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PubMed1990

Factors influencing utilization of postdischarge cognitive rehabilitation programs.

A decision to add a new treatment program has widespread and long-lasting implications for both the patient and the organization. Information about the interactions among the institution, the patient, and the treatment modality are seldom available. Cognitive rehabilitation is a relatively new treatment modality that is being adopted in a number of programs. This report examined characteristics of stroke patients that (1) precluded their selection for cognitive rehabilitation treatment and (2) were associated with patient refusal to participate in cognitive rehabilitation. The records of stroke patients treated in three rehabilitation facilities were examined for their ability to participate in an outpatient cognitive rehabilitation program. Due to stringent criteria for the research project, fewer than half of the stroke patient population were cognitively able to participate. Of eligible patients, many declined postdischarge cognitive rehabilitation. Several variables influenced patient participation. Female stroke patients were much less likely to participate than were male patients. In addition, distance from the medical facility providing cognitive rehabilitation was a major barrier to treatment participation. Individuals who opted to participate were well educated, affluent or both. The sample of cognitive rehabilitation patients was not, therefore, representative of the population. These results suggest that medical facilities considering the addition of a centralized outpatient postdischarge cognitive rehabilitation program should first evaluate the characteristics of the target population. Suggestions about the institutional considerations involved in making the decision to add a cognitive rehabilitation program are made.

Adult↗
PubMed1990

Studies up to 1980 on stroke rehabilitation outcomes.

Although rehabilitation potentials are meant to be used in prognosis, they differ from the usual prognostic signs in the morbidity sense because they relate to behavioral outcomes rather than cure of neurologic deficits. Survival studies have shown that stroke patients who live through the acute phase after onset survive long enough to warrant rehabilitation. The most important overall conclusion from scientific studies of predictors of stroke rehabilitation outcome is that the identified predictors were not accurate enough to predict gains in the rehabilitation process or the disposition of the individuals at discharge. Instead, these predictors can only be used in a statistical sample to describe the general criteria of those patients who would do better versus those who would do worse in rehabilitation. Some of these general indicators include those that seem to have no effect on rehabilitation outcomes--age, sex, amount of paralysis, side of brain involved, and place of residence at the time of the stroke. Those factors for which the effects are still unknown are race and prolonged specialized training period in either proprioceptive neuromuscular facilitation or percent-concept organization and motor output training. Factors that positively affect rehabilitation outcomes are good family support and financial status, higher socioeconomic and educational levels, early referral to rehabilitation, and the type of rehabilitation center (comprehensive rehabilitation center versus nursing home).(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrovascular Disorders↗
PubMed1995

[Theoretical aspects of rehabilitation and occupational health of pilots].

Some theoretical aspects of the rehabilitation problem and its interaction with the problem of professional health of pilot have been discussed in this paper. The authors have proposed methodologic approaches to the essence of medical and professional rehabilitation; classification of the main directions and types of rehabilitation, the principles of its application in flying practice as well as the question about economic advisability have been studied. As the main lines of medical rehabilitation there suggests the nosologic, psychologic and physiologic, professional (singly) rehabilitation with consideration of the labile and base components of professional health of pilot. As the base principle of rehabilitation there advances an etiopathogenic approach to the use of different means and methods of rehabilitation treatment and correction of a changed functional state. General requirements upon provision of multilevel, differential, individual, accessible and adequate rehabilitation are formulated. The method to calculate the economic effect of rehabilitation measures at the expense of savings in costs of pilot personnel by increasing the flight longevity and decreasing the number of flights necessary for maintaining the given level of combat effectiveness is proposed. The classifier of the main directions and types of rehabilitation is presented.

Aerospace Medicine↗
PubMed1998

Optimal timing of rehabilitation after cardiac surgery: the surgeon's view.

