Biomedical subjects

M G Stineman

Publications and source records attributed to M G Stineman.

At least 37 records · Page 2Linked to original sources

PubMed1997

Impairment-specific dimensions within the Functional Independence Measure.

OBJECTIVE: The analyses presented in this article were intended to seek more fine-grained impairment-specific dimensions beyond the motor and cognitive dimensions of the Functional Independence Measure (FIMSM). DESIGN: The study used factor analysis within 20 categories of impairment to test the hypotheses that FIM items can be grouped according to functional areas of the body and that these item groupings differ depending on the patient's impairment. PATIENTS: Data from 93,829 patients discharged in 1992 from 252 free-standing rehabilitation hospitals and units were obtained from the Uniform Data System for Medical Rehabilitation. RESULTS: In 18 of 20 impairment categories, factor analyses of patients admission FIM scores showed impairment-specific FIM dimensions. Four impairments had a 3-dimensional factor structure, and 14 had a 4-dimensional structure. The impairment-specific dimensions were always nested within the motor-FIM subscale. Reliability coefficients for subscales based on these dimensions ranged from .74 to .97. The subscales appear to cluster FIM items by the area of body involved, neurological level, or relative energy consumption. CONCLUSION: The FIM can be viewed as a multilayered multidimensional measure of human function. The impairment-specific dimensions, at an intermediate layer, provide insight about the causal linkage between the impairment and resultant patterns of disability. Impairment-specific subscales are relevant to those clinical or research applications where the type of disability needs to be more closely related to impairment.

Activities of Daily Living↗

PubMed1997

Measuring casemix, severity, and complexity in geriatric patients undergoing rehabilitation.

Geriatric rehabilitation is intended to maintain or restore function, maximize life satisfaction, enhance psychologic well-being, and maintain the social status of older persons. For clinical services to operate efficiently and equitably, payment must be based on rules that are clinically sound and thus reinforce the objectives of the services provided. This article presents a theoretical basis for casemix measurement in medical rehabilitation, contrasts structure of the functional independence measure-function-related groups (FIM-FRGs) intended for casemix measurement to the diagnosis-related groups (DRGs) and resource utilization groups (RUG) III systems designed for acute and long-term care settings, focuses on special issues of relevance to the rehabilitation of older persons, and provides four challenges in an effort to stimulate discussion.

Activities of Daily Living↗

PubMed1997

Classifying rehabilitation inpatients by expected functional gain.

OBJECTIVES: To create a more suitable payment system for medical rehabilitation, the authors developed a companion classification system to the original functional independence measure-function-related groups (FIM-FRGs), which classify patients having similar lengths of stay in a rehabilitation hospital or inpatient unit. The companion system presented here groups patients according to their gains in functional status during the rehabilitation stay. METHODS: Data from 84,492 patients discharged from 252 rehabilitation facilities in 1992 were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The gain-FRGs system used four predictor variables: (1) diagnosis leading to disability, admission scores on the (2) motor and (3) cognitive subscales of the FIM, and (4) patient age. RESULTS: The gain-FRGs system contained 74 patient groups and explained 21% of the variation in functional gain for patients in a different set of records withheld for validation. CONCLUSIONS: The gain-FRGs system should be considered for prospective payment systems because it gives the provider an incentive to improve patient outcomes, which is missing in a payment system based on FIM-FRGs alone.

Activities of Daily Living↗

PubMed1997

A prediction model for functional recovery in stroke.

BACKGROUND AND PURPOSE: Stroke-related physical disability can diminish quality of daily living, place care burden on families, and increase need for long-term institutionalization. We developed a prognostic index for use in research and with potential for adaptation to clinical practice that establishes the likelihood of an individual achieving a specific stage of functional recovery after stroke rehabilitation. METHODS: We constructed the index using logistic regression based on 3760 patient records from 96 rehabilitation facilities in 31 states. The stage, as measured by the Functional Independence Measure, includes achievement of the following: independence in eating, grooming, and dressing the upper body; continence in bowel and bladder; and transfer between a bed and chair with supervision only. RESULTS: This stage was achieved by 26.1% of patients functioning below it at rehabilitation admission. Disability onset of less than 60 days was associated with more than a 3-fold increase in the likelihood of achieving the stage (adjusted odds ratio, 3.5; 95% confidence interval, 2.0 to 6.0). Each eight-point increase in an eight-item activities of daily living score, measured at admission to rehabilitation, increased the odds 2.5-fold (95% confidence interval, 2.3 to 2.8). For those living alone or employed before the stroke, the odds of achieving the stage increased by factors of 1.3 and 2.2, respectively. The index showed minimal shrinkage on cross validation. The achievement of this profile of function is important because 95.3% of stroke patients who achieved or exceeded it were discharged home, as opposed to only 66.8% of those who did not achieve it. CONCLUSIONS: The index can be used to establish prognoses for individual stroke patients at admission to rehabilitation with regard to achieving this stage. Achievement of the stage is associated with a high likelihood of discharge to home.

