Assessment of Differences in Inpatient Rehabilitation Services for Length of Stay and Health Outcomes Between US Medicare Advantage and Traditional Medicare Beneficiaries.

Importance: Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types. Objective: To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US. Design, Setting, and Participants: This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019. Exposures: Medicare insurance plan type, TM or MA. Main Outcomes and Measures: Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge. Results: The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, -0.15 to -0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, -0.21 to -0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs within an acute care hospital) and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types. Conclusions and Relevance: This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics.

Functional Performance and Discharge Setting Predict Outcomes 3 Months After Rehabilitation Hospitalization for Stroke.

BACKGROUND: Some clinical features of patients after stroke may be modifiable and used to predict outcomes. Identifying these features may allow for refining plans of care and informing estimates of posthospital service needs. The purpose of this study was to identify key factors that predict functional independence and living setting 3 months after rehabilitation hospital discharge by using a large comprehensive national data set of patients with stroke. METHODS: The Uniform Data System for Medical Rehabilitation was queried for the records of patients with a diagnosis of stroke who were hospitalized for inpatient rehabilitation from 2005 through 2007. The system includes demographic, administrative, and clinical variables collected at rehabilitation admission, discharge, and 3-month follow-up. Primary outcome measures were the Functional Independence Measure score and living setting 3 months after rehabilitation hospital discharge. RESULTS: The sample included 16,346 patients (80% white; 50% women; mean [SD] age, 70.3 [13.1] years; 97% ischemic stroke). The strongest predictors of Functional Independence Measure score and living setting at 3 months were those same factors at rehabilitation discharge, despite considering multiple other predictor variables including age, lesion laterality, initial neurologic impairment, and stroke-related comorbid conditions. CONCLUSIONS: These data can inform clinicians, patients with stroke, and their families about what to expect in the months after hospital discharge. The predictive power of these factors, however, was modest, indicating that other factors may influence postacute outcomes. Future predictive modeling may benefit from the inclusion of educational status, socioeconomic factors, and brain imaging to improve predictive power.

Measuring Burden of Care After Catastrophic Illness or Injury.

Burden of care (BoC) is the amount of time a patient requires direct, daily assistance from another person to meet basic needs in the home; it is based on a patient's functional level, obtained using the Functional Independence Measure. Inpatient BoC is a patient's projected resource utilization during a stay at an inpatient facility, assessed using the Northwick Park Dependency Scale. At the outpatient level, function and BoC can be assessed using the LIFEware System. Measuring and monitoring outcomes of all care result in reduced health care expenditures, more streamlined patient care, and improved quality of life for patients and families.

Changes in Patient Demographics and Outcomes in the Inpatient Rehabilitation Facility Traumatic Brain Injury Population from 2002 to 2016: Implications for Patient Care and Clinical Trials.

Initial studies examining patient demographics and outcomes in traumatic brain injury (TBI) suggest a trend toward increasing patient age and decreasing rehabilitation length of stay, but such studies have not been repeated since the passage of healthcare reform legislation, most notably the Affordable Care Act. This study utilized the Uniform Data System for Medical Rehabilitation® (UDSMR) for patients admitted to medical rehabilitation facilities after sustaining a TBI from January 1, 2002 through December 31, 2016. Trends for demographic and medical data were evaluated. In total, 233,843 patients from 1290 facilities were included; mean patient age increased from 54.1 to 64.8 years, rehabilitation length of stay decreased from 19 to 14.5 days, and mean admission Functional Independence Measure® (FIM) decreased from 56.9 to 54.5. Sex and racial distribution remained relatively stable across all years, as did discharge FIM. There was an increase in Medicare patients from 40.7% to 62.1%, a concomitant decrease in commercially insured patients from 29.2% to 15.4%, and a decrease in unreimbursed patients from 7.2% to 2.6% over the course of the study. Based on these data, medical rehabilitation facilities appear to be admitting an older TBI patient population that is less functional on admission and discharging them after shorter rehabilitation lengths of stay. Similar discharge functional status, despite shorter rehabilitation lengths of stay and an older population may suggest a change in the typical mechanism of injury. Many current TBI patients would fail to meet inclusion criteria for post-acute clinical trials in TBI because of their age, and treatments based on such trials may not be generalizable, which has significant implications on both research and clinical care realms within brain injury rehabilitation.

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.

Validity and Reliability of Four Clinical Gait Measures in Patients with Multiple Sclerosis.

