CME Objectives: Upon completion of this article the reader should be able to: (1) Identify the trends in stroke onset to inpatient rehabilitation admission for adult stroke patients treated at United States inpatient rehabilitation facilities in recent years; (2) Describe the associations of early rehabilitation and stroke patient outcomes in terms of functional gain, discharge destination, and rehabilitation length of stay; and (3) Use study data in making recommendations on inpatient rehabilitation admission for stroke patients.

Level: Advanced Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)i. Physicians should only claim credit commensurate with the extent of their participation in the activity. Authors: Hua Wang, PhD Michelle Camicia, MSN, CRRN Magaret DiVita, PhD Jacqueline Mix, MPH Paulette Niewczyk, MPH, PhD

Affiliations: From the Kaiser Foundation Rehabilitation Center, Vallejo, California (HW, MC); Uniform Data System for Medical Rehabilitation, Amherst, New York (MD, JM, PN); and State University of New York at Cortland (MD).

Correspondence: All correspondence and requests for reprints should be addressed to: Hua Wang, PhD, Kaiser Foundation Rehabilitation Center, 975 Sereno Dr, Vallejo, CA 94589.

Stroke Outcomes

CME ARTICLE

.

2015 SERIES

.

NUMBER 1

Early Inpatient Rehabilitation Admission and Stroke Patient Outcomes ABSTRACT Wang H, Camicia M, DiVita M, Mix J, Niewczyk P: Early inpatient rehabilitation admission and stroke patient outcomes. Am J Phys Med Rehabil 2015;94:85Y100.

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 4Y9. With the use of 15Y365 days as reference, the severely impaired patients had a higher cognition gain (P G 0.01) and were more likely to be discharged to the community (odds ratio, 1.45; 95% confidence interval, 1.12Y1.87) when admitted within 7 days, a greater motor gain when admitted within 14 days (P G 0.01), and a lower risk for acute hospital transfer when admitted 3Y7 days (odds ratio, 0.62; 95% confidence interval, 0.43Y0.90). The moderately impaired patients had a greater motor gain when admitted within 7 days (P G 0.01). Early IRF admission was also associated with a shorter length of stay.

Conclusions: Earlier IRF admission was beneficial among severely and 0894-9115/15/9402-0085 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.

moderately impaired patients. IRF admission within 7 days is recommended for stroke patients who achieved medical stability. Key Words:

Stroke, Rehabilitation, Patient Outcomes, Onset Days

DOI: 10.1097/PHM.0000000000000226

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85

Disclosures: This study has been presented orally or as a poster in the following rehabilitation research conferences: Education Conference of the American Medical Rehabilitation Providers Association, September 17Y19, 2013; Annual Conference of the American Academy of Physical Medicine and Rehabilitation, October 3Y6, 2013; and American Congress of Rehabilitation Medicine, November 12Y16, 2013. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. FIM is a trademark of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

T

imely transition from the acute care setting to the appropriate postacute care venue is increasingly an area of focus for rehabilitation of stroke patients.1Y3 A decreasing trend of duration between stroke onset and inpatient rehabilitation admission has been observed among stroke patients treated at inpatient rehabilitation hospitals in the United States.4 The positive association of early admission to inpatient rehabilitation facilities (IRFs) and rehabilitation outcomes of stroke patients has been reported in the literature, including better functional improvement or performance,1Y3,5Y13 favorable discharge destination,14 and shorter IRF length of stay.1,3,7,11,15 Early rehabilitation care has also been noted to assist in the prevention of secondary complications of contracture, pressure sores, and deconditioning, resulting in increased independence in self-care and walking.7 Various onset days for optimum patient outcomes have been reported, from very early intervention within 3 days of acute care hospital admission15,16 to less than 60 days after stroke onset.8 However, populations investigated in previous studies vary by country, period of study, patient severity, rehabilitation program features, sample size, and single-setting or multisetting studies. To reflect the decreasing trends of duration from stroke onset to IRF admission and provide updated information using recent and nationally representative data, the authors reexamined the association of onset days and stroke patient rehabilitation outcomes using the Uniform Data System for Medical Rehabilitation (UDSMR), which is the largest inpatient rehabilitation database worldwide and represents more than 70% of the IRFs in the United States.

METHODS A secondary data analysis was conducted using UDSMR data from 2009 to 2011. The UDSMR database includes demographic, medical,