Activities of Daily Living↗

PubMed1997

A modular case-mix classification system for medical rehabilitation illustrated.

The authors present a modular set of patient classification systems designed for medical rehabilitation that predict resource use and outcomes for clinically similar groups of individuals. The systems, based on the Functional Independence Measure, are referred to as Function-Related Groups (FIM-FRGs). Using data from 23,637 lower extremity fracture patients from 458 inpatient medical rehabilitation facilities, 1995 benchmarks are provided and illustrated for length of stay, functional outcome, and discharge to home and skilled nursing facilities (SNFs). The FIM-FRG modules may be used in parallel to study interactions between resource use and quality and could ultimately yield an integrated strategy for payment and outcomes measurement. This could position the rehabilitation community to take a pioneering role in the application of outcomes-based clinical indicators.

Activities of Daily Living↗

PubMed1997

Development of function-related groups version 2.0: a classification system for medical rehabilitation.

OBJECTIVE: To present a new version (2.0) of the Functional Independence Measure-Function Related Group (FIM-FRG) case-mix measure. DATA SOURCE/STUDY SETTING: 85,447 patient discharges from 252 freestanding facilities and hospital units contained in the 1992 Uniform Data System for Medical Rehabilitation. STUDY DESIGN: Patient impairment category, functional status at admission to rehabilitation, and patient age were used to develop groups that were homogeneous with respect to length of stay. Within each impairment category patients were randomly assigned to one data set to create the system (through recursive partitioning) or a second set for validation. Clinical and statistical criteria were used to increase the percentage of patients classified, expand the impairment categories of FIM-FRGs Version 1.1, and evaluate the incremental predictive ability of coexisting medical diagnoses. Predictive stability over time was evaluated using 1990 discharges. PRINCIPAL FINDINGS: In Version 2.0, the percentage of patients classified was increased to 92 percent. Version 2.0 includes two new impairment categories and separate groups for patients admitted to rehabilitation for evaluation only. Coexisting medical diagnoses did not improve LOS prediction. The system explains 31.7 percent of the variance in the logarithm of LOS in the 1992 validation sample, and 31.0 percent in 1990 discharges. CONCLUSIONS: FIM-FRGs Version 2.0 includes more specific impairment categories, classifies a higher percentage of patient discharges, and appears sufficiently stable over time to form the basis of a payment system for inpatient medical rehabilitation.

Aged↗

PubMed1996

The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories.

OBJECTIVE: The analysis presented here evaluated the psychometric properties of the Functional Independence Measure (FIM) as a summated rating scale within context of the 20 impairment categories of the FIM-Function Related Group (FIM-FRG) system. DESIGN: This study involved a cross-sectional analysis of patient records, utilizing factor analysis and techniques of multitrait scaling to verify the summative properties of the motor and cognitive dimensions of the FIM and to study the statistical properties of admission FIM scores. PATIENTS: Included were a total of 93.829 patients discharged from 252 freestanding rehabilitation hospitals and units during calendar year 1992. Cases were excluded that had missing or out-of-range values or atypical lengths of stay. These criteria were developed previously in conjunction with an expert clinical panel and confirmed through statistical analyses. RESULTS: Factor analyses supported the motor and cognitive dimensions across all 20 impairment categories. The resulting subscales exceeded minimum criteria for item internal consistency in 96.9% of tests and item discriminant validity in 100% of tests. Reliability coefficients for each impairment category for both subscales ranged from .86 to .97. There were no major ceiling effects, but patients in certain impairment categories were unable to climb stairs at admission. CONCLUSION: The psychometric properties of the summated FIM compare favorably to most standardized health measures used in medical practice. Findings provide support for the motor and cognitive subscales as used in the FIM-FRGs. As a unidimensional scale, the FIM quantifies care burden. Split into the motor and cognitive (as used in the FIM-FRGs) it distinguishes physical disabilities from those arising from communication or cognitive difficulties.

Activities of Daily Living↗

PubMed1995

Case-mix measurement in medical rehabilitation.

Case-mix measurement offers a way to take patient characteristics into account in the determination of payment rates. This article begins with an overview of major case-mix measures across inpatient hospital and other institutional settings and describes ways to measure the suitability and relative strengths of these measures. It then briefly discusses issues of payment and the appropriateness of alternative case-mix measures to inpatient rehabilitation. The literature review extends back to the 1970s, thus preceding advent of the Diagnosis-Related Groups, which was the first major case-mix measure developed and implemented in a hospital setting.

Activities of Daily Living↗

PubMed1995

Efficiency pattern analysis for medical rehabilitation.