BACKGROUND: The gold standards for assessing ambulation are the Expanded Disability Status Scale (EDSS) and the Timed 25-Foot Walk (T25FW) test. In relation with these measures, we assessed the reliability and validity of four clinical gait measures: the Timed Up and Go (TUG) test, the Dynamic Gait Index (DGI), the 2-Minute Walk Test (2MWT), and the 6-Minute Walk Test (6MWT). Patient self-report of gait was also assessed using the 12-item Multiple Sclerosis Walking Scale (MSWS-12). METHODS: Individuals 20 years or older with a diagnosis of multiple sclerosis (MS) and an EDSS score of 2.0 to 6.5 completed the MSWS-12, T25FW test, TUG test, DGI, 2MWT, and 6MWT. All the tests were repeated 2 weeks later at the same time of day to establish their reliability and concurrent validity. Predictive validity was established using the EDSS. RESULTS: Forty-two patients with MS were included. All measures showed high test-retest reliability. The TUG test, 2MWT, and 6MWT were significantly correlated with the T25FW test (Spearman ρ = -0.902, -0.919, and -0.905, respectively). The EDSS was also significantly correlated with all the walking tests. The MSWS-12 demonstrated the highest correlation to the EDSS (ρ = 0.788). CONCLUSIONS: The TUG test, the DGI, the 2MWT, and the 6MWT exhibited strong psychometric properties and were found to be significant predictors of the EDSS score. Use of these tests to prospectively monitor the effects of medical and rehabilitation treatment should be considered in the comprehensive care of patients with MS.

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.

Impact of Cognition on Burn Inpatient Rehabilitation Outcomes.

BACKGROUND: A significant proportion of burn injury patients are admitted to inpatient rehabilitation facilities (IRFs). There is increasing interest in the use of functional variables, such as cognition, in predicting IRF outcomes. Cognitive impairment is an important cause of disability in the burn injury population, yet its relationship to IRF outcomes has not been studied. OBJECTIVE: To assess how cognitive function affects rehabilitation outcomes in the burn injury population. DESIGN: Retrospective study. SETTING: Inpatient rehabilitation facilities in the United States. PARTICIPANTS: A total of 5347 adults admitted to an IRF with burn injury between 2002 and 2011. METHODS OR INTERVENTIONS: Multivariable regression was used to model rehabilitation outcome measures, using the cognitive domain of the Functional Independence Measure (FIM) instrument as the independent variable and controlling for demographic, medical, and facility covariates. MAIN OUTCOME MEASUREMENTS: FIM total gain, readmission to an acute care setting at any time during inpatient rehabilitation, readmission to an acute care setting in the first 3 days of IRF admission, rate of discharge to the community setting, and length of stay efficiency. RESULTS: Cognitive FIM total at admission was a significant predictor of FIM total gain, length of stay efficiency, and acute readmission at 3 days (P < .05). Cognitive FIM total scores did not have an impact on acute care readmission rate or discharge to the community setting. CONCLUSIONS: Cognitive status may be an important predictor of rehabilitation outcomes in the burn injury population. Future work is needed to further examine the impact of specific cognitive interventions on rehabilitation outcomes in this population. LEVEL OF EVIDENCE: II.

Functional Status Outperforms Comorbidities as a Predictor of 30-Day Acute Care Readmissions in the Inpatient Rehabilitation Population.

OBJECTIVES: Functional status is associated with patient outcomes, but is rarely included in hospital readmission risk models. The objective of this study was to determine whether functional status is a better predictor of 30-day acute care readmission than traditionally investigated variables including demographics and comorbidities. DESIGN: Retrospective database analysis between 2002 and 2011. SETTING: 1158 US inpatient rehabilitation facilities. PARTICIPANTS: 4,199,002 inpatient rehabilitation facility admissions comprising patients from 16 impairment groups within the Uniform Data System for Medical Rehabilitation database. MEASUREMENTS: Logistic regression models predicting 30-day readmission were developed based on age, gender, comorbidities (Elixhauser comorbidity index, Deyo-Charlson comorbidity index, and Medicare comorbidity tier system), and functional status [Functional Independence Measure (FIM)]. We hypothesized that (1) function-based models would outperform demographic- and comorbidity-based models and (2) the addition of demographic and comorbidity data would not significantly enhance function-based models. For each impairment group, Function Only Models were compared against Demographic-Comorbidity Models and Function Plus Models (Function-Demographic-Comorbidity Models). The primary outcome was 30-day readmission, and the primary measure of model performance was the c-statistic. RESULTS: All-cause 30-day readmission rate from inpatient rehabilitation facilities to acute care hospitals was 9.87%. C-statistics for the Function Only Models were 0.64 to 0.70. For all 16 impairment groups, the Function Only Model demonstrated better c-statistics than the Demographic-Comorbidity Models (c-statistic difference: 0.03-0.12). The best-performing Function Plus Models exhibited negligible improvements in model performance compared to Function Only Models, with c-statistic improvements of only 0.01 to 0.05. CONCLUSION: Readmissions are currently used as a marker of hospital performance, with recent financial penalties to hospitals for excessive readmissions. Function-based readmission models outperform models based only on demographics and comorbidities. Readmission risk models would benefit from the inclusion of functional status as a primary predictor.