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and rehabilitation data collected from the Inpatient Rehabilitation Facility Patient Assessment Instrument. In addition to medical diagnosis and impairment group, patient severity can be described in terms of case-mix group (CMG), a designation defined by the Centers for Medicare and Medicaid Services. Patients are placed in a CMG on the basis of impairment, age, as well as motor and cognitive functional status at IRF admission. Individuals in the same CMG group are expected to require similar resources. This study included a total of 286,909 patients who were discharged from IRFs in the United States between 2009 and 2011 with an impairment code of stroke. The following study inclusion criteria were applied: age at IRF admission of 18 yrs or older, an onset day between 0 and 365 days, initial rehabilitation admission during the study period, as well as length of stay between 3 and 365 days. Patients who died while in an IRF were excluded from the study. There were 261,212 patients who remained after the exclusion process. A 2% sample (n = 5,224) was randomly selected from this population, with consideration that an overly large sample size may lead to rejection of the null hypothesis even if the actual association does not have clinical significance. Bivariate analyses showed that there was no significant difference in any of the exposure and outcomes measures under study between the study sample and the base population. Power analyses were conducted on the basis of findings from the literature that reported that the minimum clinically important difference in FIM gain was 3 and 17 for cognition and motor measures, respectively, in patients with stroke.17 With a two-sided test, a significance level of 0.05, and a study power of 80%, this study sample allowed for the detection of a minimum cognition FIM gain between 0.8 and 2.0 as well as a minimum motor FIM gain between 1.94 and 3.86, which provided adequate power for the study. The authors then categorized the patients by CMG as suggested in the literature1,2: mildly impaired (CMG 0101Y0103, n = 649), moderately impaired (CMG 0104Y0107, n = 2,185), and severely impaired (CMG 0108Y0110, n = 2,390). Rehabilitation outcomes of interest included cognition FIM gain, motor FIM gain, acute care hospital transfer (percentage), discharge to the community (percentage), and length of stay. The FIM instrument is embedded in the Inpatient Rehabilitation Facility Patient Assessment Instrument and is a criterion-referenced functional assessment tool that measures functional dependence for 18 basic life activities. It comprises

Am. J. Phys. Med. Rehabil. & Vol. 94, No. 2, February 2015

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5 cognition and 13 motor activity items. Each item is rated on a 7-level ordinal scale, with a rating of 1 corresponding to a requirement of total assistance from a helper to accomplish the task and a rating of 7 representing complete independence in that item. The sum of the item scores is an indicator of the severity of a patient’s functional disability and reflects the burden of care and amount of assistance that is required for an individual to complete daily activities.18 Community settings were defined as home, assisted living residence, a board and care facility, or a transitional living setting. Noncommunity settings included acute care, subacute care, or long-term care settings. The onset day variable was analyzed as a continuous variable and a categorical variable (0Y2, 3Y7, 8Y14, and 15Y365 days). The grouping was based on the variable distribution and consideration of clinical meaningfulness. Considering that the patients who were admitted to an IRF within 2 days of stroke onset may not be all medically stable, especially for the severely injured patients, the separate 0Y2 onset day category would provide more refined and subtle information for the group. Sociodemographic covariates of interest included age, sex, marital status (married, single), race (white, black, Hispanic, other), prehospital living situation (living alone, living with others), and primary insurance payer (Medicare, Medicaid, Blue Cross, commercial, workers’ compensation, other). Medical covariates included affected body side (left, right, bilateral, no paresis, other) and Centers for Medicare and Medicaid Services comorbidity tier (tier A, none; tier B, major; tier C, moderate; tier D, minor), which has been used by the Centers for Medicare and Medicaid Services to address added cost during IRF stay,19 as well as healthcare settings before IRF admission. Facility-level covariates included facility type (freestanding hospital or unit in an acute care hospital), number of operating beds, and United States region. Univariate analysis was conducted to provide descriptive statistics for all explanatory and outcome measures. For continuous variables, the mean, standard deviation, median, and interquartile range (IQR) were calculated. Frequency distributions and percentages were calculated for categorical variables. Bivariate analysis was used to examine unadjusted associations between exposures, covariates, and outcomes. Pearson correlation coefficients and one-way analysis of variance were used for continuous data. Nonparametric tests including Wilcoxon’s test, Kruskal-Wallis test, and W2 tests were used for categorical data. Generalized linear models were www.ajpmr.com

developed to examine the association between onset days and patient functional gains during IRF stay as well as length of stay, while controlling for other covariates. Log transformation of length of stay was conducted to fulfill the assumption of linear regression analysis. The estimated coefficients, standard errors, and P values were used to measure the strength of the associations. The least-square means were obtained to present the adjusted linear outcomes by onset day groups. The least-square means and the standard errors of the log-transformed length of stay were then converted back to actual length of stay in days by way of exponentiation and multiplication with a smearing factor.20 Logistic regression modeling was used to calculate odds ratios and 95% confidence intervals to determine the strength of the association between onset days and discharge destinations within each impairment group, while controlling for other covariates. Onset days of 15Y365 were used as the referent group. A backward selection procedure with a criterion of P G 0.05 was used to select variables for inclusion in regression models. The adjusted R2 and C-statistic were used as measures of goodness of fit for linear models and logistic models, respectively. Whereas R2 statistic was used to express the percentage of total variation that a linear model explained, C-statistic was used to show the predictability of the model by using area under a receiver operating characteristic curve. The Cstatistic values range from 0.5 (discriminating power not better than chance) to 1.0 (perfect discriminating power). All analyses were performed with SAS version 9.13. The study was approved by the institutional review board at Kaiser Permanente Northern California.

