Retrospective study demonstrating therapy time impact on inpatient rehabilitation functional gains.

PURPOSE: The purpose of this retrospective study is to evaluate the association of total therapy time during inpatient rehabilitation and gain in functional independence for patients admitted to an inpatient rehabilitation facility (IRF). MATERIALS AND METHODS: The study utilized a retrospective design that included all IRF patients from three IRFs in California from January 1, 2012 to December 31, 2013. Patient data collected as part of usual, routine medical, and rehabilitation care were used and includes demographics, medical variables, and functional outcomes data. RESULTS: There were 3212 patients discharged from the three IRFs, with 2,777 patients having received speech language pathology (SLP) therapy along with occupational therapy and physical therapy. Speech language pathology services were not provided for 435 patients in the database. Our results support that among all types of patients, increased therapy hours were associated with increased functional gains. For total functional independence measure (FIM) gain, an additional hour of PT therapy per day was associated with an increase of 7.55 FIM gain points (p < 0.001) and an additional hour of OT therapy per day was associated with an increase of 1.16 FIM gain points (p = 0.045), when adjusted for other variables in the model. SLP hours per day did not remain in the FIM gain model. CONCLUSIONS: The findings of this study add to the understanding of therapy time and functional gain in an inpatient rehabilitation program. There is a positive relationship between total therapy time and functional gain. In the future determining the intensity and the related therapy activities provided will be needed to impact functional change. This has implications for shaping rehabilitation practice in the future.Implications for rehabilitationIncreased number of therapy hours were associated with functional gains in an inpatient rehabilitation program for all types of patients.An additional hour of physical therapy per day was associated with an increase of 7.55 functional independence measure (FIM) point gain.An additional hour of occupational therapy per day was associated with an increase of 1.16 FIM point gain.Determining the intensity and related activities are needed to impact functional change which has implications for shaping rehabilitation practice.

Characterization of inpatient rehabilitation outcomes among HIV/AIDS patients: a retrospective cohort study.

ABSTRACT Survival time in HIV/AIDS patients has increased as a result of improved treatments, but many acquire functional impairments that may necessitate multidisciplinary medical rehabilitation. In the United States, inpatient rehabilitation facilities (IRF) provide this care, but outcomes are not well described in this population. We used the Uniform Data System for Medical Rehabilitation (UDSMR) database to describe 11,051 HIV/AIDS IRF patients; HIV/AIDS patients were grouped according to the following admission criteria: (1) HIV/AIDS as primary reason for admission (n = 225); (2) HIV/AIDS symptomatic comorbidity (n = 6569); and (3) HIV/AIDS asymptomatic comorbidity (n = 4257). We used standard descriptive statistics to summarize demographic, medical, rehabilitation, and discharge setting characteristics by group. When compared to patients with HIV/AIDS as a comorbidity, primary HIV/AIDS patients had worse outcomes. They made less functional change (25.1 versus 29.8 and 28.9, p < .001), went home less (73.8% versus 74.5% and 77.8%, p < .001) and to an acute care hospital more frequently (18.2% versus 13.9% and 10.1%, p < .001). These findings help to characterize the HIV/AIDS patient population who receive inpatient medical rehabilitation, which helps inform clinical care, and highlight the positive impact IRF care can make to minimize functional disability among chronic HIV/AIDS patients and possibly decrease costs of home health care.

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.

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.

Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population.

