Predictors of discharge to home/community following inpatient-rehabilitation in a US national sample of Guillain-Barre-Syndrome patients.

BACKGROUND: Guillain-Barre-Syndrome (GBS), an autoimmune polyneuropathy causing acute flaccid paralysis, is a rare condition with1-2 cases per 100,000 annually (approximately 5000 cases/year) in the United States (US). There is a paucity of published data regarding patient outcomes in association with discharge destinations following inpatient-rehabilitation (IR) in this patient population, thus this study. OBJECTIVES: To analyze IR efficacy, and possible predictors of discharge to home/community in a US-national-sample of GBS patients. METHODS: Retrospective-observational-cohort study of 1304 GBS patients admitted to IR comparing discharge disposition destinations (community/home, skilled-nursing-facility [SNF], or return to acute-care) by demographic (age, gender) and clinical variables (length-of-stay [LOS], case-mix-index [CMI], and Functional-Independence-Measure [FIM] score changes). Multinomial-logistic-regression and discriminant-function-analysis were performed to determine model fit in predicting discharge destination. RESULTS: 81.8% were discharged to home/community- average LOS 19-days, total-FIM-gain 43.2; 9.8% discharged to SNFs- average LOS 27.5-days, total-FIM-gain 27.2; and 8.4% discharged to acute-care- average LOS 15.4-days and total-FIM-gain 16.5, (F = 176, p < .001). Stepwise-linear-regression for prediction of community discharge showed change in FIM-Bed/chair/wheelchair-Transfers was the most significant predictor (Wald = 42.2; p < .001), followed by CMI (Wald = 26.9; p < .001), change in FIM-walking/wheelchair (Wald = 14.9; p < .001), and age (Wald = 9.5; p < .002). Using discriminant-function-analysis to test model validity for predicting discharge disposition, FIM-change for Bed/chair/wheelchair Transfers, Walking, and Self-Care as predictors resulted in a classification rate of 78.1%, 92% of variance explained, and Eigenvalue of .53 (p < .001). CONCLUSIONS: Total-FIM scores improved in all groups, and most patients were discharged to home/community suggesting IR efficacy. The ability to transfer bed/chair/wheelchair was the most important predictive factor associated with discharge destination.

Comparison of Patients Discharged to Skilled Nursing and Inpatient Rehabilitation Facilities After Hospitalization for COVID-19: A Retrospective Study.

OBJECTIVE: The aim of the study is to identify differences in demographics, severity of disease, and rates of hospital readmission among adults discharged to skilled nursing facilities and inpatient rehabilitation facilities after hospitalization for coronavirus 2019. DESIGN: This is a retrospective cohort study of adults hospitalized with coronavirus 2019 infection at academic medical centers participating in the Vizient Clinical Data Base between April 1, 2020, and June 30, 2021, who were discharged to skilled nursing facilities or inpatient rehabilitation facilities ( N = 39,882). Data from the Clinical Data Base are used with permission of Vizient, Inc. All rights reserved. RESULTS: Among adults hospitalized with coronavirus 2019 infection, those discharged to skilled nursing facilities were 1.4 times more likely to require hospital readmission than those discharged to inpatient rehabilitation facilities. They were, on average, older (73 vs. 61 yrs, P < 0.001) and had shorter hospital lengths of stay (15 vs. 26 days, P < 0.0001) than the patients discharged to inpatient rehabilitation facilities. Persons discharged to inpatient rehabilitation facilities were more likely to have received intensive care and mechanical ventilation while hospitalized ( P < 0.001). CONCLUSIONS: Individuals discharged to inpatient rehabilitation facilities after hospitalization for coronavirus 2019 differ from those discharged to skilled nursing facilities on a number of key variables, including age, hospital length of stay, having received intensive care, and odds of hospital readmission.

Psychosocial and Functional Predictors of Depression and Anxiety Symptoms in Veterans and Service Members With TBI: A VA TBI Model Systems Study.