RESULTS Study Sample Table 1 presents descriptive statistics of the overall study sample and by impairment group. A total of 5224 stroke patients were in the study sample and had a mean age of 69.2 yrs (SD, 13.6 yrs). The mildly, moderately, and severely impaired subgroups of patients differed significantly in all covariates under study except for sex, marital status, and prehospital living status. The median of onset days for the total study sample was 5.5, with an IQR of 4Y9 days. The mildly and moderately impaired stroke patients had a shorter median of onset days of 5, with an IQR of 3Y7 and 3Y8, respectively, in comparison with the onset days (median, Early Admission and Rehabilitation Outcomes

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TABLE 1 Description of stroke patients, UDSMR 2009Y2011 Impairment Severity Parameter

Total

Mild (CMG 0101Y0103)

Moderate (CMG 0104Y0107)

Severe (CMG 0108Y0110)

N (%) Age, yrs Mean (SD) Median (IQR) Age, % 0Y44 yrs 45Y64 yrs 65Y74 yrs Q75 yrs Sex, % Male Female Marital status, % Married Single Race, % Black Hispanic Other White Prehospital living, % Alone Other Primary payer source, % Blue Cross Commercial Medicaid Medicare Other Workers’ compensation Admitted from, % Acute Community Long-term care Other Subacute care Affected side, % Right Left Bilateral No paresis Other stroke Comorbidity tier, % 0 (A, no comorbidity) 1 (B, severe) 2 (C, moderate) 3 (D, mild) Facility type Freestanding hospital Unit in acute care hospital Operating beds, n Mean (SD) Median (IQR) Region, % Central East West Onset days Mean (SD) Median (IQR) Onset days, % 0Y2 3Y7 8Y14 15Y365

5224

649 (12.4)

2185 (41.8)

2390 (45.8)

65.1 (13.8) 66 (55Y76)

69.1 (13.6) 71 (59Y80)

74.5 (13.3) 72 (62Y81)

69.2 (13.6) 71 (60Y80)

P V G0.0001 G0.0001

4.4 30.6 24.8 40.2

7.2 38.2 26.2 28.4

4.1 32.0 24.0 39.9

3.9 27.2 25.2 43.7

50.7 49.3

53.2 46.8

50.6 49.5

50.3 49.8

48.8 51.2

52.6 47.4

47.5 52.6

49.1 51.0

16.6 7.7 3.2 69.8

14.3 5.6 3.4 73.8

17.2 7.1 3.8 69.0

16.7 8.9 2.6 69.5

26.8 73.2

28.8 71.2

27.1 72.9

25.9 74.1

7.3 7.0 6.6 68.5 10.6 0.1

10.2 12.2 6.0 57.6 14.0 0.0

7.0 6.6 6.9 68.2 11.1 0.1

6.8 5.9 6.4 71.7 9.2 0.0

96.2 1.7 1.5 0.1 0.5

98.2 1.4 0.3 0.0 0.2

97.0 1.6 1.0 0.1 0.4

94.9 1.8 2.3 0.2 0.7

39.9 40.7 3.7 12.3 3.5

36.8 34.8 2.8 20.3 5.2

40.1 38.4 3.4 13.6 4.6

40.5 44.4 4.2 8.8 2.1

74.8 2.4 1.6 21.1

83.5 1.2 0.6 14.6

77.4 2.1 1.4 19.1

70.1 3.1 2.1 24.7

34.0 66.0

24.7 75.4

28.8 71.2

41.3 58.7

0.4108 0.0707 0.0108

0.3007 G0.0001

0.0003

G0.0001

G0.0001

G0.0001 G0.0001 44.1 (34.0) 33 (20Y60)

36.9 (29.7) 26 (18Y48)

41.6 (32.4) 30 (20Y56)

48.3 (35.9) 40 (22Y61) G0.0001

39.8 46.0 14.2

45.9 40.1 14.0

39.6 44.5 15.9

38.3 49.0 12.8

10.1 (19.8) 5.5 (4Y9)

6.9 (9.0) 5 (3Y7)

8.3 (16.3) 5 (3Y8)

12.7 (24.1) 7 (4Y12)

10.8 55.2 19.9 14.2

14.3 60.9 16.2 8.6

13.1 60.2 16.6 10.1

7.7 49.0 24.0 19.3

G0.0001 G0.0001

CMG indicates case-mix group; IQR, interquartile range; SD, standard deviation.

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TABLE 2 Functional measures, length of stay, and discharge destination Impairment Severity Parameter FIM cognition Admission Mean (SD) Median (IQR) Discharge Mean (SD) Median (IQR) Gain Mean (SD) Median (IQR) FIM motor Admission Mean (SD) Median (IQR) Discharge Mean (SD) Median (IQR) Gain Mean (SD) Median (IQR) Length of stay Mean (SD) Median (IQR) Log-transformed length of stay Mean (SD) Median (IQR) Discharge destination, % Community Acute care hospital

Total

Mild (CMG 0101Y0103)

Moderate (CMG 0104Y0107)

Severe (CMG 0108Y0110)

19.5 (7.7) 20 (14Y25)

24.2 (6.6) 25 (20Y29)

21.8 (6.7) 22 (17Y27)

16.1 (7.3) 16 (10Y21)

24.5 (7.3) 26 (20Y30)

28.0 (5.7) 29 (25Y32)

26.4 (6.1) 27 (23Y31)

21.7 (7.6) 23 (16Y28)

5.0 (4.9) 4 (2Y8)

3.8 (4.1) 3 (1Y6)

4.6 (4.4) 4 (1Y7)

5.6 (5.3) 5 (2Y9)

34.4 (14.3) 34 (22Y46)

57.0 (5.5) 57 (53Y60)

41.7 (6.8) 42 (37Y47)

21.6 (6.9) 21 (16Y27)