Efficiency pattern analysis (EPA) is a technique proposed for use in medical rehabilitation that links patient functional gain to resource use, as approximated by length of stay (LOS), after adjusting for initial severity. The Functional Independence Measure version of the Function Relation Groups (FIM-FRGs) is used to adjust for patient severity and to define the efficiency groups. The efficiency groups are based on LOS and functional gain cut point values in the statistical distribution that are above, below, or within the national interquartile range for each of 53 FRGs. Data from 32,494 patients discharged in 1990 from 123 rehabilitation facilities were used. EPA is a simple way to monitor change in functional gain in response to transformations in health care practices and resource availability. The technique could also provide individual facilities with a means to evaluate treatment efficiencies across time and to compare patterns of LOS and functional gain to national norms.

Activities of Daily Living↗

PubMed1994

Development of complications during rehabilitation.

BACKGROUND AND METHODS: Although studies have demonstrated that medical rehabilitation patients have many complications that warrant attention, none has attempted to categorize complications by severity. This retrospective cohort study examined the incidence, types, and severity of problems that interrupt rehabilitation and the major risk factors for these events. RESULTS: Of 1075 patients, 359 (33.4%) had acute medical complications on rehabilitation considered severe enough to interrupt treatment. Of the 359 patients, 158 (44%) required an unexpected transfer off rehabilitation. The most common reasons for unexpected transfer were surgical causes (22.8%), followed by infection or fever (17.1%) and by thromboembolic events (16.5%). Logistic regression revealed that major risk factors for complications requiring transfer were a primary diagnosis of deconditioning or nontraumatic spinal cord injury (adjusted odds ratio, 2.7; confidence interval, 1.8 to 4.2), severity of initial disability (adjusted odds ratio, 1.2; confidence interval, 1.1 to 1.3 for every 10-point drop in a Modified Barthel Index), and number of comorbid conditions (adjusted odds ratio, 1.1; confidence interval, 1.0 to 1.2). Risk factors for any complication were similar, but there was an interaction between comorbidity and the degree of functional impairment; in patients who were severely functionally impaired, the number of comorbidities was not as strongly associated with the risk of complications as it was in patients who were less functionally impaired. CONCLUSION: There is a complex relationship among the type of underlying medical impairment, severity of functional limitation, comorbidity, and unanticipated medical or surgical complications that interrupt rehabilitation. The interruptions vary both in type and in severity.

Activities of Daily Living↗

PubMed1994

A case-mix classification system for medical rehabilitation.

Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.

Activities of Daily Living↗

PubMed1994

Four methods for characterizing disability in the formation of function related groups.

The Functional Independence Measure-Function Related Groups (FIM-FRGs) were developed to classify medical rehabilitation inpatients into homogeneous groups based on length of stay (LOS). Patients are first grouped into clinically relevant rehabilitation impairment categories, then by functional status, as expressed by the FIM, and in certain cases by patient age. The statistical approach used to form the final groupings was a recursive partitioning algorithm applied to the FIM scores and patient age within impairment category. This analysis compares four FIM-FRG classification schemes developed from four scale sets that combine FIM items differently: (1) use of the 18 FIM items as separate variables, (2) the combination of FIM items into six clinical subscales, (3) the combination of the six clinical subscales into motor and cognitive subscales, and (4) the combination of all FIM items into a single scale. The FIM-FRG schemes explain similar amounts of variance in the logarithm of LOS and contain approximately equal numbers of FRGs. The motor and cognitive subscale scheme is recommended for use in payment, however, this scheme and the other schemes have additional uses. Each FRG scheme provides different insight into the clinical relationship between disability and LOS.

Activities of Daily Living↗

PubMed1993

Applying quantitative methods to the prediction of full functional recovery in adult rehabilitation patients.

The purpose of this project was to construct a pilot prognostic index for use in research and clinical practice that would predict functional recovery in adult rehabilitation patients at discharge using clinical characteristics at admission to rehabilitation (independent performance of seven activities of daily living and three basic mobility tasks). We constructed the index from retrospectively collected data on 1,020 adult rehabilitation patients who underwent rehabilitation between 1980 and 1986. Adjusting for patient characteristics, the odds of recovering independent function doubled for each ten-point increase in the 100-point functional status score measured at admission to rehabilitation (odds ratio = 2.1, 95% confidence interval [CI] = 1.9 to 2.4). The odds increased by a factor of 1.9 (95% CI = 1.1 to 3.2) in patients with an impairment considered more functionally reversible and by a factor of 2.1 (95% CI = 1.3 to 3.4) in patients transferred from an acute hospital. The odds of functional recovery decreased in those over 79 years of age, in those who were unemployed before hospitalization, and as the number of comorbid conditions increased. Our findings demonstrate the feasibility of developing quantitative estimates of functional prognosis. Prior to use, the index should be externally validated in different rehabilitation facilities.