Cardiac rehabilitation has become an accepted adjunct treatment for the majority of patients with cardiovascular disease, especially for those who have received cardiac surgery. However, improved survival has not been generally demonstrated in a supervised cardiac rehabilitation programme, while some benefits have been found in functional capacity, psychosocial characteristics and lipoprotein patterns of patients who underwent sustained periods of exercise training. The influence of post-surgical conditions on phase II rehabilitation following cardiac surgery has not yet been well addressed. Many factors may influence the timing of phase II rehabilitation following cardiac surgery, especially the pre-operative condition of the patient, the concomitant morbidity, the incidence of peri-operative complications and the rapidity of recovery, mainly influenced by post-operative cardiac and lung function, pain and wound healing. This article reviews the general and specific medical and surgical problems encountered during early follow-up of cardiac surgery patients, which might affect the timing of postoperative rehabilitation, analyses briefly the impacts of less invasive heart surgery on cardiac rehabilitation as well as that of fast tract protocols after conventional heart surgery. Some patients required service intervention during cardiac rehabilitation while others were withdrawn from cardiac rehabilitation for medical reasons or surgery-related complications. Specific problems in patients following cardiac transplantation are depicted briefly. Cardiac transplant recipients may suffer from pre-operative end-stage heart failure, prolonged cold ischaemia of the donor heart, denervation of the cardiac allograft, immunological allomismatch, and unusual psychological stress. In summary, phase II cardiac rehabilitation on a stationary and more recently on an ambulatory basis is generally recommended two to four weeks following uncomplicated coronary and valvular procedures, while patients following cardiac transplantation may be included in such programmes after approximately four to six weeks. The earliest rehabilitation is possible in patients following less invasive heart surgery and may start one to two weeks postoperatively.

Coronary Artery Bypass↗
PubMed2005

[Eva-Reha: a computer software supporting outcome-based quality management in medical rehabilitation].

PURPOSE: Development of a computer software for supporting medical quallity management by documenting progression and results of medical rehabilitation in neurologic, orthopaedic, and geriatric patients. METHODS: The software "Eva-Reha" (Evaluation of Medical Rehabilitation) was generated using C ++ in a client-server structure with Interbase being the underlying relational database management system. The software is network-compatible and runs under Windows NT and Windows 2000. RESULTS: "Eva-Reha", developed by the "Medizinischer Dienst der Krankenversicherung Rheinland-Pfalz (MDK RLP)" supports quality management systems in medical rehabilitation. Since 2003 the MDK RLP provides neurologic and geriatric rehabilitation centres with the software free of charge. With the help of "Eva-Reha" progression and results of medical rehabilitation can be displayed metrically, thus facilitating individual rehabilitation planning and supporting motivation of the rehabilitation team. Therapeutic strategies can be evaluated for different ICD-10-diagnoses or impairment groups. Moreover, "Eva-Reha" provides valuable data for administration and controlling purposes, e. g. age structure, case mix, impairment on admission and medical as well as rehabilitative procedures. The system generates a request for extension in a set form which facilitates communication between rehabilitation centres and sponsors.

Aged↗
PubMedDate not supplied

Women's views of cardiac rehabilitation programs.

BACKGROUND: Previous approaches to understanding participation in cardiac rehabilitation programs based on middle-aged men may not be useful to explain the participation of women. The focus group research method produces unique data about attitudes and experiences that can serve as an adjunct to other forms of data collection in an effort to develop models explaining cardiac rehabilitation participation. The aim of this pilot study was to examine the perceptions and experiences of women participating in a cardiac rehabilitation program using focus groups. METHODS: Ten women (mean age 72 years) who had recently participated in a cardiac rehabilitation program were interviewed in focus groups of 6 and 4 members each using a semi-structured interview guide. Verbatim transcriptions of the focus group interviews were analyzed by two individuals using content analysis methods. RESULTS: Results indicated that prior to participation women had no idea what to expect in a cardiac rehabilitation program. Features women liked most about the program included: (1) feeling "safe" during exercise because they were monitored; (2) peer group support during rehabilitation; and (3) pleasant, encouraging staff. Women desired more: (1) social interaction during the cardiac rehabilitation exercise sessions; (2) emotional support from staff members about all dimensions of cardiac recovery; and (3) exercise options other than cycle or treadmill. CONCLUSIONS: Several cardiac rehabilitation program design and operational features are perceived by women as not meeting their needs. Although limited by its small sample size, findings from this study provide valuable insights into women's perceptions of cardiac rehabilitation programs.

Aged↗
PubMed2004

[Comparison of activities of daily living for a convalescent rehabilitation ward and general ward for stroke patients].