OBJECTIVE: Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissions in the inpatient rehabilitation stroke population compared with medical comorbidities using a large, administrative data set. METHODS: A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed examining stroke patients admitted to inpatient rehabilitation facilities. A Basic Model for predicting acute care readmission risk based on age and functional status was compared with models incorporating functional status and medical comorbidities (Basic-Plus) or models including age and medical comorbidities alone (Age-Comorbidity). C-statistics were compared to evaluate model performance. FINDINGS: There were a total of 803,124 patients: 88,187 (11%) patients were transferred back to an acute hospital: 22,247 (2.8%) within 3 days, 43,481 (5.4%) within 7 days, and 85,431 (10.6%) within 30 days. The C-statistics for the Basic Model were 0.701, 0.672, and 0.682 at days 3, 7, and 30 respectively. As compared to the Basic Model, the best-performing Basic-Plus model was the Basic+Elixhauser model with C-statistics differences of +0.011, +0.011, and + 0.012, and the best-performing Age-Comorbidity model was the Age+Elixhauser model with C-statistic differences of -0.124, -0.098, and -0.098 at days 3, 7, and 30 respectively. CONCLUSIONS: Readmission models for the inpatient rehabilitation stroke population based on functional status and age showed better predictive ability than models based on medical comorbidities.

Functional status and readmissions in unilateral hip fractures.

OBJECTIVES: To test whether functional status is a robust predictor of acute care readmission risk in patients who have been discharged to an inpatient rehabilitation facility (IRF) following a unilateral hip fracture. STUDY DESIGN: Retrospective database study using a large administrative data set. METHODS: A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed, examining patients with an impairment of unilateral hip fracture. A basic prediction model based on functional status was compared with competing models incorporating medical comorbidities. C statistics were compared to evaluate model performance. RESULTS: There were a total of 433,154 patients: 32,783 (7.87%) patients were transferred back to an acute hospital, including 7937 (1.91%) transferred within 3 days, 16,150 (3.88%) transferred within 7 days, and 32,607 (7.83%) transferred within 30 days after IRF admission. The C statistics for the Basic Model are 0.710, 0.674, and 0.667 at days 3, 7, and 30, respectively. Compared with the Basic Model, the best performing Basic-Plus model was the Basic+Elixhauser Model with C statistic differences of +0.013, +0.014, and +0.019, and the best performing Age-Comorbidity Model was the Age+Elixhauser Model with C statistic differences of -0.110, -0.079, and -0.065 at days 3, 7, and 30, respectively. CONCLUSIONS: Functional status is a robust and potentially modifiable risk factor for patients admitted to IRFs following a unilateral hip fracture.

Impact of Intensive Handwashing Promotion on Secondary Household Influenza-Like Illness in Rural Bangladesh: Findings from a Randomized Controlled Trial.

RATIONALE: There is little evidence for the efficacy of handwashing for prevention of influenza transmission in resource-poor settings. We tested the impact of intensive handwashing promotion on household transmission of influenza-like illness and influenza in rural Bangladesh. METHODS: In 2009-10, we identified index case-patients with influenza-like illness (fever with cough or sore throat) who were the only symptomatic person in their household. Household compounds of index case-patients were randomized to control or intervention (soap and daily handwashing promotion). We conducted daily surveillance and collected oropharyngeal specimens. Secondary attack ratios (SAR) were calculated for influenza and ILI in each arm. Among controls, we investigated individual risk factors for ILI among household contacts of index case-patients. RESULTS: Among 377 index case-patients, the mean number of days between fever onset and study enrollment was 2.1 (SD 1.7) among the 184 controls and 2.6 (SD 2.9) among 193 intervention case-patients. Influenza infection was confirmed in 20% of controls and 12% of intervention index case-patients. The SAR for influenza-like illness among household contacts was 9.5% among intervention (158/1661) and 7.7% among control households (115/1498) (SAR ratio 1.24, 95% CI 0.92-1.65). The SAR ratio for influenza was 2.40 (95% CI 0.68-8.47). In the control arm, susceptible contacts <2 years old (RRadj 5.51, 95% CI 3.43-8.85), those living with an index case-patient enrolled ≤24 hours after symptom onset (RRadj 1.91, 95% CI 1.18-3.10), and those who reported multiple daily interactions with the index case-patient (RRadj 1.94, 95% CI 1.71-3.26) were at increased risk of influenza-like illness. DISCUSSION: Handwashing promotion initiated after illness onset in a household member did not protect against influenza-like illness or influenza. Behavior may not have changed rapidly enough to curb transmission between household members. A reactive approach to reduce household influenza transmission through handwashing promotion may be ineffective in the context of rural Bangladesh. TRIAL REGISTRATION: ClinicalTrials.gov NCT00880659.