OBJECTIVE: To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI). SETTING: Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS). PARTICIPANTS: A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations. DESIGN: Secondary analysis from multicenter prospective longitudinal study. MAIN MEASURES: Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale. RESULTS: The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores. CONCLUSION: Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Influence of Prior and Intercurrent Brain Injury on 5-Year Outcome Trajectories After Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To characterize the influence of additional (both prior and subsequent) traumatic brain injuries (TBIs) on recovery after a moderate to severe index TBI. SETTING: Traumatic Brain Injury Model Systems centers. PARTICIPANTS: Persons with moderate to severe TBI (N = 5054) enrolled in the TBI Model Systems National Database with complete outcome data for the outcomes of interest at 1-, 2-, and 5-year follow-up. DESIGN: Secondary analysis of a prospective longitudinal data set. MAIN MEASURES: Prior and intercurrent TBI from the Ohio State University TBI Identification Method (OSU TBI-ID), Disability Rating Scale (DRS), and Functional Independence Measure (FIM). RESULTS: Prior moderate-severe TBIs significantly predicted overall level of functioning on the DRS, FIM Cognitive, and FIM Motor for participants with less severe index injuries. Moderate-severe intercurrent TBIs (TBIs subsequent to the index injury) were predictive of poorer functioning for both Index Severity groups, reflected in higher mean scores on the DRS in participants with less severe index injuries and lower mean Cognitive FIM in participants with more severe index injuries. CONCLUSION: Multiple brain injuries, particularly those of moderate or greater severity, have a significantly greater impact on patients' level of functioning compared with a single injury, but not the rate or shape of recovery.

Swallowing Outcomes and Discharge Destinations in Acute Stroke Tube-Feeding Dependent Dysphagia Patients Treated With Neuromuscular Electrical Stimulation During Inpatient Rehabilitation.

OBJECTIVE: Inpatient rehabilitation study comparing swallowing outcomes and discharge destinations in acute stroke tube-feeding dependent dysphagia patients treated with neuromuscular electrical stimulation and traditional dysphagia therapy versus those treated with only traditional dysphagia therapy. DESIGN: Retrospective case-control study including 359 patients with acute stroke having initial Functional Oral Intake Scale scores of 3 or lower (profound to severe tube-feeding dependent dysphagia). One hundred ninety participants received neuromuscular electrical stimulation with traditional dysphagia therapy, and 169 controls received only traditional dysphagia therapy. Treatment occurred in hourly sessions 5 d/wk. Main outcome measures were comparison of Functional Oral Intake Scale scores after treatment (N = 359) and comparison of discharge destinations (n = 267). RESULTS: The neuromuscular electrical stimulation posttreatment mean ± SD Functional Oral Intake Scale score was 4.21 ± 2.1 versus 2.94 ± 1.96 for controls (t = 5.85, P < 0.001). The neuromuscular electrical stimulation group posttreatment mean ± SD Functional Oral Intake Scale gain was 3.24 ± 2.26 points versus 1.87 ± 2.01 for controls (t = 6.05, P < 0.001). After treatment, 51.6% (98/190) neuromuscular electrical stimulation patients had minimal or no swallowing restrictions (Functional Oral Intake Scale scores = 5-7), whereas only 26.6% (45/169) controls improved with Functional Oral Intake Scale scores of 5-7 (χ = 23.3, P < 0.0001). Groups differed by discharge destinations: neuromuscular electrical stimulation having more discharges to community than controls, 60% versus 44% (χ = 9.16, P = 0.003), and neuromuscular electrical stimulation having fewer acute care transfers compared with controls, 8% versus 25% (χ = 32.7, P < 0.0001). CONCLUSIONS: Neuromuscular electrical stimulation with traditional dysphagia therapy was associated with better discharge swallowing outcomes and Functional Oral Intake Scale scores than traditional dysphagia therapy alone during inpatient rehabilitation in treating acute stroke feeding tube-dependent dysphagia and was associated with more discharges to community and less transfers back to acute care.