We investigated changes in the Activities of Daily Living (ADL) of stroke patients in a convalescent rehabilitation ward and a general ward using a Functional Independent Measure (FIM). The subjects were 109 patients hospitalized for rehabilitation purposes at the Oyamada Memorial Spa Hospital. The change in FIM at the time of hospitalization and that at 1 week later was investigated in 81 patients in the convalescent rehabilitation group (CRG) and 28 patients in the control group (CG). In addition, the CRG was investigated again after one month. Intensive rehabilitation service based on ADL and worksheets was introduced in the CRG. On the other hand, these were not introduced in the CG. The total score of FIM increased significantly (p<0.01) in the first week after hospitalization in both groups. The FIM-gain after one week in the CRG was high. With regard to each item, a significant improvement was observed in patients' motor skills while eating, grooming, bathing, dressing the upper body, dressing the lower body, toilet, bladder management, transfer bed/chair, toilet and tub, and walking/wheelchair (11/13). Multiple regressions were used to assess the relationships between FIM-gain (one week, one month), age, rehabilitation intensity and other predictive variables. Better rehabilitation outcomes were observed in patients with lower level of dementia and high rehabilitation intensity. It was thought that planned rehabilitation based on ADL was effective in the CRG, and it was suggested that the CRG's system is effective in the rehabilitation of stroke patients.

Activities of Daily Living↗
PubMed1999

[Demographic and curative factors of need for rehabilitation--possibilities and limits of simple time series models].

Regarding rehabilitation demands, macro-analytical time-series models outline a method for the estimation of effective rehabilitation needs and for explaining the magnitude of the requirements. Their range is limited, in so far as they are unable to clarify the rehabilitation requirement regarding individual micro-level behavioural aspects. For the moment the rehabilitation requirements are hidden units in the models. Differing macro-dimensions have been gradually included in the analysis. The demographic parameters of the potential patients in need of rehabilitation are the fundamental starting point. Rehabilitation requirements are increasingly modelled by the magnitude of the curative requirements. These are characterised in the rehabilitation as "preliminary or follow up". Two examples of simple time-series models in rehabilitation--for the development of rehabilitation demand--illustrate empirically, which possibilities and boundaries are set in view of demographic and curative requirements by the interpretative range of the macro-concepts. What is methodically interesting with it, is how the analytical borders of such time-series models can experience a recognisable theoretical broadening, through a projection in real logistical facts--here in the interaction between prognosis and retrospection.

Coronary Disease↗
PubMed1988

Prospective payment for medical rehabilitation: the DHHS report to Congress.

Since 1983, when Congress established the Medicare DRG-based Prospective Payment System (PPS) for inpatient hospital care, rehabilitation hospitals and units that qualify under federal regulations have been exempted from the system. Congress recognized that the DRGs were not designed to consider the specific circumstances of rehabilitation patients. It required the Secretary of the Department of Health and Human Services (DHHS) to report on the feasibility of developing a PPS for rehabilitation (and other excluded) hospitals and units. In October 1987, DHHS released its long-awaited report to Congress on "Developing a Prospective Payment System for Excluded Hospitals." The Report concludes that further research is necessary before DHHS can develop specific legislative and regulatory recommendations. Yet, the report also indicates DHHS' desire ultimately to implement a capitation-based PPS for rehabilitation. Until this goal is achieved, DHHS would like to develop a transitional PPS for rehabilitation. However, given that studies indicate that DRGs are an inappropriate basis for a rehabilitation PPS, and measures that would provide a better basis (eg, functional status or capitation) have not yet been fully developed for purposes of rehabilitation payment, it is uncertain how DHHS will achieve these goals in the short run. Until further studies are conducted, development of a transitional system appears ill-advised. Congress and DHHS should, therefore, continue to exempt rehabilitation hospitals and units until an appropriate payment system for rehabilitation can be developed.

Capitation Fee↗
PubMed2000

Cognitive rehabilitation for traumatic brain injury: A randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group.

CONTEXT: Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields. OBJECTIVE: To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI. DESIGN AND SETTING: Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center. PATIENTS: One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging. INTERVENTIONS: Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53). MAIN OUTCOME MEASURES: Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group. RESULTS: At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval ¿CI¿, -5% to 14%]) or fitness for duty (73% vs 66%, respectively; P=. 43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=. 05). CONCLUSIONS: In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions. JAMA. 2000;283:3075-3081

Absenteeism↗
PubMed1998

[Quality management in medical rehabilitation].

