ICF framework in cardiac rehabilitation: a real-life implementation in post-cardiac surgery and chronic heart failure patients.

BACKGROUND: The International Classification of Functioning, Disability, and Health (ICF) is growing in importance in cardiac rehabilitation (CR) as the number of elderly comorbid patients increases. AIM: To classify through the ICF framework a group of post-cardiac surgery (CS) and chronic heart failure (CHF) patients undergoing rehabilitation. Then, to compare the two groups and identify possible factors at admission that could affect ICF evaluations at discharge. DESIGN: Observational retrospective real-life study. SETTING: Two inpatient CR units. POPULATION: Consecutive CS and CHF patients admitted for CR (January-December 2019). METHODS: Clinical, anthropometric data and functional status at admission and discharge were extracted from patient health records. A set of 26 ICF codes regarding body functions (b) and activities (d) was analyzed to identify: 1) the qualifiers attributed (from 0=no impairment to 4=severe impairment) for each code, 2) the percent distribution of qualifiers (0/1/2/3/4) attributed per patient. We then evaluated changes in both (1) and (2 - defined as ICF Delta%) from admission to discharge. RESULTS: All patients (55% males; mean age 73±12 years) showed an improvement post-rehabilitation in the ICF qualifiers attributed (P<0.0001 for all codes). CS patients (N.=150) were less functionally impaired at admission than CHF (N.=194) (P<0.05 for all codes), and at discharge showed greater Delta% in the qualifiers 0/1/2 attributed than CHF (P<0.0001 for b codes; P<0.05 for d codes). Delta% for qualifiers 3 and 4 was similar in the two groups. No impairment at admission (qualifier 0), CS group, and presence/complexity of comorbidities were identified as possible covariates influencing ICF qualifiers at discharge, impacting the rate of both no/mild impairment (ICF% aggregate 0+1 - adjusted R2=0.627; P<0.0001) and moderate impairment (ICF% qualifier 2 - adjusted R2=0.507; P<0.0001). CONCLUSIONS: CHF patients showed a worse ICF picture at admission and less improvement at discharge than CS. The presence and complexity of comorbidities negatively influenced the ICF classification at discharge, especially in CHF patients. CLINICAL REHABILITATION IMPACT: This study shows the utility of ICF classification in CR as a means for describing, measuring, and comparing patient functioning across the care continuum.

Patients recovering from exacerbations of COPD with and without hospitalization need: could ICF score be an additional pulmonary rehabilitation outcome?

OBJECTIVE: To compare disability changes measured with the Respiratory ICF Maugeri core set on COPD patients, recovering from acute exacerbation with and without hospitalization, submitted to pulmonary rehabilitation (PR). MATERIALS AND METHODS: All COPD inpatients admitted for rehabilitation in 9 Respiratory Units (January-August 2019) were considered eligible. 2066 patients were included (540 discharged from an acute Hospital = Hospital group and 1526 coming from their home = Home group). Healthcare professionals filled, in a digitalized chart, the Respiratory ICF Maugeri core set (26 items), assessing ICF categories at admission and discharge. RESULTS: The baseline distribution of the more severe ICF qualifiers was higher in the Hospital group (p < .001) when compared to the Home group. After rehabilitation, all patients -irrespective of hospitalization need- statistically decreased the rate of the higher ICF qualifiers (p < .0001). Hospital group improved more both the rate of qualifiers ≥2 [Δ: -21.32 (22.41) vs -15.48 (17.32), p < .001] and the rate of qualifiers 0-1 [Δ: + 18.38 (24.67) vs 13.25 (19.13), p < .001] than Home group. CONCLUSIONS: Disability measured with the "Respiratory ICF Maugeri core set" after PR improves in COPD patients recovering from acute exacerbation irrespective of hospitalization need. Its use an additional outcome remains to be further elucidated.KEY MESSAGESRoutine implementation of an ICF set for chronic respiratory diseases can enhance a patient-centered approach in rehabilitation for different severity conditions.Pulmonary rehabilitation (PR) seems to improve global disability measured with the Respiratory ICF Maugeri core set in COPD patients recovering from acute exacerbation irrespective of hospitalization need, suggesting the use of ICF set as additional PR outcome.The description, through the ICF language, of rehabilitative needs of patients, coming "from-Home" and "from-Hospital" settings, could help staff and instrument organization.

Patients recovering from COVID-19 pneumonia in sub-acute care exhibit severe frailty: Role of the nurse assessment.