Neurocognitive status and return to work after moderate to severe traumatic brain injury.

PURPOSE/OBJECTIVE: To examine the relationship of cognitive status to employment outcomes at 1-year post moderate-severe traumatic brain injury (TBI), using a brief telephone-administered instrument. Research Method/Design: Prospective longitudinal study in which 320 people with moderate-severe TBI, all employed at injury, were enrolled during inpatient rehabilitation and evaluated at 1-year postinjury. Follow-up measures included whether and when participants had returned to work (RTW), and cognitive status assessed with the Brief Test of Adult Cognition by Telephone (BTACT). Multivariable logistic regression and survival analyses were used to assess the contribution of BTACT (overall and subscale scores) to employment outcomes, controlling for covariates with known associations to those outcomes, including demographic variables, injury severity, and driving status. RESULTS: Fewer than 40% of participants (n = 124) were employed at 1-year follow-up. BTACT scores were strongly associated with RTW even after controlling for known covariates. Females had faster and higher rates of RTW compared to males. Resumption of driving and injury severity were also related to RTW. CONCLUSIONS/IMPLICATIONS: Neurocognitive status is a potentially modifiable factor with an important relationship to RTW following TBI. Vocational rehabilitation efforts should provide cognitive remediation or compensation as well as addressing transportation barriers. As a brief telephone-based assessment, the BTACT offers a new and efficient tool for evaluation of episodic memory and executive function. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Relationship Between Hispanic Nativity, Residential Environment, and Productive Activity Among Individuals With Traumatic Brain Injury: A TBI Model Systems Study.

OBJECTIVE: To examine the influence of nativity and residential characteristics on productive activity among Hispanics at 1 year after traumatic brain injury (TBI). SETTING: Acute rehabilitation facilities and community follow-up. PARTICIPANTS: A total of 706 Hispanic individuals in the TBI Model Systems National Database. DESIGN: Secondary data analysis from a multicenter longitudinal cohort study. MAIN MEASURES: Nativity (foreign born or US native), productive activity derived from interview questions regarding employment status, and other demographic information. Census data were extracted by zip code to represent residential characteristics of aggregate household income and proportion of foreign language speakers (FLS). RESULTS: Among foreign-born individuals with TBI, those living in an area with a higher proportion of FLS were 2.8 times more likely to be productive than those living in areas with a lower proportion of FLS. Among individuals living in an area with a lower proportion of FLS, US-born Hispanics were 2.7 times more likely to be productive compared with Hispanic immigrants. CONCLUSION: The relationship between nativity and productive activity at 1 year post-TBI was moderated by the residential proportion of FLS. Findings underscore the importance of considering environmental factors when designing vocational rehabilitation interventions for Hispanics after TBI.

Obesity and Overweight Problems Among Individuals 1 to 25 Years Following Acute Rehabilitation for Traumatic Brain Injury: A NIDILRR Traumatic Brain Injury Model Systems Study.

OBJECTIVE: Examine the prevalence of weight classifications and factors related to obesity/overweight among persons 1 to 25 years following traumatic brain injury (TBI) using the Traumatic Brain Injury Model Systems national database. DESIGN: Multicenter, cross-sectional, observational design. SETTING: Traumatic Brain Injury Model Systems inpatient rehabilitation facilities. PARTICIPANTS: Persons (N = 7287) 1, 2, 5, 10, 15, 20, or 25 years after TBI who required inpatient acute rehabilitation. MAIN OUTCOME MEASURES: Body mass index, demographic characteristics, functional, health, satisfaction with life, and global outcomes. RESULTS: Overall postinjury weight prevalence rates were 23% obese, 36% overweight, 39% normal, and 3% underweight. Higher rates for obesity and overweight problems were associated with increasing time since injury. Younger (18-19 years) and older (80+ years) age, those in a vegetative state, and those reporting excellent health were less likely to be obese. Individuals with a history of hypertension, heart failure, or diabetes were more likely to be obese. CONCLUSIONS: Being obese or overweight presents a health risk in the years following rehabilitation for TBI. The findings support the need for longitudinal studies and highlight the advisability of monitoring weight and promoting healthy lifestyle behaviors over time in survivors of TBI.