55.9 (18.7) 61 (45Y71)

75.7 (8.4) 77 (70Y81)

65.4 (11.3) 66 (59Y74)

44.0 (17.4) 45 (30Y57)

22.5 (12.4) 23 (14Y31)

18.7 (8.1) 19 (14Y24)

23.7 (10.6) 24 (17Y31)

22.4 (14.6) 23 (10Y33)

16.4 (9.2) 15 (10Y21)

8.8 (3.9) 8 (6Y11)

13.6 (6.6) 13 (9Y16)

20.9 (10.0) 21 (14Y25)

P G0.0001 G0.0001 G0.0001

G0.0001 G0.0001 G0.0001 G0.0001 G0.0001 2.6 (0.6) 2.7 (2.3Y3.0)

2.1 (0.4) 2.1 (1.8Y2.4)

2.5 (0.5) 2.6 (2.2Y2.8)

2.9 (0.5) 3.0 (2.6Y3.2) G0.0001

70.5 8.5

94.1 1.5

83.4 5.5

52.2 13.1

CMG indicates case-mix group; IQR, interquartile range; SD, standard deviation.

7 days; IQR, 4Y12 days) of the severely impaired stroke patients (P G 0.0001). Table 2 presents rehabilitation outcome data for the total study sample and by stroke impairment severity. The total sample had a mean cognition FIM gain of 5.0 (SD, 4.9) and a mean motor FIM gain of 22.5 (SD, 12.4). The stroke subgroups differed significantly in all functional measures (P G 0.0001). In general, the patients who were more severely impaired had lower functional measures at admission and discharge but had greater functional gains during their IRF stay. The mean length of stay for the total sample was 16.4 days (SD, 9.2 days), with the shortest among the mildly impaired group followed by the moderately and severely impaired groups (P G 0.0001). The study sample had a total acute care transfer rate of 8.5% and a total community discharge rate of 70.5%. The mildly impaired group had the lowest acute care hospital transfer rate in comparison with the moderately and severely impaired groups (P G 0.0001). In contrast, the mildly impaired group had the highest rate of www.ajpmr.com

being discharged to the community followed by the moderately and severely impaired groups (P G 0.0001).

Onset Days and FIM Gain The linear regression analyses for functional gains are presented in Table 3. For the severely impaired patients, IRF admission within 7 days of stroke was associated with higher cognition compared with patients admitted between day 15 and 365 after stroke (P G 0.01); IRF admission within 2 wks was associated with a higher motor gain during IRF stay (P G 0.01). For the moderately impaired patients, IRF admission within 7 days was associated with a higher motor gain in comparison with patients admitted between day 15 and 365 after stroke (P G 0.01). There was no significant association between onset days and functional gain in the mildly impaired group. Figure 1 shows the adjusted least-square means of cognition and motor FIM gains by onset day groups and impairment severity. Early Admission and Rehabilitation Outcomes

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TABLE 3 General linear model of functional gain by impairment severity Cognition FIM Gain Parameter

Estimate

Mild (CMG = 0101 to 0103, n = 649) Onset days 0 to 2 j0.506 3 to 7 j0.510 8 to 14 j0.685 15 to 365 0.000 Primary payer source Blue Cross V Commercial V Medicaid V Other V Medicare V Length of stay j0.095 FIM admission cognition j0.324 FIM admission motor V Facility type Freestanding hospital V Unit in acute care hospital V R2 0.265 Moderate (CMG = 0104 to 0107, n = 2185) Onset days 0 to 2 0.628 3 to 7 0.393 8 to 14 0.159 15 to 365 0.000 Age, yrs 18 to 44 1.086 45 to 64 0.500 65 to 74 0.464 Q75 0.000 Prehospital living Alone V Other V Comorbidity tier 1 (B, severe) V 2 (C, moderate) V 3 (D, mild) V 0 (A, no comorbidity) V Length of stay (days) 0.061 FIM admission cognition j0.308 FIM admission motor 0.059 Facility type Freestanding hospital 0.928 Unit in acute care 0.000 Region East 0.342 West 0.590 Central 0.000 R2 0.240 Severe (CMG = 0108 to 0110, n = 2390) Onset days 0 to 2 1.395 3 to 7 0.804 8 to 14 0.422 15 to 365 0.000 Age, yrs 18 to 44 2.236 45 to 64 0.678 65 to 74 0.641 Q75 0.000