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.

Assessing the ability of comorbidity indexes to capture comorbid disease in the inpatient rehabilitation burn injury population.

OBJECTIVE: Burn patients exhibit comorbidities that influence outcomes. This study examines whether existing comorbidity measures capture comorbidities in the burn inpatient rehabilitation population. DESIGN: Data were obtained from the Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury. International Classification of Diseases, 9th Revision, codes were used to assess three comorbidity measures (Charlson Comorbidity Index, Elixhauser Comorbidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers). The number of subjects and unique comorbidity codes (>1% of frequency) captured by each comorbidity measure was calculated. RESULTS: The study included 5347 patients with a median total body surface area burn decile of 20%-29%, mean age of 51.6 yrs, and mean number of comorbidities of 7.6. There were 2809 unique International Classification of Diseases, 9th Revision, comorbidity codes. The Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Centers for Medicare and Medicaid Services Comorbidity Tiers did not capture 67%, 27%, and 58% of the subjects, respectively. There were 107 unique comorbidities that occurred with a frequency of greater than 1%. Of these, 67% were not captured in all three comorbidity measures. CONCLUSIONS: Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the burn rehabilitation population. Future work is needed to assess the need for comorbidity indexes specific to the inpatient rehabilitation setting.

Inpatient rehabilitation experience of children with burn injuries: a 10-yr review of the uniform data system for medical rehabilitation.

OBJECTIVE: This study aimed to describe the pediatric burn inpatient rehabilitation population and short-term functional outcomes using the Uniform Data System for Medical Rehabilitation. DESIGN: This is a secondary analysis of data from the Uniform Data System for Medical Rehabilitation database between 2002 and 2011 included children younger than 18 yrs at time of admission to inpatient rehabilitation with primary diagnosis of burn injury. Demographic, medical, and functional data were evaluated. Function was assessed with the Functional Independence Measure or the WeeFIM. RESULTS: A total of 509 children were included, of whom 124 were evaluated with Functional Independence Measure and 385 with WeeFIM. The mean age of the population was 8.6 yrs and most were boys (72%). The mean length of stay for the population was 35 days. Functional status improved significantly from admission to discharge; most gains were in the motor subscore. Most patients were discharged home (95%). Of those discharged home, most (96%) went home with family. CONCLUSIONS: Children receiving multidisciplinary inpatient rehabilitation make significant functional improvements in total functional scores and in both motor and cognitive subscores. Most patients are discharged home with family. This study advances understanding of pediatric burn post-acute care outcomes.

Rehabilitation outcomes among burn injury patients with a second admission to an inpatient rehabilitation facility.

BACKGROUND: Burn survivors tend to have complex medical issues requiring rehabilitation to improve overall function and quality of life. A subset of burn patients treated in inpatient rehabilitation facilities (IRFs) may require more than 1 rehabilitation stay for the same injury. OBJECTIVE: To compare the rehabilitation outcomes among burn patients admitted to an IRF who were discharged to acute care and then readmitted to an IRF with burn patients admitted to an IRF only 1 time. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Burn injury patients aged 18 years or more who were admitted to IRFs between 2002 and 2011. METHODS: We performed a secondary analysis of data from Uniform Data System for Medical Rehabilitation, a national data repository. Outcomes of the repeaters' second stay (n = 188) were compared to the nonrepeaters' first and only stay (n = 6,855), using linear regression and logistic regression to determine whether repeater status was associated with rehabilitation outcomes. MAIN OUTCOME MEASUREMENTS: Functional status (using the Functional Independence Measure [FIM] instrument) at admission, discharge and change, length of stay, FIM efficiency (total FIM points gained per day), and discharge disposition. RESULTS: Repeater status was inversely associated with discharge FIM total (coefficient = -3.42, 95% confidence interval = -5.76, -1.07) and FIM change (coefficient = -4.05, 95% CI = -6.34, -1.75) in linear regression models. No other significant differences were found, and those differences in discharge FIM total and FIM change were small. CONCLUSIONS: Differences found in rehabilitation outcomes between the repeater and nonrepeater groups were small and may not reflect clinically meaningful differences. Burn injury patients who required a second IRF admission had rehabilitation outcomes similar to those of burn injury patients who did not require a second IRF admission, emphasizing the value of inpatient rehabilitation for burn injury IRF readmissions.