Association of Urinary Incontinence with Cognition, Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation.

BACKGROUND: Acute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination. OBJECTIVE: To examine if urinary incontinence is associated with inpatient-rehabilitation (IR) outcomes in cognition, transfers, and discharge destinations. DESIGN: Retrospective observational study of 303 of 579(52%) acute-stroke patients admitted to IR 2012-2015 with complete urinary incontinence (total assistance for bladder management). Discharge Functional Independence Measure (FIM) scores were correlated for continence, cognition, transfers-(bed/chair/wheelchair), and discharge destination. RESULTS: Patients were admitted to IR on average 7.4 days after acute stroke. Average length-of-stay in IR was 14 days. At discharge 118 of 303(39%) remained urinary incontinent (total assistance). Continence/bladder-management FIM scores at discharge were associated with cognition FIM scores at discharge (chi square =105.8; P < .0001), and associated with transfer FIM scores at discharge (chi square = 153.1; P < .0001). Patients total to moderate assistance for continence at discharge included greater percentage that were dependent to moderate assistance for cognition and transfers than those minimal assistance to independent for continence. Continence/bladder-management FIM scores at discharge were associated with discharge disposition destinations (chi square = 29.98; P < .002). Patients total to moderate assistance for continence at discharge included greater percentage of acute care transfers, and skilled-nursing-facility dispositions, than patients that recovered to minimal assist to independent for continence. Urinary-incontinence recovery to minimal assistance to independent was associated with a home/community disposition rate of 82%. CONCLUSIONS: 52% stroke patients were total assistance with bladder management for urinary incontinence on IR admission. Partial to complete continence recovery occurred in 61%. Continence/bladder-management FIM scores at discharge were associated with cognition and transfer FIM scores, and discharge destinations.

Clinical Neuropsychology in Integrated Rehabilitation Care Teams.

Neuropsychologists have been an integral part of rehabilitation-oriented integrated care teams for some time and they provide care that is complimentary to other specialties, such as rehabilitation psychologists. Neuropsychologists are more likely than other specialties to offer objective cognitive data that includes consideration of emotional and behavioral features when assessing patients who have known or suspected brain injury or illness. Objective cognitive data is then often used for treatment and discharge planning as well as anticipating safety issues and impairment of functional skills. Unlike a consultative model, neuropsychologists in rehabilitation must work as part of a team of rehabilitation professionals and understand the contributions each specialty offers patients. This paper will highlight a number of issues pertaining to the practice of neuropsychology in rehabilitation settings including: (i) essential skills and duties, (ii) reimbursement, (iii) practice specifics, (iv) types of recommendations, (v) communication issues, (vi) impact of neuropsychological services, (vii) role satisfaction; (viii) advice for early career neuropsychologists, and (ix) a sample report.

The Feasibility of Telephone-Administered Cognitive Testing in Individuals 1 and 2 Years after Inpatient Rehabilitation for Traumatic Brain Injury.