In the context of the quality assurance program of the German pension insurance institutions, instruments and procedures have been developed in the past few years in order to assess the quality of structure, process, and results of inpatient rehabilitation, as well as patient satisfaction. The routine implementation of these procedures aims at providing rehabilitation hospitals with fast information on shortcomings in their current practice, so that concepts of treatment and--in the long run--effects of rehabilitation can be systematically improved. When the "quality profiles" of rehabilitation hospitals are compared ("benchmarking"), paying institutions of rehabilitation could gain information on the cost-quality-ratio of particular hospitals as well as important leads for improving the steering processes of patients and hospitals. In the present article, results of a first "field-run" of the procedures for measuring patient satisfaction and quality of rehabilitation processes are reported. A comparative analysis of patient satisfaction in four orthopaedic/rheumatologic rehabilitation hospitals showed high degrees of overall satisfaction in all hospitals. In several subdimensions of patient satisfaction, however, significant differences between hospitals were found. Quality of rehabilitation processes--as assessed by a standardized peer-review--varied substantially between 36 hospitals. Problems of quality were found especially in some dimensions that must be considered as crucial for rehabilitation, e.g., in the history and diagnosis of disabilities, in the consideration of psycho-social problems, or in the assessment of occupational capacities.

Benchmarking↗
PubMed2004

Nutritional status of cancer patients and its relationship to function in an inpatient rehabilitation setting.

BACKGROUND: Malnutrition is associated with prolonged hospitalization, lower survival rate, and various medical complications. However, little is known about malnutrition and its relationship with the functional status. We undertook this retrospective study to examine whether or not malnutrition affects rehabilitation outcome in patients who had undergone cancer rehabilitation. METHODS: We conducted a review of the charts of 30 consecutive cancer patients who had been admitted to the inpatient rehabilitation unit in a tertiary cancer center, from the beginning of March 2001 to the end of April 2001. RESULTS: The patients' mean rehabilitation stay was 9 days and their mean age was 58 years (range 22-86 years). On rehabilitation admission, 15 of the patients (50%) had a below normal prealbumin (<18 mg/dl) level (95% confidence interval 31-69%), and on discharge 10 of the patients (33%) had a below normal prealbumin level (95% CI 17-54%). The serum prealbumin concentration level correlated with motor functional independence measure scores on admission. After inpatient rehabilitation, statistically significant gains in functional independence measure scores (P<0.0001) were obtained in patients with below normal admission prealbumin, as well as in those whose prealbumin levels were within the normal range; no statistically significant difference was found in functional gain between these two groups. CONCLUSION: Our study showed that a large number of cancer rehabilitation patients had malnutrition. Nevertheless, functional gain was achieved in all patients after rehabilitation, whether or not malnutrition was present. We conclude that malnourished patients should still be considered candidates for rehabilitation.

Adult↗
PubMed2005

Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation.

OBJECTIVE: To determine the prevalence of venous thromboembolic disease (VTED) and impact on functional outcome in patients with major lower-extremity (LE) amputation admitted to an inpatient rehabilitation unit. DESIGN: Retrospective medical records review. SETTING: Acute inpatient rehabilitation unit in a tertiary, urban academic medical center. PARTICIPANTS: Fifty consecutive patients admitted to an acute inpatient rehabilitation unit after a major LE amputation. Participants were screened at rehabilitation admission for LE deep vein thrombosis using duplex ultrasonography. INTERVENTIONS: Not applicable. Main outcome measures VTED incidence, FIM instrument, total rehabilitation charges, and length of stay (LOS). RESULTS: Six of 50 patients (12%) had evidence of VTED. The VTED cohort had significantly lower admission and discharge FIM scores than the no-VTED cohort (admission FIM score, 57.2 vs 76.0; discharge FIM score, 66.0 vs 90.1, respectively; P< or =.02). Subjects with VTED had a longer rehabilitation LOS (22.8d vs 13.9d, respectively; P=.02) and higher total rehabilitation charges (28,314 US dollars vs 17,724 US dollars, respectively; P<.05). CONCLUSIONS: In this study, VTED prevalence after LE amputation in a rehabilitation setting was 12%. Subjects with VTED had lower admission and discharge functional status, longer LOS, and higher hospital charges. The utility of screening duplex ultrasound examinations at rehabilitation admission remains unclear.