Activities of Daily Living↗

PubMed1993

Specificity of ICD-9-CM coding practices for stroke rehabilitation.

Designed for acute care classification, the 9th version of the International Classification of Disease, Clinical Modification (ICD-9-CM) is also used to describe the principal diagnosis in medical rehabilitation. ICD-9-CM (ICD-9) coding practices for all stroke cases found in two nationally representative databases were examined (sample sizes over 17,000 and over 2,000). Of the more than 100 codes selected, four were indicated for 67% and 72% of stroke cases in the two data sets, respectively. Codes 436 and 438 distinguish acute from late stroke effects; whereas code 434.9 identifies stroke, but not its duration. The most frequently used code in the larger database, 342.9, refers to the manifestation of hemiplegia rather than to diagnosis, and thus is not specific to stroke. Other less frequently selected ICD-9 codes are more specific to the underlying pathophysiology (e.g., thrombosis, embolus or hemorrhage). Results emphasize the need for more precise selection of etiologic ICD-9 codes for stroke rehabilitation so that they describe specific pathology.

Cerebrovascular Disorders↗

PubMed1990

Research in physical medicine and rehabilitation. VII. The role of the principal investigator.

The roles and responsibilities of the principal investigator of a research project are described to allow the young researcher to make an intelligent decision regarding which role to take in a research project. Guidelines are given about which tasks may be delegated and how to do this. These tasks include formulation of the question, project design, obtaining funding, project startup and ongoing management, data analysis and publication. Particular attention is paid to design/analysis and publication, since these determine authorship on biomedical research articles.

Humans↗

PubMed1990

Predicting inpatient rehabilitation length of stay.

Using standardized forms and predefined criteria, information was collected on all 1,238 patients admitted to the inpatient rehabilitation facility at our university hospital between August 1, 1980 and December 30, 1986. Data from 96% of these patients were used retrospectively to create a mathematic model, based on multiple linear regression, that predicts the patient's total rehabilitation length of stay (LOS). The model requires only information about the patient's admitting diagnosis, referral source, admission functional status, and date of admission. The model compared favorably with prospective estimates of LOS made independently by attending physicians at admission to rehabilitation. We conclude that such models could be used to facilitate management of rehabilitation units, forecast patient census, schedule unit personnel, set interim goals for LOS, and facilitate discharge planning. The delivery of rehabilitation services, like the delivery of other medical services, can be defined in part by objective, measurable patient characteristics.

Adult↗

PubMed1989

Research in physical medicine and rehabilitation. V. Data entry and early exploratory data analysis.

The process of data entry and initial analysis to locate data errors is described. Basic terms are defined and a simple method of entering data by using word processing software is illustrated. Data checking is done by using visual check of the raw data. Statistical programs are then used to locate possible data errors by finding data points (outliers) that are very different from the average. Special graphic output of statistical programs, scatterplots and box and whisker plots can be used to further locate questionable data. Examples of data entry forms and annotated step by step data cleaning with the use of inexpensive programs for personal computers are presented.

Computers↗

PubMedDate not supplied

Functional gain and length of stay for major rehabilitation impairment categories. Patterns revealed by function related groups.

This study evaluates the relationship of functional severity to patterns of functional gain and length of stay (LOS) for patients discharged from medical rehabilitation. It further compares differences in patterns between summed and Rasch transformed subscales of the Functional Independence Measure (FIM). Two different schemes of the FIM-Function Related Groups (FIM-FRGs) are used to define groups of patients who present with similar degrees of functional severity. The first scheme was developed using summed admission motor and cognitive FIM subscores (FIM-FRGs). The second scheme was developed by transforming these same motor and cognitive FIM subscores into logits (Logit FIM-FRGs), thus making FIM scores more equal-interval. The study included 32,494 patients who were discharged from 123 facilities that submitted data to the Uniform Data System for Medical Rehabilitation (UDSMR) and involved the separate evaluation of 18 different rehabilitation impairment categories. Motor FIM gain was calculated for each FRG in both schemes as the patient's discharge motor FIM score minus the admission motor FIM score. There were four patterns of motor FIM gain and two patterns of LOS across rehabilitation impairment. The most common pattern in both schemes was linear trend, for which median gains and LOS were highest for patients in the most disabled FRGs and lowest for patients in the least disabled FRGs. Gain patterns differed across impairment and across the two schemes. The motor FIM gain distributions provide clinicians with a range of typical functional outcomes for patients admitted to medical rehabilitation. This descriptive approach provides clinicians and administrators with a simple way to compare the motor FIM gain and LOS patterns of patients teated in local facilities with broad-based norms. This sample includes about one-quarter of rehabilitation facilities nationwide, thus representing population standards for facilities participating in the UDSMR. Suggestions are made on how to use these norms most appropriately for both facility and patient comparison.

Activities of Daily Living↗