Cognition in patients with burn injury in the inpatient rehabilitation population.

OBJECTIVE: To analyze potential cognitive impairment in patients with burn injury in the inpatient rehabilitation population. DESIGN: Rehabilitation patients with burn injury were compared with the following impairment groups: spinal cord injury, amputation, polytrauma and multiple fractures, and hip replacement. Differences between the groups were calculated for each cognitive subscale item and total cognitive FIM. Patients with burn injury were compared with the other groups using a bivariate linear regression model. A multivariable linear regression model was used to determine whether differences in cognition existed after adjusting for covariates (eg, sociodemographic factors, facility factors, medical complications) based on previous studies. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Data from Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury (N=5347) were compared with other rehabilitation populations (N=668,816). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparison of total cognitive FIM scores and subscales (memory, verbal comprehension, verbal expression, social interaction, problem solving) for patients with burn injury versus other rehabilitation populations. RESULTS: Adults with burn injuries had an average total cognitive FIM score ± SD of 26.8±7.0 compared with an average FIM score ± SD of 28.7±6.0 for the other groups combined (P<.001). The subscale with the greatest difference between those with burn injury and the other groups was memory (5.1±1.7 compared with 5.6±1.5, P<.001). These differences persisted after adjustment for covariates. CONCLUSIONS: Adults with burn injury have worse cognitive FIM scores than other rehabilitation populations. Future research is needed to determine the impact of this comorbidity on patient outcomes and potential interventions for these deficits.

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.

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.

Validity and reliability of the FIM instrument in the inpatient burn rehabilitation population.

OBJECTIVE: To provide evidence of construct validity for the FIM instrument in the inpatient rehabilitation burn population. DESIGN: Confirmatory factor analysis and item response theory were used to assess construct validity. Confirmatory factor analysis was performed on a 2-factor model of the FIM instrument and on a 6-subfactor model. Mokken scale analysis, a nonparametric item response theory, was performed on each of the FIM instrument's 2 major factors, motor and cognitive domains. Internal consistency using Cronbach alpha and Molenaar and Sijtsma's statistic was also examined. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Data from the Uniform Data System for Medical Rehabilitation for patients with an impairment code of burn injury from the years 2002 to 2011 were used for this analysis. A total of 7569 subjects were included in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparative fit index results for the confirmatory factor analyses and adherence to assumptions of the Mokken scale model. RESULTS: Confirmatory factor analysis provided a comparative fit index of .862 for the 2-factor model and .941 for the 6-subfactor model. Mokken scale analysis showed scalability coefficients of .681 and .891 for the motor and cognitive domains, respectively. Measures of internal consistency statistic gave values of >.95 for each major domain of the FIM instrument. CONCLUSIONS: The FIM instrument has evidence of validity and reliability as an outcome measure for patients with burn injuries in the inpatient rehabilitation setting. The 6-subfactor model provides a better fit than the 2-factor model by confirmatory factor analysis. There is evidence that the motor and cognitive domains each form valid unidimensional metrics based on nonparametric item response theory.

Time to rehabilitation in the burn population: incidence of zero onset days in the UDSMR national dataset.