Aged↗
PubMed2005

Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002.

OBJECTIVE: To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 1998 through 2002. DATA SOURCES: PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. Reference lists from identified articles were reviewed and a bibliography listing 312 articles was compiled. STUDY SELECTION: One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded after detailed review. Excluded articles included 14 studies without data, 6 duplicate publications or follow-up studies, 5 nontreatment studies, 4 reviews, and 2 case studies involving diagnoses other than TBI or stroke. DATA EXTRACTION: Articles were assigned to 1 of 7 categories reflecting the primary area of intervention: attention; visual perception; apraxia; language and communication; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria. DATA SYNTHESIS: Of the 87 studies evaluated, 17 were rated as class I, 8 as class II, and 62 as class III. Evidence within each area of intervention was synthesized and recommendations for practice standards, practice guidelines, and practice options were made. CONCLUSIONS: There is substantial evidence to support cognitive-linguistic therapies for people with language deficits after left hemisphere stroke. New evidence supports training for apraxia after left hemisphere stroke. The evidence supports visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition. Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.

Brain Injuries↗
PubMed2005

Prehabilitation and rehabilitation for attenuating hindlimb unweighting effects on skeletal muscle and gait in adult and old rats.

OBJECTIVE: To compare the effectiveness of no exercise with prehabilitation (exercise before hindlimb unweighting [HLU]) versus rehabilitation (exercise given after HLU) on gait function and skeletal muscle mass and force. DESIGN: Randomized controlled trial. SETTING: Animal laboratory. ANIMALS: Male-specific, pathogen-free Fisher344/Brown Norway rats (N=149). Groups consisted of adult and old controls, HLU, prehabilitation, rehabilitation, natural cage recovery (reloading), and exercise without HLU. INTERVENTIONS: Ten days of general conditioning exercise were given to 6-month-old adult and 30-month-old old rats before or after a week of HLU. MAIN OUTCOME MEASURES: Gait stride length and width; soleus, plantaris, extensor digitorum longus, and peroneus longus mass and peak contractile force; whole gastrocnemius mass; and total protein concentration for the soleus and gastrocnemius. RESULTS: Muscle mass (approximately 30%) and force (24%-36%) declined with age in all muscles studied. In adult rats declines in muscle mass occurred with HLU in the soleus, plantaris, and gastrocnemius. Prehabilitation did not prevent the loss of muscle mass in adult rats. Rehabilitation and natural recovery effectively restored soleus and gastrocnemius muscle mass in adult rats but not soleus peak force. Old rats had a significant 23% HLU effect only on gastrocnemius mass (control, 1670+/-129 mg; HLU, 1274+/-184 mg). Prehabilitation did not prevent the decline in gastrocnemius mass. Rehabilitation in old rats restored gastrocnemius mass to within 13% of control levels. Prehabilitation was effective for preventing and rehabilitation was effective for restoring soleus contractile force in old rats (control, 114+/-9 mg; HLU, 67+/-22 mg; prehabilitation, 106+/-31 mg; rehabilitation, 120+/-26 mg) compared with recovery without exercise (86+/-29 g). A significant reduction in stride length was observed with aging (136+/-18 mm vs 98+/-10 mm), which decreased further with HLU (78+/-14 mm). Prehabilitation attenuated HLU-related reductions in stride length, and rehabilitation was effective for stride length restoration in old rats. CONCLUSIONS: Exercise, particularly rehabilitation, was more effective for old than young rats. Prehabilitation and rehabilitation diminished some of the detrimental effects of HLU on skeletal muscle mass and force and gait function in old rats.

Age Factors↗
PubMed2006

Usefulness of the nursing home quality measures and quality indicators for assessing skilled nursing facility rehabilitation outcomes.