AIMS AND OBJECTIVES: To document the level of frailty in sub-acute COVID-19 patients recovering from acute respiratory failure and investigate the associations between frailty, assessed by the nurse using the Blaylock Risk Assessment Screening Score (BRASS), and clinical and functional patient characteristics during hospitalisation. BACKGROUND: Frailty is a major problem in patients discharged from acute care, but no data are available on the frailty risk in survivors of COVID-19 infection. DESIGN: A descriptive cross-sectional study (STROBE checklist). METHODS: At admission to sub-acute care in 2020, 236 COVID-19 patients (median age 77 years - interquartile range 68-83) were administered BRASS and classified into 3 levels of frailty risk. The Short Physical Performance Battery (SPPB) was also administered to measure physical function and disability. Differences between BRASS levels and associations between BRASS index and clinical parameters were analysed. RESULTS: The median BRASS index was 14.0 (interquartile range 9.0-20.0) denoting intermediate frailty (32.2%, 41.1%, 26.7% of patients exhibited low, intermediate and high frailty, respectively). Significant differences emerged between the BRASS frailty classes regards to sex, comorbidities, history of cognitive deficits, previous mechanical ventilation support and SPPB score. Patients with no comorbidities (14%) exhibited low frailty (BRASS: median 5.5, interquartile range 3.0-12.0). Age ≥65 years, presence of comorbidities, cognitive deficit and SPPB % predicted <50% were significant predictors of high frailty. CONCLUSIONS: Most COVID-19 survivors exhibit substantial frailty and require continuing care after discharge from acute care. RELEVANCE TO CLINICAL PRACTICE: The BRASS index is a valuable tool for nurses to identify those patients most at risk of frailty, who require a programme of rehabilitation and community reintegration.

Minimal Clinically Important Difference in Barthel Index Dyspnea in Patients with COPD.

Background: The Barthel Index dyspnea (BId) is responsive to physiological changes and pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). However, the minimum clinically important difference (MCID) has not been established yet. Aim: To identify the MCID of BId in patients with COPD stratified according to the presence of chronic respiratory failure (CRF) or not. Materials and Methods: Using the Medical Research Council (MRC) score as an anchor, receiver operating characteristic curves and quantile regression were retrospectively evaluated before and after pulmonary rehabilitation in 2327 patients with COPD (1151 of them with CRF). Results: The median post-rehabilitation changes in BId for all patients were -10 (interquartile range = -17 to -3, p<0.001), correlating significantly with changes in MRC (r = 0.57, 95% CI = 0.53 to 0.59, p<0.001). Comparing different methods of assessment, the MCID ranged from -6.5 to -9 points for patients without and -7.5 to -12 points for patients with CRF. Conclusion: The most conservative estimate of the MCID is -9 points in patients with COPD, without and -12 in those with CRF. This estimate may be useful in the clinical interpretation of data, particularly in response to intervention studies.

Implementation of a real-world based ICF set for the rehabilitation of respiratory diseases: a pilot study.

BACKGROUND: International Classification Functioning (ICF) Core Sets represent a holistic approach to functioning within rehabilitation field. Information-reporting efficacy of a rehabilitation-based Respiratory ICF set applied on a large scale throughout the ICS Maugeri network was tested. METHODS: A prospective multi-center study (May-November 2018) was conducted for all respiratory inpatients consecutively admitted for rehabilitation. Doctors, physiotherapists, psychologists, nurses used an electronic Respiratory ICF set (33 items among the ICF body functions, activity and participations components) at admission and at discharge to assess the disability changes. The ICF report qualifiers, from 0 (no impairment) to 4 (maximum impairment), guided clinical, diagnostic and rehabilitation prescriptions. RESULTS: 1886 patients (69.6±10.8 years; M=1045) were admitted (589 chronic obstructive pulmonary disease, 494 chronic respiratory failure [CRF], 21 prolonged mechanical ventilation [PMV], 496 with other respiratory diseases), of whom 15 died, and 117 were transferred to acute care. The mean length of stay was 23.1±11.8 days (range 1-122). The mean time to fill in the ICF set was 23.16±0.70 min. The rate of filled charts improved from 16% in May to 100% in November. The baseline distribution of the more severe qualifiers (>2) progressively increased from the whole sample to the PMV subgroup. After rehabilitation, in the whole sample and in the CRF and PMV subgroups, the severity qualifiers significantly decreased (P<0.0001), showing a positive effect of the intervention on patients' disability. CONCLUSIONS: Routine use of a Respiratory ICF set for chronic respiratory diseases helps to prepare a personalized rehabilitation program discriminating disability level in different respiratory diseases and assessing disability outcomes pre-post rehabilitation.

[Diagnostic and therapeutic therapeutic pathways, including rehabilitative ones or only "discharge" rehabilitation?] / Percorsi diagnostico terapeutici assistenziali anche riabilitativi o riabilitazione "da scarico"?

SUMMARY: Due to epidemiological and social changes related to the increase in the average life expectancy, hospital users are characterized by elderly chronic and comorbid patients who require recurrent hospitalizations often with disability outcomes. In this framework, an innovative clinical and management hospitalization model is the adequate answer to systematically promote the patient independence. Main features are interdisciplinary and integrated care pathways facing both disease and disability biologically and functionally diagnosed by ICD and ICF. The definition, personalization of pathways/protocols and outcome evaluation represent the foundations of this new model for patient care. The digitalization of hospital clinical data and medical knowledge make the model feasible and fitting the recent WHO guideline: recommendations on digital interventions for health system strengthening.

Integrated care of chronic degenerative non-communicable diseases and rehabilitation: the odd couple?

Chronic degenerative non-communicable diseases affecting different organs and systems are considered by the World Health Organization (WHO) as the emergent epidemic in the third millennium...