Traumatic brain injury (TBI) often results in cognitive impairment, and trajectories of cognitive functioning can vary tremendously over time across survivors. Traditional approaches to measuring cognitive performance require face-to-face administration of a battery of objective neuropsychological tests, which can be time- and labor-intensive. There are numerous clinical and research contexts in which in-person testing is undesirable or unfeasible, including clinical monitoring of older adults or individuals with disability for whom travel is challenging, and epidemiological studies of geographically dispersed participants. A telephone-based method for measuring cognition could conserve resources and improve efficiency. The objective of this study is to examine the feasibility and usefulness of the Brief Test of Adult Cognition by Telephone (BTACT) among individuals who are 1 and 2 years post-moderate-to-severe TBI. A total of 463 individuals participated in the study at Year 1 post-injury, and 386 participated at Year 2. The sample was mostly male (73%) and white (59%), with an average age of (mean ± standard deviation) 47.9 ± 20.9 years, and 73% experienced a duration of post-traumatic amnesia (PTA) greater than 7 days. A majority of participants were able to complete the BTACT subtests (61-69% and 56-64% for Years 1 and 2 respectively); score imputation for those unable to complete a test due to severity of cognitive impairment yields complete data for 74-79% of the sample. BTACT subtests showed expected changes between Years 1-2, and summary scores demonstrated expected associations with injury severity, employment status, and cognitive status as measured by the Functional Independence Measure. Results indicate it is feasible, efficient, and useful to measure cognition over the telephone among individuals with moderate-severe TBI.

Sleep quality in well-defined Lyme disease: a clinical cohort study in Maryland.

Study Objectives: Lyme disease (LD) is the most common vector-borne disease in the United States. Approximately 5-15 per cent of patients develop postantibiotic treatment symptoms termed post-treatment Lyme disease syndrome (PTLDS). The primary objective of this study is to examine and quantify sleep quality among patients with early LD during the acute and convalescent periods, including among the subset who met criteria for PTLDS. Methods: This paper draws from a clinical cohort study of participants with early LD (n = 122) and a subcohort of individuals who later met criteria for PTLDS (n = 6). Participants were followed for 1 year after antibiotic treatment. The Pittsburgh Sleep Quality Index and standardized measures of pain, fatigue, depressive symptoms, and functional impact were administered at all visits for participants and controls (n = 26). Participants meeting criteria for PTLDS at 1 year post-treatment were compared with a subset of PSQI-defined poor sleeping controls (n = 10). Results: At the pretreatment visit, participants with early LD reported poorer sleep than controls. By 6 months post-treatment, participant sleep scores as a group returned to control levels. Participants with PTLDS reported significantly worse global sleep and sleep disturbance scores and worse fatigue, functional impact, and more cognitive-affective depressive symptoms compared with poor sleeping controls. Conclusions: Participants with early LD experienced poor sleep quality, which is associated with typical LD symptoms of pain and fatigue. In the subset of patients who developed PTLDS, sleep quality remains affected for up to 1 year post-treatment and is commonly associated with pain. Sleep quality should be considered in the clinical picture for LD and PTLDS.

Deciding to adopt revised and new psychological and neuropsychological tests: an inter-organizational position paper.

OBJECTIVE: Neuropsychological tests undergo periodic revision intended to improve psychometric properties, normative data, relevance of stimuli, and ease of administration. In addition, new tests are developed to evaluate psychological and neuropsychological constructs, often purporting to improve evaluation effectiveness. However, there is limited professional guidance to neuropsychologists concerning the decision to adopt a revised version of a test and/or replace an older test with a new test purporting to measure the same or overlapping constructs. This paper describes ethical and professional issues related to the selection and use of older versus newer psychological and neuropsychological tests, with the goal of promoting appropriate test selection and evidence-based decision making. METHOD: Ethical and professional issues were reviewed and considered. CONCLUSIONS: The availability of a newer version of a test does not necessarily render obsolete prior versions of the test for purposes that are empirically supported, nor should continued empirically supported use of a prior version of a test be considered unethical practice. Until a revised or new test has published evidence of improved ability to help clinicians to make diagnostic determinations, facilitate treatment, and/or assess change over time, the choice to delay adoption of revised or new tests may be viewed as reasonable and appropriate. Recommendations are offered to facilitate decisions about the adoption of revised and new tests. Ultimately, it is the responsibility of individual neuropsychologists to determine which tests best meet their patients' needs, and to be able to support their decisions with empirical evidence and sound clinical judgment.