OBJECTIVE: To examine the usefulness of the nursing home quality indicators and nursing home quality measures for differentiating among providers from a rehabilitation outcomes perspective. DESIGN: Retrospective. SETTING: Skilled nursing facilities (SNFs) across the United States. PARTICIPANTS: A total of 211 SNFs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All quality indicators, all quality measures except for CWLS01 (residents who lose too much weight), and a set of rehabilitation outcomes including residualized FIM motor gain, the percentage of patients discharged to community, and the percentage of patients reporting "quite a lot" or "completely" prepared to manage their care at discharge from SNF-based rehabilitation. RESULTS: No quality measures correlated with any rehabilitation outcomes. Residualized FIM motor gain did not correlate with any quality indicators or quality measures. Only 1 quality indicator-prevalence of daily use of restraints (QI 22)-correlated with the rehabilitation indicator community discharge percentage. The third rehabilitation indicator, prepared to manage care at discharge, correlated (negatively) only with QI 18 incidence of decrease in range of motion. Among the rehabilitation outcomes, residualized FIM motor gain correlated significantly with both community discharge percentage and prepared to manage care at discharge. CONCLUSIONS: Patients and referrers choosing SNF-based medical rehabilitation need tools that differentiate among prospective providers from a rehabilitation outcomes perspective. Data in this study indicate that nursing home quality indicators and quality measures are inadequate for this purpose.

Aged↗
PubMed2000

Rehabilitative placement of poststroke patients: reliability of the Clinical Practice Guideline of the Agency for Health Care Policy and Research.

OBJECTIVE: To determine the interrater reliability of the United States Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Number 16 for rehabilitative placement of poststroke patients. DESIGN: Pairs of rehabilitation professionals, highly trained in the Guideline, rated the appropriateness of rehabilitative placements. SETTING: Acute care hospitals in three regions of the country. PATIENTS: Sixty patients with moderate-to-severe stroke. MEASURES: Numerous factors affecting appropriate placement according to the Guideline were abstracted from medical records or obtained by direct evaluation of patients. RESULTS: Good reliability was attained for home and nursing facility placement with rehabilitation services but with no multidisciplinary rehabilitation program (intraclass correlation coefficient = .73 and .60, respectively). Serious reliability problems were found for placements in low-intensity outpatient rehabilitation and high-intensity inpatient rehabilitation programs. Chief sources of unreliability were ambiguous or missing data in hospital medical records, complexities in the Guideline, and raters' tendencies to follow their own clinical judgments. More than one type of placement was appropriate for 65% of patients. CONCLUSIONS: Reliable placement guidelines are possible, but aspects of the Guideline require additional development. Evidence of demonstrated reliability and validity will be required to resolve disputes between rehabilitation professionals and payers regarding appropriate levels and types of rehabilitation and to guide patients and their families.

Adult↗
PubMed1997

Impact of a function-based payment model on the financial performance of acute inpatient medical rehabilitation providers: a simulation analysis.

OBJECTIVES: To operationalize research findings about a medical rehabilitation classification and payment model by building a prototype of a prospective payment system, and to determine whether this prototype model promotes payment equity. This latter objective is accomplished by identifying whether any facility or payment model characteristics are systematically associated with financial performance. DESIGN: This study was conducted in two phases. In Phase 1 the components of a diagnosis-related group (DRG)-like payment system, including a base rate, function-related group (FRG) weights, and adjusters, were identified and estimated using hospital cost functions. Phase 2 consisted of a simulation analysis in which each facility's financial performance was modeled, based on its 1990-1991 case mix. A multivariate regression equation was conducted to assess the extent to which characteristics of 42 rehabilitation facilities contribute toward determining financial performance under the present Medicare payment system as well as under the hypothetical model developed. PARTICIPANTS: Phase 1 (model development) included 61 rehabilitation hospitals. Approximately 59% were rehabilitation units within a general hospital and 48% were teaching facilities. The number of rehabilitation beds averaged 52. Phase 2 of the stimulation analysis included 42 rehabilitation facilities, subscribers to UDS in 1990-1991. Of these, 69% were rehabilitation units and 52% were teaching facilities. The number of rehabilitation beds averaged 48. MAIN OUTCOME MEASURE: Financial performance, as measured by the ratio of reimbursement to average costs. RESULTS: Case-mix index is the primary determinant of financial performance under the present Medicare payment system. None of the facility characteristics included in this analysis were associated with financial performance under the hypothetical FRG payment model. CONCLUSIONS: The most notable impact of an FRG-based payment model would be to create a stronger link between resource intensity and level of reimbursement, resulting in greater equity in the reimbursement of inpatient medical rehabilitation hospitals.

Health Services Research↗