Silver-Collagen Dressing and High-voltage, Pulsed-current Therapy for the Treatment of Chronic Full-thickness Wounds: A Case Series.

Research suggests high-voltage, pulsed-current electric therapy (HVPC) is safe and effective for treating chronic wounds, and some data suggest silver- and collagen-based dressings may facilitate healing. A combination therapy utilizing both HVPC and silver-collagen dressing may present clinical advantages. To explore the effect of the combined therapy for chronic full-thickness wounds, a prospective, consecutive case series study was conducted. All participants were adults with wounds of at least 6 weeks' duration. After obtaining informed consent, patient and wound characteristics were obtained, wounds were assessed and measured, and patients received 2 to 3 HVPC treatments per week followed by application of the silver- and collagen-based dressing for a period of 2 weeks. Data were analyzed descriptively, and changes in wound size and volume from baseline were analyzed using Wilcoxon Signed Rank Test. The dressings were saturated with normal saline, used simultaneously during the 45-minute HVPC treatment, and left on top of the wound after treatment. The HVPC electro pads (stainless steel electrodes with a sponge interface) also were moistened with normal saline and the cathode placed on top of the wound. If the patient had more than 1 wound on the same leg, the anode was placed on the additional wound (otherwise over the intact skin nearby). Secondary dressings (eg, foam and/ or gauze) were used as clinically appropriate, and a 4-layer compression wrap was used, if indicated, for patients with venous ulcers. Ten (10) patients (3 women, 7 men, 57.30 ± 9.70 years old with 14 wounds of 273.10 ± 292.03 days' duration before study) completed the study and were included in the final analyses. Average wound surface area decreased from 13.78 ± 21.35 cm(2) to 9.07 ± 16.81 cm(2) (42.52% ± 34.16% decrease, P = 0.002) and wound volume decreased from 3.39 ± 4.31 cm(3) to 1.28 ± 2.25 cm(3) (66.84% ± 25.07% decrease, P = 0.001). One (1) patient was discharged with complete wound closure. No serious adverse events were noted, but a diagnosis of osteomyelitis in 1 patient and increased pain in a patient with significant Reynaud's syndrome suggest clinicians should be cautious using HVPC in these instances. The combined intervention utilizing both HVPC and silver-collagen dressing was effective in the treatment of chronic fullthickness wounds in this patient population. Controlled clinical studies of longer duration are needed to further explore the safety, effectiveness, and efficacy of this treatment.

Using Functional Status in the Acute Hospital to Predict Discharge Destination for Stroke Patients.

OBJECTIVE: The aim of this study was to determine whether functional status, as measured by the AcuteFIM instrument, can be used to predict discharge destination of stroke patients from the acute hospital setting. DESIGN: A retrospective cohort study was carried out in an urban academic medical center. Data were collected on 481 new-onset stroke patients 18 yrs or older in an acute hospital between January 1 and September 30, 2013. Functional Independence Measure (FIM) instrument data were linked to a subset of 54 patients who received additional services at an inpatient rehabilitation facility. A receiver operator characteristic curve was constructed to validate the predictive ability of the AcuteFIM instrument and to determine the optimal cutoff score associated with discharge to a community setting. RESULTS: All AcuteFIM items in stroke patients at admission demonstrated strong interitem correlation coefficients (all above 0.6) and high internal consistency (Cronbach α = 0.94). The AcuteFIM total score was positively associated with discharge to the community from the acute hospital (odds ratio, 1.06; 95% confidence interval, 1.05-1.07). Receiver operator characteristic curve analysis generated a c statistic of 0.89 (95% confidence interval, 0.87-0.92), indicating that the AcuteFIM instrument is predictive of patient discharge to the community setting. CONCLUSION: This study suggests that the AcuteFIM instrument is a reliable tool that can be used to predict discharge destination from the acute hospital among stroke patients.