Standardized Symptom Measurement of Individuals with Early Lyme Disease Over Time.

OBJECTIVE: Understanding the Lyme disease (LD) literature is challenging given the lack of consistent methodology and standardized measurement of symptoms and the impact on functioning. This prospective study incorporates well-validated measures to capture the symptom picture of individuals with early LD from time of diagnosis through 6-months post-treatment. METHOD: One hundred seven patients with confirmed early LD and 26 healthy controls were evaluated using standardized instruments for pain, fatigue, depressive symptoms, functional impact, and cognitive functioning. RESULTS: Prior to antibiotic treatment, patients experience notable symptoms of fatigue and pain statistically higher than controls. After treatment, there are no group differences, suggesting that symptoms resolve and that there are no residual cognitive impairments at the level of group analysis. However, using subgroup analyses, some individuals experience persistent symptoms that lead to functional decline and these individuals can be identified immediately post-completion of standard antibiotic treatment using well-validated symptom measures. CONCLUSIONS: Overall, the findings suggest that ideally-treated early LD patients recover well and experience symptom resolution over time, though a small subgroup continue to suffer with symptoms that lead to functional decline. The authors discuss use of standardized instruments for identification of individuals who warrant further clinical follow-up.

Discriminating cognitive screening and cognitive testing from neuropsychological assessment: implications for professional practice.

OBJECTIVE: To provide clarification on the distinction between cognitive screening, cognitive testing, and neuropsychological assessment and highlight practical implications. METHOD: Non-systematic brief clinical review. RESULTS: There is a present lack of explicit distinction between the various levels of measurement of cognitive functioning with regard to goals, indications for use, levels of complexity, and outcome. There is also a lack of guidance regarding the identification of who should be responsible for the administration and interpretation at each level. CONCLUSIONS: There is a growing awareness of the importance of cognitive health and disability, and of the importance of measurement of cognitive functions across the lifespan. For example, cognitive screening has been mandated by the Patient Protection and Affordable Care Act of 2010, and language contained within new psychiatric diagnostic criteria and healthcare regulatory changes reflect increased consideration of the importance of measurement of cognition. Changes such as these necessitate greater clarity on this important issue as it bears implications for professional practice, which ranges from education and training competencies, practice standards, and the way that neuropsychologists clarify and advocate for the value of specialty referrals for comprehensive assessment in a competitive and ever-changing healthcare market.

Prognostic models for predicting posttraumatic seizures during acute hospitalization, and at 1 and 2 years following traumatic brain injury.

OBJECTIVE: Posttraumatic seizures (PTS) are well-recognized acute and chronic complications of traumatic brain injury (TBI). Risk factors have been identified, but considerable variability in who develops PTS remains. Existing PTS prognostic models are not widely adopted for clinical use and do not reflect current trends in injury, diagnosis, or care. We aimed to develop and internally validate preliminary prognostic regression models to predict PTS during acute care hospitalization, and at year 1 and year 2 postinjury. METHODS: Prognostic models predicting PTS during acute care hospitalization and year 1 and year 2 post-injury were developed using a recent (2011-2014) cohort from the TBI Model Systems National Database. Potential PTS predictors were selected based on previous literature and biologic plausibility. Bivariable logistic regression identified variables with a p-value < 0.20 that were used to fit initial prognostic models. Multivariable logistic regression modeling with backward-stepwise elimination was used to determine reduced prognostic models and to internally validate using 1,000 bootstrap samples. Fit statistics were calculated, correcting for overfitting (optimism). RESULTS: The prognostic models identified sex, craniotomy, contusion load, and pre-injury limitation in learning/remembering/concentrating as significant PTS predictors during acute hospitalization. Significant predictors of PTS at year 1 were subdural hematoma (SDH), contusion load, craniotomy, craniectomy, seizure during acute hospitalization, duration of posttraumatic amnesia, preinjury mental health treatment/psychiatric hospitalization, and preinjury incarceration. Year 2 significant predictors were similar to those of year 1: SDH, intraparenchymal fragment, craniotomy, craniectomy, seizure during acute hospitalization, and preinjury incarceration. Corrected concordance (C) statistics were 0.599, 0.747, and 0.716 for acute hospitalization, year 1, and year 2 models, respectively. SIGNIFICANCE: The prognostic model for PTS during acute hospitalization did not discriminate well. Year 1 and year 2 models showed fair to good predictive validity for PTS. Cranial surgery, although medically necessary, requires ongoing research regarding potential benefits of increased monitoring for signs of epileptogenesis, PTS prophylaxis, and/or rehabilitation/social support. Future studies should externally validate models and determine clinical utility.

