 impairments, and there was an overall increase in reality. CONCLUSION: Comparison with actual data identified that gaps exist between diagnostic category perceptions and actual diagnostic category admission performance. Regulations such as the 75%-60% rule and audit focus on non-neurologic conditions as well as actual inpatient rehabilitation facility program payment reports may have influenced respondents perceptions to change associated with the Medicare Benefit Policy Manual modifications. This disparity between perception and actual data may have implications for programmatic planning, forecasting, and resource allocation.

Risk factors for discharge to an acute care hospital from inpatient rehabilitation among stroke patients.

OBJECTIVE: To identify medical and functional health risk factors for being discharged directly to an acute-care hospital from an inpatient rehabilitation facility among patients who have had a stroke. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PARTICIPANTS: A total of 783 patients with a primary diagnosis of stroke seen from 2008 to 2012; 60 were discharged directly to an acute-care hospital and 723 were discharged to other settings, including community and other institutional settings. METHODS OR INTERVENTIONS: Logistic regression analysis. MAIN OUTCOME MEASUREMENTS: Direct discharge to an acute care hospital compared with other discharge settings from the inpatient rehabilitation unit. RESULTS: No significant differences in demographic characteristics were found between the 2 groups. The adjusted logistic regression model revealed 2 significant risk factors for being discharged to an acute care hospital: admission motor Functional Independence Measure total score (odds ratio 0.97, 95% confidence interval 0.95-0.99) and enteral feeding at admission (odds ratio 2.87, 95% confidence interval 1.34-6.13). The presence of a Centers for Medicare and Medicaid-tiered comorbidity trended toward significance. CONCLUSION: Based on this research, we identified specific medical and functional health risk factors in the stroke population that affect the rate of discharge to an acute-care hospital. With active medical and functional management, early identification of these critical components may lead to the prevention of stroke patients from being discharged to an acute-care hospital from the inpatient rehabilitation setting.

Regional variation in stroke rehabilitation outcomes.

OBJECTIVE: To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation. DESIGN: Retrospective cohort design. SETTING: Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States. PARTICIPANTS: Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS). RESULTS: Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days. CONCLUSIONS: Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.

The Uniform Data System for Medical Rehabilitation: report of follow-up information on patients discharged from inpatient rehabilitation programs in 2002-2010.

OBJECTIVE: The aim of this study was to present yearly aggregated summaries of rehabilitation outcomes at admission, discharge, and follow-up from a national sample of patients receiving inpatient medical rehabilitation for stroke, traumatic brain injury, lower extremity fracture, lower extremity joint replacement, traumatic spinal cord injury, or debility. DESIGN: This is an analysis of secondary data from more than 300 inpatient rehabilitation facilities in the United States that contributed inpatient and follow-up data to the Uniform Data System for Medical Rehabilitation during the period January 2002 through December 2010. Aggregate variables reported include demographic information, social situation, and functional status (Functional Independence Measure instrument ratings at admission, discharge, and follow-up). Follow-up data were obtained 80-180 days after discharge through telephone interviews by trained clinical staff. RESULTS: The final sample included 287,104 patients with follow-up information. The median time to follow-up was 95 days. Overall, more than 90% of the patients within each impairment group were living in the community at follow-up. Follow-up Functional Independence Measure total ratings were stable to slightly increased over time. Change scores (discharge to follow-up) increased in all six groups. The mean Functional Independence Measure gains from discharge to follow-up, as a percentage of mean gains from admission to discharge, varied by impairment category: 46% for spinal cord injury to 71% for lower extremity fracture. Locomotion yielded the lowest ratings at all three assessments within each of the six impairment groups. CONCLUSIONS: The follow-up data from the national sample of patients discharged from inpatient rehabilitation indicate that gains in mean functional independence scores from both admission to discharge and discharge to follow-up gradually increased from 2002 to 2010. At follow-up, more than nine of ten patients in all six groups are living in the community.

Inpatient rehabilitation volume and functional outcomes in stroke, lower extremity fracture, and lower extremity joint replacement.