Length of Stay at Inpatient Rehabilitation Facility and Stroke Patient Outcomes.

PURPOSE: To examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes. DESIGN: A secondary data analysis of the Uniform Data System for Medical Rehabilitation database. METHODS: Stroke patients discharged from IRFs in the United States between 2009 and 2011 were identified and divided into mild (n = 639), moderate (n = 2,065), and severely (n = 2,077) impaired groups. Study outcomes included cognition and motor functional gains measured by the Functional Independence Measure (FIM) instrument and discharge to the community. FINDINGS: The average LOS was 8.9, 13.9, and 22.2 days for mild, moderate, and severely impaired stroke patients, respectively. After controlling for FIM admission and other important covariates, a longer LOS was associated with a modest increase in cognition gain (ß = 0.038, p = .0045) for the moderately impaired patients, and a modest increase in cognition (ß = 0.13, p < .0001) and motor gains (ß = 0.25, p < .0001) as well as a tendency for discharge to the community (OR = 1.01, 95% CI = 1.00-1.02) among the severely impaired patients. However, a longer LOS showed a negative association with functional gains among the mildly impaired patients as well as discharge to community for both mild and moderately impaired patients. CONCLUSION: The association of IRF LOS and patient outcomes varied by stroke impairment severity, positively for more severely impaired patients and negatively for mildly impaired patients. CLINICAL RELEVANCE: The study provides evidence for the care of stroke patients at the IRF setting.

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.

Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients.

OBJECTIVE: To examine functional status versus medical comorbidities as predictors of acute care readmissions in medically complex patients. DESIGN: Retrospective database study. SETTING: U.S. inpatient rehabilitation facilities. PARTICIPANTS: Subjects included 120,957 patients in the Uniform Data System for Medical Rehabilitation admitted to inpatient rehabilitation facilities under the medically complex impairment group code between 2002 and 2011. INTERVENTIONS: A Basic Model based on gender and functional status was developed using logistic regression to predict the odds of 3-, 7-, and 30-day readmission from inpatient rehabilitation facilities to acute care hospitals. Functional status was measured by the FIM(®) motor score. The Basic Model was compared to six other predictive models-three Basic Plus Models that added a comorbidity measure to the Basic Model and three Gender-Comorbidity Models that included only gender and a comorbidity measure. The three comorbidity measures used were the Elixhauser index, Deyo-Charlson index, and Medicare comorbidity tier system. The c-statistic was the primary measure of model performance. MAIN OUTCOME MEASURES: We investigated 3-, 7-, and 30-day readmission to acute care hospitals from inpatient rehabilitation facilities. RESULTS: Basic Model c-statistics predicting 3-, 7-, and 30-day readmissions were 0.69, 0.64, and 0.65, respectively. The best-performing Basic Plus Model (Basic+Elixhauser) c-statistics were only 0.02 better than the Basic Model, and the best-performing Gender-Comorbidity Model (Gender+Elixhauser) c-statistics were more than 0.07 worse than the Basic Model. CONCLUSIONS: Readmission models based on functional status consistently outperform models based on medical comorbidities. There is opportunity to improve current national readmission risk models to more accurately predict readmissions by incorporating functional data.

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.

Early inpatient rehabilitation admission and stroke patient outcomes.

OBJECTIVE: The aim of this study was to examine the associations of onset days, time from stroke onset to inpatient rehabilitation facility (IRF) admission, and patient outcomes (FIM gain, discharge destination, and IRF length of stay), using nationally representative data. DESIGN: A secondary data analysis was conducted on a random sample of stroke patients discharged from IRFs in the United States between 2009 and 2011, including mildly (n = 649), moderately (n = 2185), and severely (n = 2390) impaired patients. RESULTS: The study sample had a median of onset days of 5.5, with an interquartile range of 4-9. With the use of 15-365 days as reference, the severely impaired patients had a higher cognition gain (P < 0.01) and were more likely to be discharged to the community (odds ratio, 1.45; 95% confidence interval, 1.12-1.87) when admitted within 7 days, a greater motor gain when admitted within 14 days (P < 0.01), and a lower risk for acute hospital transfer when admitted 3-7 days (odds ratio, 0.62; 95% confidence interval, 0.43-0.90). The moderately impaired patients had a greater motor gain when admitted within 7 days (P < 0.01). Early IRF admission was also associated with a shorter length of stay. CONCLUSIONS: Earlier IRF admission was beneficial among severely and moderately impaired patients. IRF admission within 7 days is recommended for stroke patients who achieved medical stability.

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.