Evaluating the Siebens Model in Geriatric-Stroke Inpatient Rehabilitation to Reduce Institutionalization and Acute-Care Readmissions.

BACKGROUND: The objective of the study is to evaluate the use of Siebens Domain Management Model (SDMM) in geriatric-stroke patients during inpatient rehabilitation (IR) to increase functional independence, and to reduce institutionalization and acute-care readmissions, which are quality indicators under the U.S. Affordable Care Act. METHODS: In 2010 (preintervention), 66 stroke patients aged more than 75 years were admitted to an IR facility, on average, 8.8 days postacute care. In 2012 (postintervention), 58 patients aged more than 75 years were admitted to the same IR facility, on average, 5.0 days postacute care. SDMM intervention involved weekly adjustments of clinical care focused on potential barriers to discharge home. Functional Independence Measure (FIM) efficiency, length of stay (LOS), and disposition rates to community or home, acute care, and long-term care were compared pre- and postintervention within facility, and facility data were compared to national case-mix-group-adjusted data from the Uniform Data System for Medical Rehabilitation for both years (2010/2012). RESULTS: Pre- and postintervention demographics and prestroke living support/setting were similar, but preintervention had on average 4 more days LOS in IR and 3.8 more days to IR onset. There were significantly more discharges to community in postintervention (79.3%) compared to preintervention (56.9%) (chi-square = 6.02, P < .013). The preintervention group did not significantly differ from 2010 national data whereas the postintervention/2012 group significantly differed from 2012 national data for higher FIM efficiency (t = -3.1, P < .002) and more discharges to community (chi-square = 19.7; P < .0001). From 2010 to 2012, there were 3.8 times more discharges to community (chi-square = 8535; P < .0001) and 6 times fewer acute-care dispositions postintervention than nationally (chi-square = 58.7; P < .0001).

Evaluating Siebens Domain Management Model for inpatient rehabilitation to increase functional independence and discharge rate to home in geriatric patients.