BACKGROUND: It is unclear if volume-outcome relationships exist in inpatient rehabilitation. OBJECTIVES: Assess associations between facility volumes and 2 patient-centered outcomes in the 3 most common diagnostic groups in inpatient rehabilitation. RESEARCH DESIGN: We used hierarchical linear and generalized linear models to analyze administrative assessment data from patients receiving inpatient rehabilitation services for stroke (n=202,423), lower extremity fracture (n=132,194), or lower extremity joint replacement (n=148,068) between 2006 and 2008 in 717 rehabilitation facilities across the United States. Facilities were assigned to quintiles based on average annual diagnosis-specific patient volumes. MEASURES: Discharge functional status (FIM instrument) and probability of home discharge. RESULTS: Facility-level factors accounted for 6%-15% of the variance in discharge FIM total scores and 3%-5% of the variance in home discharge probability across the 3 diagnostic groups. We used the middle volume quintile (Q3) as the reference group for all analyses and detected small, but statistically significant (P<0.01) associations with discharge functional status in all 3 diagnosis groups. Only the highest volume quintile (Q5) reached statistical significance, displaying higher functional status ratings than Q3 each time. The largest effect was observed in FIM total scores among fracture patients, with only a 3.6-point difference in Q5 and Q3 group means. Volume was not independently related to home discharge. CONCLUSIONS: Outcome-specific volume effects ranged from small (functional status) to none (home discharge) in all 3 diagnostic groups. Patients with these conditions can be treated locally rather than at higher volume regional centers. Further regionalization of inpatient rehabilitation services is not needed for these conditions.

In-patient rehabilitation outcomes following lower extremity fracture in patients with pneumonia.

BACKGROUND: Pneumonia is a common comorbidity among hospitalized older adults and may impede functional restoration and increase medical cost. Medicare reimbursement rates for patients receiving in-patient medical rehabilitation services are higher for individuals who have comorbid pneumonia. We examined the impact of comorbid pneumonia on outcomes for patients with lower extremity fracture receiving in-patient medical rehabilitation services. METHODS: Secondary data analysis of medical records obtained from 919 in-patient rehabilitation facilities in the United States. The sample included 153,241 subjects who received in-patient rehabilitation services following lower extremity fracture in 2005-2007. We used multivariable linear regression to evaluate the independent effects of pneumonia on stay and discharge functional status (Functional Independence Measure instrument), and logistic regression models to explore discharge to home versus not home. RESULTS: Pneumonia was a comorbidity for 4,265 (2.8%) of the subjects with lower extremity fracture. The multivariable models indicated that subjects with no payment-eligible comorbidity experienced shorter stay (regression coefficient -0.44, 95% CI -0.60 to -0.28 d), higher discharge functional status ratings (regression coefficient 1.84, 95% CI 1.42-2.25 points), and higher odds of home discharge (odds ratio 1.19, 95% CI 1.09-1.29), compared to subjects with pneumonia. CONCLUSIONS: Our findings suggest that comorbid pneumonia is associated with poorer rehabilitation outcomes (stay, discharge functional status, and discharge setting) among subjects receiving in-patient rehabilitation services for lower extremity fracture.

The Uniform Data System for Medical Rehabilitation: report of patients with debility discharged from inpatient rehabilitation programs in 2000-2010.

OBJECTIVE: Benchmark data are provided for a national sample of patients who received inpatient rehabilitation for debility. DESIGN: Patients with debility from 830 inpatient rehabilitation facilities in the United States contributing to the Uniform Data System for Medical Rehabilitation from 2000 to 2010 were examined. Demographic information (age, marital status, sex, race/ethnicity, prehospital living setting, and discharge setting), hospital information (length of stay, program interruptions, payer, and codes for admitting diagnosis), and functional status (Functional Independence Measure [FIM] instrument ratings at admission and discharge, FIM change, and FIM efficiency) were analyzed. RESULTS: Data from 2000 to 2010 (N = 260,373) revealed a decrease in mean (SD) FIM total admission ratings from 73.9 (16.2) to 62.5 (15.8). The FIM total discharge ratings decreased from 95.0 (19.7) to 88.2 (19.8). Mean (SD) length of stay decreased from 14.3 (9.1) to 12.1 (6.2) days. The FIM efficiency (change/day) increased from 1.9 (1.7) to 2.4 (1.9). Discharge to community decreased from 80% to 75%. Acute care discharges accounted for 12% of the cases. Policy changes affecting classification, reimbursement, and/or documentation processes may have influenced the results. CONCLUSIONS: National data indicate that the number of debility cases is increasing with diverse composition of etiologic diagnoses. A high proportion of these patients is discharged to acute care compared with other impairment groups.