Motor FIM Gain

SE

P

Estimate

SE

P

0.596 0.502 0.611 V

0.3964 0.3101 0.2372 V

j0.284 j0.296 j0.645 0.000

1.343 1.131 1.261 V

0.8328 0.7934 0.6092 V

V V V V V 0.036 0.021 V

V V V V V 0.0083 G0.0001 V

4.267 3.977 1.481 3.387 0.000 j0.197 V j0.463

1.021 0.966 1.323 0.915 V 0.078 V 0.056

G0.0001 G0.0001 0.2635 0.0002 V 0.0123

V V V

V V V

2.059 0.000 0.146

0.692 V V

0.0030 V

0.358 0.290 0.334 V

0.0793 0.1758 0.6329 V

2.798 2.142 0.682 0.000

0.918 0.744 0.854 V

0.0023 0.0040 0.4251 V

0.488 0.277 0.216 V

0.0262 0.0706 0.0319 V

6.572 2.840 1.867 0.000

1.114 0.525 0.555 V

G0.0001 G0.0001 0.0008 V

V V

V V

1.315 0.000

0.492 V

0.0076 V

V V V V 0.013 0.013 0.013

V V V V G0.0001 G0.0001 G0.0001

j3.133 j2.300 j0.935 0.000 0.125 0.233 j0.383

1.507 1.806 0.545 V 0.034 0.033 0.034

G0.0001 G0.0001 0.0008 V 0.0002 G0.0001 G0.0001

0.188 V

G0.0001 V

3.937 0.000

0.475 V

G0.0001 V

0.184 0.248 V

0.0632 0.0174 V

V V V 0.135

V V V

0.434 0.289 0.312 V

0.0013 0.0054 0.1761 V

6.488 4.886 2.673 0.000

1.917 0.797 0.860 V

G0.0001 G0.0001 0.0019 V

0.530 0.245 0.244 V

G0.0001 0.0058 0.0088 V

8.616 4.674 2.703 0.000

1.453 0.672 0.670 V

G0.0001 G0.0001 G0.0001 V

G0.0001

(continued on next page)

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TABLE 3 (Continued) Cognition FIM Gain Parameter Severe (CMG = 0108 to 0110, n = 2390) Admit from Community Long-term care Other Subacute care Acute care Affected side Bilateral No paresis Other stroke Left Right Length of stay (days) FIM admission cognition FIM admission motor Facility type Freestanding hospital Unit in acute care Region East West Central R2

Motor FIM Gain

Estimate

SE

P

Estimate

SE

P

j0.756 j1.757 2.256 j1.246 0.000

0.730 0.664 2.125 1.208 V

0.3004 0.0082 0.2883 0.3024 V

j5.010 j3.359 1.886 j3.921 0.000

2.001 1.823 5.817 3.313 V

0.0123 0.0655 0.7458 0.2368 V

V V V V V 0.151 j0.270 0.132

V V V V V 0.010 0.016 0.016

V V V V V G0.0001 G0.0001 G0.0001

j1.627 1.500 0.997 j3.173 0.000 0.417 0.257 0.380

1.372 1.025 1.903 0.594 V 0.027 0.044 0.045

0.2358 0.1434 0.6006 G0.0001 V G0.0001 G0.0001 G0.0001

1.311 0.000

0.203 V

G0.0001 V

5.173 0.000

0.579 V

G0.0001 V

V V V 0.215

V V V

V V V

0.935 2.859 0.000 0.218

0.586 0.863 V

0.1110 0.0009 V

CMG indicates case-mix group; SE, standard error.

FIGURE 1 Onset days and functional gains by impairment severity. LSMean, adjusted least-square mean; Std Err, standard error. www.ajpmr.com

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TABLE 4 Logistic model for discharge destination by impairment severity Acute Care Hospital Parameter Mild (CMG = 0101Y0103, n = 649) Onset days 0Y2 3Y7 8Y14 15Y365 Admission cognition C-statistic Moderate (CMG = 0104Y0107, n = 2185) Onset days 0Y2 3Y7 8Y14 15Y365 Age, yrs 18Y44 45Y64 65Y74 Q75 Marital status Married Single LOS (days) FIM admission cognition FIM admission motor Region East West Central C-statistic Severe (CMG = 0108Y0110, n = 2390) Onset days 0Y2 3Y7 8Y14 15Y365 Age, yrs 18Y44 45Y64 65Y74 Q75 Race Black Hispanic Other White Prehospital living Alone Other Affected side Bilateral No paresis Other stroke Left Right LOS (days) FIM admission cognition FIM admission motor Facility type Freestanding hospital Unit in acute care Operating beds (n) Region East West Central C-statistic

Community

Odds Ratio

95% CI

Odds Ratio

95% CI

0.29 0.29 0.79 1.00 V 0.63

0.01Y3.13 0.05Y2.03 0.13Y6.17 V V

0.83 0.85 0.995 1.00 1.09 0.67

0.16Y3.57 0.20Y2.59 0.20Y4.00 V 1.04Y1.15

0.46 0.81 0.97 1.00

0.19Y1.08 0.45Y1.56 0.48Y2.02 V

1.42 1.39 1.20 1.00

0.87Y2.33 0.94Y2.03 0.77Y1.88 V

V V V V

V V V V

5.93 1.82 1.28 1.00

2.38Y19.83 1.35Y2.45 0.96Y1.72 V

V V 0.79 0.97 0.95

V V 0.72Y0.83 0.94Y0.997 0.92Y0.98

1.49 1.00 V 1.05 1.05

1.13Y1.97 V V 1.028Y1.07 1.026Y1.06

V V V 0.77

V V V

1.19 1.66 1.00 0.69

0.93Y1.54 1.15Y2.46 V

0.62 0.62 0.95 1.00

0.33Y1.11 0.43Y0.90 0.64Y1.42 V

1.60 1.45 1.05 1.00

1.08Y2.36 1.12Y1.87 0.79Y1.39 V

V V V V

V V V V

3.13 1.47 1.09 1.00

1.84Y5.50 1.17Y1.85 0.87Y1.36 V

V V V V

V V V V

1.81 1.75 0.87 1.00

1.41Y2.33 1.27Y2.44 0.49Y1.56 V

V V

V V

0.39 1.00

0.31Y0.48 V

V V V V V 0.83 V 0.95

V V V V V 0.81Y0.97 V 0.93Y0.97

0.71 0.98 1.42 0.75 1.00 1.05 1.02 1.09

0.45Y1.13 0.70Y1.38 0.74Y2.73 0.61Y0.91 V 1.03Y1.06 1.01Y1.04 1.08Y1.11

V V 0.01

V V 0.003Y0.01

1.69 1.00 V

1.39Y2.06 V V

V V V 0.85

V V V

1.11 2.34 1.00 0.75

0.91Y1.35 1.73Y3.17 V

CI indicates confident interval; CMG, case-mix group; LOS, length of stay.