OBJECTIVE: To evaluate the Siebens Domain Management Model (SDMM) for geriatric inpatient rehabilitation (IR) to increase functional independence and dispositions to home. DESIGN: Before and after study. SETTING: IR facility. PARTICIPANTS: During 2010 (preintervention), 429 patients aged ≥75 years who were on average admitted to IR 8.2 days postacute care, and during 2012 (postintervention), 524 patients aged ≥75 years who were on average admitted to IR 5.5 days postacute care. Case-mix group (CMG) comorbidity tier severity, preadmission living setting, and living support were similar in both groups. INTERVENTION: The SDMM involving weekly adjustments of IR care focused on potential barriers to discharge home. MAIN OUTCOME MEASURES: FIM efficiency, length of stay (LOS), and disposition rates to community/home, acute care, and long-term care (LTC) to compare pre-/postintervention facility data and comparison of facility to national CMG-adjusted data from the Uniform Data System for Medical Rehabilitation for both years (2010/2012). RESULTS: Pre-/postintervention group admission FIM scores were similar (t=2.96, P<.003), but the preintervention group had on average 2.6 days greater LOS during IR and greater time to onset of IR (8.2 vs 5.5d) from acute care. Preintervention FIM efficiency was 2.1, whereas postintervention FIM efficiency was 2.76, a significant difference (t=4.1, P<.0001). There were significantly more discharges to the community in the postintervention group (74.4%) than the preintervention group (58.5%, χ(2)=26.2, P<.0001). There were significantly fewer patients discharged to LTC in the postintervention group (χ(2)=30.47, P<.0001). The preintervention group did not significantly differ from the 2010 national data, but the postintervention group significantly differed from the 2012 national data for both greater FIM efficiency (t=-5.5, P<.0001) and greater discharge to community (χ(2)=34, P<.0001). LOS decreased by 2.6 days in the postintervention group compared with the preintervention group, whereas LOS decreased by only 0.6 days nationally from 2010 to 2012, a significant difference with postintervention LOS lower than the national data (t=31.1, P<.0001). CONCLUSIONS: Use of the SDMM during IR in geriatric patients is associated with increased functional independence and discharges to home/community and reduced institutionalization.

Evaluating use of the Siebens Domain Management Model during inpatient rehabilitation to increase functional independence and discharge rate to home in stroke patients.

OBJECTIVE: To evaluate use of the Siebens Domain Management Model (SDMM) during stroke inpatient rehabilitation (IR) to increase functional independence and rate of discharge to home. DESIGN: Before and after study. SETTING: IR facility. PARTICIPANTS: Before the intervention: 154 patients with ischemic/hemorrhagic strokes who were admitted to an IR facility in 2010; on average, they were admitted 9.1 days after receiving acute care. After the intervention: 151 patients with ischemic/hemorrhagic strokes who were admitted to an IR facility in 2012; on average they were admitted 7.3 days after receiving acute care. The comorbidity tier severity and prestroke living setting and living support appeared to be similar in both the preintervention and postintervention groups. INTERVENTION: Use of the SDMM involving weekly adjustments of IR care focused on potential barriers to discharge home including medical/surgical issues, cognitive/emotional coping issues, physical function, and living environment/community re-entry needs. MAIN OUTCOME MEASURES: Use of Functional Independence Measure (FIM) score change during IR length of stay (LOS; FIM-LOS efficiency) and rates of discharge to community/home, acute care, and long-term care (LTC) to compare 2010/preintervention data with postintervention data from 2012, along with comparison of facility data to national aggregate data from the Uniform Data System for Medical Rehabilitation (UDSMR) for both years. RESULTS: Preintervention 2010 FIM-LOS efficiency was 1.44 compared with a 2012 postintervention FIM-LOS efficiency of 2.24, which was significant (t = 4.3; P < .0001). Comparison of the UDSMR 2012 national FIM-LOS efficiency score (1.72) to the 2012 postintervention score of 2.24 reached significance (t = 2.6; P < .01). In addition, a significant difference was found between groups for discharge location: In the preintervention group, 57.8% were discharged to home/community, 14.9% to LTC, and 27.3% back to acute care compared with the postintervention group, in which 81.2% were discharged to home/community, 9.4% to LTC, and 9.4% back to acute care (χ(2) = 8.98; P < .001). Also significant was comparison between the 2012 postintervention group and the 2012 national UDSMR data for the same 3 discharge locations (χ(2) = 3.94; P < .05). Comparison of 2010 to 2012 facility data then shows a 23.4% increase in discharge to the community compared with an increase of 5.8% for the UDSMR 2010 to 2012 data, representing a community discharge rate that is 4 times greater for the 2012 facility postintervention group (χ(2) = 83.596; P < .0001). CONCLUSIONS: Use of the SDMM during stroke IR may convey improvement in functional independence and is associated with an increased discharge rate to home/community and a reduction in institutionalization and acute-care transfers.