The uniform data system for medical rehabilitation: report of patients with traumatic spinal cord injury discharged from rehabilitation programs in 2002-2010.

OBJECTIVE: This study aimed to provide benchmarking information from a large national sample of patients receiving inpatient rehabilitation after a traumatic spinal cord injury. DESIGN: This was an analysis of secondary data from 891 inpatient medical rehabilitation facilities in the United States that contributed traumatic spinal cord injury data to the Uniform Data System for Medical Rehabilitation from January 2002 to December 2010. Variables analyzed included demographic information (age, sex, marital status, race/ethnicity, prehospital living setting, discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, International Classification of Diseases 9 codes for admitting diagnosis, co-morbidities), and functional status (Functional Independence Measure [FIM] instrument ratings at admission and discharge, FIM efficiency, FIM gain). RESULTS: The final sample included 47,153 patients with traumatic spinal cord injury. Overall, the mean length of stay was 26.2 ± 23.2 days: yearly means ranged from 29.7 ± 25.4 in 2002 to 22.9 ± 18.9 in 2009. FIM total admission and discharge ratings also declined during the 8-yr study period; admission decreased from 60.5 ± 17.4 to 55.9 ± 16.3; discharge decreased from 86.1 ± 23.8 to 82.4 ± 23.4. Rehabilitation efficiency (FIM gain per day) remained relatively stable over time (1.6 ± 1.7 points per day). The percentage of all patients discharged to the community ranged from 75.8% to 71.5% per year. Wheelchair users stayed in rehabilitation longer than did persons who could walk (34.6 ± 217.4 vs. 17.4 ± 14.1 days) and also experienced less functional improvement (21.6 ± 15.8 vs. 29.6 ± 16.3 FIM points). CONCLUSIONS: National data from persons with traumatic spinal cord injury in 2002-2010 indicate that lengths of stay declined, but efficiency in functional independence was stable to slightly increased. More than 70% of patients were consistently discharged to community settings after inpatient rehabilitation.

Looking back and thinking forward: 20 years of disability and rehabilitation research.

The National Center for Medical Rehabilitation Research recently celebrated its 20th Anniversary. The celebration included a symposium highlighting advances in rehabilitation science over the past 2 decades. The anniversary also reminds us of the challenges that remain in order to strengthen the foundation of disability and rehabilitation research. These challenges have been described in 3 reports published by the Institute of Medicine (IOM) in 1991, 1997, and 2007. Three areas of concern appear across the IOM reports. These include (1) the lack of a comprehensive disability monitoring program, (2) the need for better integration and coordination of federally supported disability research, and (3) funding levels that are inconsistent with the current and projected impacts of disability on individuals, families, and communities. In this commentary we examine the lack of progress in addressing the recommendations contained in the IOM reports. We conclude that renewed efforts by consumers, clinicians, educators, researchers, administrators, and policy makers are needed to achieve the promise of rehabilitation and disability science identified 20 years ago.

Inpatient rehabilitation outcomes for older adults with nondebility generalized weakness.

OBJECTIVE: This study aimed to compare the functional outcomes and discharge locations of older adults admitted to inpatient rehabilitation with debility (International Classification of Diseases, 9th Revision, Clinical Modification, [ICD-9-CM] code 799.3) with those of patients with a nondebility generalized weakness diagnosis (ICD-9-CM codes 728.2, 728.87, and 780.79). DESIGN: This is a retrospective cohort study using 2002-2003 information from the Uniform Data System for Medical Rehabilitation. Patients were 65 yrs or older admitted to inpatient rehabilitation with a primary diagnosis of debility (n = 14,835) and nondebility generalized weakness (n = 6,403). Primary outcome measures were change in functional status, including efficiency (functional status change divided by length of stay in days), and discharge setting. RESULTS: The efficiency of the patients with nondebility generalized weakness (1.8 ± 1.9) was statistically greater than that of patients with debility (1.7 ± 2.1, P = 0.002), and significantly more patients with nondebility generalized weakness were discharged home (70% vs. 68%, P = 0.003). CONCLUSIONS: From a clinical standpoint, the functional recovery and rate of discharge to home of inpatient rehabilitation patients with nondebility generalized weakness are nearly identical to those of patients with debility. Although it would require a policy change, we recommend using a single diagnostic code for all of these patients to further research in this area of rehabilitation.