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Several covariates under study were significantly associated with FIM gain (Table 3), including age at IRF admission among the moderately and severely impaired patients, functional status at IRF admission, facility type, as well as length of stay for all three impairment groups. In addition, prehospital living situation, primary payer source, healthcare setting before IRF admission, affected body side, comorbidities, and geographic region contributed to functional gains in the corresponding impairment groups.

Onset Days and Discharge Destination Table 4 shows logistic regression analysis results of the association between onset days and

discharge destination. Among the severely impaired group, the patients who were admitted to an IRF within 3Y7 days were less likely to be transferred to an acute care hospital and those admitted within 7 days were more likely to be discharged to the community than the patients admitted between day 15 and 365 after stroke. IRF admission 0Y2 days after stroke onset had the same odds ratio of 0.62 as that of the 3Y7 onset days in terms of acute care hospital transfer but was not statistically significant, possibly because of a larger variation (95% confidence interval, 0.33Y1.11). There was no significant association between onset days and discharge destination among the mildly and mod-

TABLE 5 General linear model of log-transformed length of stay at IRFs by impairment severity Parameter Mild (CMG = 0101 to 0103, n = 649) Onset to IRF admission, days 0 to 2 3 to 7 8 to 14 15 to 365 Prehospital living status Alone Other FIM admission cognition FIM admission motor R2 Moderate (CMG = 0104 to 0107, n = 2185) Onset to IRF admission (days) 0 to 2 3 to 7 8 to 14 15 to 365 FIM admission motor R2 Severe (CMG = 0108 to 0110, n = 2390) Onset to IRF admission (days) 0 to 2 3 to 7 8 to 14 15 to 365 Primary payer source Blue Cross Commercial Medicaid Other Workers’ compensation Medicare Affected side Bilateral No paresis Other stroke Left Right FIM admission cognition FIM admission motor R2

Estimate

SE

P

j0.188 j0.151 j0.125 0.000

0.068 0.057 0.067 V

0.0061 0.0089 0.0613 V

0.146 0.000 j0.013 j0.015 0.120

0.035 V 0.002 0.003

G0.0001 V G0.0001 G0.0001

j0.095 j0.053 j0.049 0.000 j0.019 0.086

0.039 0.032 0.037 V 0.001

0.0149 0.0912 0.1883 V G0.0001

j0.099 j0.065 j0.089 0.000

0.047 0.031 0.033 V

0.0362 0.0331 0.0076 V

0.181 0.149 0.105 0.115 0.365 0.000

0.049 0.052 0.052 0.044 0.522 V

0.0002 0.0040 0.0432 0.0097 0.4846 V

j0.132 j0.132 j0.018 0.010 0.000 0.004 j0.004 0.044

0.055 0.040 0.076 0.024 V 0.002 0.002

0.0169 0.0009 0.8172 0.6681 V 0.0322 0.0141

CMG indicates case-mix group; IRF, inpatient rehabilitation facility; SE, standard error.

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FIGURE 2 Onset days and length of stay by impairment severity. LSMean, adjusted least-square mean; Std Err, standard error.

erately impaired patients. Similarly, several covariates were associated with discharge destination for the corresponding impairment groups, and there was variation in discharge destination by facility type, number of IRF beds, and health geographic region.

Onset Days and Length of Stay Table 5 presents the multiple regression analysis of onset days and log-transformed length of stay. In comparison with the patients admitted between day 15 and 365 after stroke, a shorter length of stay was observed for the mildly impaired patients if admitted within 7 days, for the moderately impaired patients if admitted within 2 days, and for the severely impaired patients if admitted within 14 days. Figure 2 shows the adjusted and converted leastsquare means of length of stay by impairment group. In addition, functional status at IRF admission contributed to the number of days at IRF. Prehospital living status of alone was associated with a longer length of stay for the mildly impaired patients, and the patients with Medicare as their primary payer source had a shorter length of stay in comparison with those covered by Blue Cross, commercial, Medicaid, and other payer sources in the severely impaired group.