A preliminary investigation of the burn rehabilitation population found a large variability of zero onset day frequency between facilities. Onset days is defined as the time from injury to inpatient rehabilitation admission; this variable has not been investigated in burn patients previously. This study explored if this finding was a facility-based phenomena or characteristic of burn inpatient rehabilitation patients. This study was a secondary analysis of Uniform Data System for Medical Rehabilitation (UDSmr) data from 2002 to 2007 examining inpatient rehabilitation characteristics among patients with burn injuries. Exclusion criteria were age less than 18 years and discharge against medical advice. Comparisons of demographic, medical and functional data were made between facilities with a high frequency of zero onset days versus facilities with a low frequency of zero onset days. A total of 4738 patients from 455 inpatient rehabilitation facilities were included. Twenty-three percent of the population exhibited zero onset days (n = 1103). Sixteen facilities contained zero onset patients; two facilities accounted for 97% of the zero onset subgroup. Facilities with a high frequency of zero onset day patients demonstrated significant differences in demographic, medical, and functional variables compared to the remainder of the study population. There were significantly more zero onset day admissions among burn patients (23%) than other diagnostic groups (0.5- 3.6%) in the Uniform Data System for Medical Rehabilitation database, but the majority (97%) came from two inpatient rehabilitation facilities. It is unexpected for patients with significant burn injury to be admitted to a rehabilitation facility on the day of injury. Future studies investigating burn rehabilitation outcomes using the Uniform Data System for Medical Rehabilitation database should exclude facilities with a high percentage of zero onset days, which are not representative of the burn inpatient rehabilitation population.

The impact of comorbidities and complications on burn injury inpatient rehabilitation outcomes.

OBJECTIVE: To examine the impact of comorbidities and complications on burn inpatient rehabilitation facilities (IRF) outcomes. DESIGN: A retrospective cross-sectional study. SETTING: Inpatient rehabilitation hospitals. PATIENTS: A total of 4572 patients with a primary diagnosis of burn injury from the Uniform Data System for Medical Rehabilitation database from 2002 to 2010. METHODS OR INTERVENTIONS: Regression analyses were used to determine whether 3 different comorbidity measures (Charlson Comorbidity Index, Elixhauser Comoribidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers) and 1 complication measure improved the predictive model (c-statistic) for each outcome measure. MAIN OUTCOME MEASUREMENTS: Community discharge, Functional Independence Measure (FIM) gain, length of stay efficiency, transfer to acute care within the first 3 days of IRF stay, and transfer to acute care for all time periods. RESULTS: For all outcomes, there was no difference between the Standard Model and the models that include the comorbidity and complication variables as measured by the c-statistic confidence intervals. CONCLUSIONS: Comorbidities and complications did not significantly affect burn IRF outcomes. Future research is needed to examine the impact of comorbidities and complications on outcomes of other IRF populations to better understand the implications for current and future health care policy.

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.

Predictors of transfer from rehabilitation to acute care in burn injuries.

BACKGROUND: Transfer to acute care from rehabilitation represents an interruption in a patient's recovery and a potential deficiency in quality of care. The objective of this study was to examine predictors of transfer to acute care in the inpatient burn rehabilitation population. METHODS: Data are obtained from Uniform Data System for Medical Rehabilitation from 2002 to 2010 for patients with a primary diagnosis of burn injury. Predictor variables include demographic, medical, and facility data. Descriptive statistics are calculated for acute and nonacute transfer patients. Logistic regression analysis is used to determine significant predictors of acute transfer within the first 3 days. A scoring system is developed to determine the risk of acute transfer. RESULTS: There were 78 acute transfers in the first 3 days of a total of 4,572 burn admissions. Functional level at admission, age, and admission classification are significant predictors of transfer to acute care (p < 0.05). Total body surface area burned and medical comorbidities were not significantly associated with acute transfer risk. A 12-point acute transfer risk scoring system was developed, which demonstrates validity. CONCLUSION: Efforts to reduce readmissions to acute care should include greater scrutiny of older, lower-functioning patients with burn injury who are evaluated for admission to inpatient rehabilitation. This acute transfer scoring system may be useful to clinicians, health care institutions, and policymakers to help predict those patients at highest risk for early transfer to the acute hospital from rehabilitation. LEVEL OF EVIDENCE: Prognostic/diagnostic study, level II.