DISCUSSION A secondary analysis was performed on a random sample of stroke patients discharged from United States IRFs between 2009 and 2011. The findings of this study support the positive associations of duration of stroke onset to IRF admission and patient rehabilitation outcomes in the literature1Y3,5Y13 as well as agree with the report by

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Maulden et al.1 that the association of onset days with functional outcomes was strongest among severely impaired stroke patients. In addition, the authors observed that, among the severely impaired patients, early IRF admission was associated with favorable discharge destination as well as short length of stay. The current study also confirmed the decreasing trends of duration between stroke onset and inpatient rehabilitation admission among patients treated at IRFs in the United States (Granger et al.4 2009). The study sample had a median of overall onset days of 5.5 (IQR, 4Y9), with the longest median of onset days of 7 (IQR, 4Y12) among the severely impaired patients, followed by 5 (IQR, 3Y8) and 5 (IQR, 3Y7) for the moderately and mildly impaired patients, respectively. The short and narrow range of onset days among the moderately and mildly impaired patients might contribute to the lack of association between onset days and patient outcomes in the two impairment groups. Although a large policy update to the Medicare Benefit Policy Manual occurred in 2010, which included updates to the required preadmission screen, multidisciplinary group meetings, and others, previous literature did not find any difference in the types of cases, severity of cases, or outcomes because of this shift.21 Therefore, the authors are confident that this study’s time frame is appropriate for the research question at hand. A wide range of times to initiate rehabilitation for optimum patient outcomes have been recommended in the literature,7,8,13Y16 from very early intervention within 3 days of acute care hospital admission15,16 to less than 60 days after stroke onset.8 In the current study, more recent IRF data

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from a nationally representative database were analyzed, and the findings reflected the decreasing trend of onset days that has been reported previously in other IRF populations. In general, it was found that IRF admission within 7 days of stroke onset is associated with better outcomes for all levels of stroke patients. However, IRF admission within 2 days of stroke may have larger variation in acute care hospital transfer for the severely impaired patients. These study findings support the clinical practice guideline that, once medical stability is achieved, rehabilitation therapy should be initiated as early as possible.22 Although the generalizability of this study population to the general IRF population is high, there are limitations to consider. The use of previously collected data for purposes other than this particular research study limited the amount of variables that could be analyzed. In addition, coding inaccuracies are difficult to determine because the authors did not have access to medical chart data to validate what was reported. However, there are standard data collection procedures for the Inpatient Rehabilitation Facility Patient Assessment Instrument (Inpatient Rehabilitation Facility Patient Assessment Instrument manual23), so there is no reason to believe that coding inaccuracies were numerous or contributed to any misclassification of cases such as acute strokes or led to misclassification of stroke severity. If there had been misclassification of stroke cases or the severity of stroke, it is unlikely that such misclassification would be differential between exposure groups. Therefore, any such nondifferential misclassification would lead to an attenuation of this study’s findings. A stratified analysis was conducted on the three levels of impairment CMG groups on the basis of diagnosis, age, and FIM rating at IRF admission. The Centers for Medicare and Medicaid Services comorbidity tier was also used as a proxy for patient severity. However, there were no direct measures of patient severity or detailed data on medical stability after stroke. Some regression analyses had a low value of R2 and C-statistics, suggesting relatively large variations left unexplained. Further studies with data that include more variables that could explain more of the variance are recommended.

CONCLUSIONS The study provides updated information on associations of duration from stroke onset to inpatient rehabilitation and patient rehabilitation outcomes using recent nationwide data from the UDSMR database. The duration of stroke onset to IRF admission observed was consistent with the decreasing www.ajpmr.com

trends reported in the literature. The findings of this study suggest that IRF admission within 7 days of stroke onset is associated with better outcomes of stroke patients. The impact of early IRF admission was particularly important in the severely impaired group of patients who have achieved medical stability, with favorable cognition and motor gains, a lower risk of acute care hospital transfer, as well as a higher rate of returning to the community. Early IRF admission was also associated with a shorter IRF length of stay. REFERENCES 1. Maulden SA, Gassaway J, Horn SD, et al: Timing of initiation of rehabilitation after stroke. Arch Phys Med Rehabil 2005;86(suppl):S34Y40 2. Horn SD, DeJong G, Smout RJ, et al: Stroke rehabilitation patients, practice, and outcomes: Is earlier and more aggressive therapy better? Arch Phys Med Rehabil 2005;86(suppl):S101Y14 3. Salter K, Jutai J, Hartley M, et al: Impact of early vs. delayed admission to rehabilitation on functional outcomes in persons with stroke. J Rehabil Med 2006;38:113Y7 4. Granger CV, Markello SJ, Graham JE, et al: The uniform data system for medical rehabilitation: Report of patients with stroke discharged from comprehensive medical programs in 2000Y2007. Am J Phys Med Rehabil 2009;88:961Y72 5. Feigenson JS, McCarthy ML, Meese PD, et al: Stroke rehabilitation I. Factors predicting outcome and length of stayVAn overview. N Y State J Med 1977; 77:1426Y30 6. Ottenbacher KJ, Jannell S: The results of clinical trials in stroke rehabilitation research. Arch Neurol 1993;50:37Y44 7. Rossi PW, Forer S, Wiechers D: Effective rehabilitation for patients with stroke: Analysis of entry, functional gain, and discharge to community. J Neurol Rehabil 1997;11:27Y33 8. Stineman MG, Maislin G, Fiedler RC, et al: A prediction model for functional recovery in stroke. Stroke 1997;28:550Y6 9. Cifu DX, Stewart DG: Factors affecting functional outcome after stroke: A critical review of rehabilitation interventions. Arch Phys Med Rehabil 1999; 80(suppl):S35Y9 10. Paolucci S, Antonucci G, Grasso MG, et al: Early versus delayed inpatient stroke rehabilitation: A matched comparison conducted in Italy. Arch Phys Med Rehabil 2000; 81:695Y700 11. Ancheta J, Husband M, Law D, et al: Initial functional independence measure score and interval post stroke help assess outcome, length of hospitalization, and quality of care. Neurorehabil Neural Repair 2000; 14:127Y34 12. Musicco M, Emberti L, Nappi G, et al, for the Italian Multicenter Study on Outcomes of Rehabilitation

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of Neurological Patients: Early and long-term outcome of rehabilitation in stroke patients: The role of patient characteristics, time of initiation, and duration of interventions. Arch Phys Med Rehabil 2003;84:551Y8 13. Wang H, Camicia M, Terdiman J, et al: Time to inpatient rehabilitation hospital admission and functional outcomes of stroke patients. PM R 2011;3: 296Y304 14. Stineman MG, Ross R, Maislin G, et al: Risks of acute hospital transfer and mortality during stroke rehabilitation. Arch Phys Med Rehabil 2003;84:712Y8 15. Hayes SH, Carroll SR: Early intervention care in the acute stroke patient. Arch Phys Med Rehabil 1986; 67:319Y21 16. Matsui H, Hashimoto H, Horiguchi H, et al: An exploration of the association between very early rehabilitation and outcome for the patients with acute ischaemic stroke in Japan: A nationwide retrospective cohort survey. BMC Health Serv Res 2010;10:213 doi:10.1186/1472-6963-10-213 17. Beninato M, Gill-Body KM, Salles S, et al: Determination of the minimal clinically important difference in the FIM instrument in patients with stroke. Arch Phys Med Rehabil 2006;87:32Y9

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18. Granger CV, Cotter AC, Hamilton BB, et al: Functional assessment scales: A study of persons after stroke. Arch Phys Med Rehabil 1993;74:133Y8 19. Carter GM, Totten ME: Preliminary analyses for refinement of the tier comorbidities in the inpatient rehabilitation facility prospective payment system. Available at: http://www.rand.org/content/dam/rand/ pubs/technical_reports/2005/RAND_TR201.pdf. Accessed October 25, 2013 20. Duan N: Smearing estimate: A nonparametric retransformation method. J Am Stat Assoc 1983; 78:605Y10 21. Riggs RV, Roberts PS, DiVita MA, et al: Perceptions of inpatient rehabilitation changes after the Centers for Medicare and Medicaid Service 2010 regulatory updates contrasted with actual performance. PM R 2014;6:44Y9.e2 22. Management of Stroke Rehabilitation Working Group: VA/DOD clinical practice guideline for the management of stroke rehabilitation. J Rehabil Res Dev 2010; 47:1Y43 23. Inpatient Rehabilitation Facility Patient Assessment Instrument Training Manual. Buffalo, NY, Uniform Data System for Medical Rehabilitation, 2004

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CME SELF-ASSESSMENT EXAM

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2. Read the following CME Self- Assessment Exam Questions. 3. Photocopy and complete the CME Self-Assessment Exam Answering Sheet and CME Evaluation. 4. Send the completed Answering Sheet and Evaluation to: CME Department, AAP National Office, 7250 Parkway Drive, Suite 130, Hanover, MD 21076.

T

his is an adult learning experience and there is no requirement for obtaining a certain score. The objective is to have each participant learn from the total experience of studying the article, taking the exam, and being able to immediately receive feedback with the correct answers. For complete information, please see BInstructions for Obtaining Continuing Medical Education Credit[ at the front of this issue. Every question must be completed on the exam answering sheet to be eligible for CME credit. Leaving any item unanswered will make void the participant’s response. This CME activity must be completed and postmarked by December 31, 2016. The documentation received will be compiled throughout the calendar year, and once a year in January, participants will receive a certificate indicating CME credits earned for the prior year of work. This CME activity was planned and produced in accordance with the ACCME Essentials.

CME Self-Assessment Exam Questions CME Article 2015 Series Number 1: Wang et al. 1. In this study, what were the mean and median intervals of stroke onset to inpatient rehabilitation admission for the total study sample? A. 10.1 and 5.5 days B. 6.9 and 5 days C. 8.3 and 5 days D. 12.7 and 7 days

4. In this study, early inpatient rehabilitation admission was associated with a shorter inpatient rehabilitation length of stay for: A. Mildly impaired group B. Moderately impaired group C. Severely impaired group D. All three groups

2. In this study, early inpatient rehabilitation admission was associated with the improvement of motor functional gain for: A. Mildly impaired group B. Moderately impaired group C. Severely impaired group D. Both B and C

5. According to this study, what is the recommended interval between stroke onset and inpatient rehabilitation admission for adult stroke patients? A. The earlier the better B. 0Y7 days for all three impairment groups C. Within 7 days for medically appropriate patients D. Within 14 days for medically appropriate patients

3. In this study, early inpatient rehabilitation admission was associated with a higher chance of discharge to the community for: A. Mildly impaired group B. Moderately impaired group C. Severely impaired group D. Both B and C

(Continued next page)

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Early inpatient rehabilitation admission and stroke patient outcomes.

The aim of this study was to examine the associations of onset days, time from stroke onset to inpatient rehabilitation facility (IRF) admission, and ...
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