Search

Objective To investigate whether indicators of patient need (comorbidity burden, fall risk) predict acute care rehabilitation utilization, and whether this relation varies across patient characteristics (ie, demographic characteristics, insurance type). Design Secondary analysis of electronic health records data. Setting Five acute care hospitals. Participants Adults (N=110,209) admitted to 5 regional hospitals between 2014 and 2018. Interventions Not applicable. Main Outcome Measures Occupational therapy (OT) and physical therapy (PT) utilization. Logistic regression models determined whether indicators of patient need predicted OT and PT utilization. Interactions between indicators of need and both demographic factors (eg, minority status, presence of significant other) and insurance type were included to investigate whether the relation between patient need and therapy access varied across patient characteristics. Results Greater comorbidity burden was associated with a higher likelihood of receiving OT and PT. Relative to those with low fall risk, those with moderate and high fall risk were more likely to receive OT and PT. The relation between fall risk and therapy utilization differed across patient characteristics. Among patients with higher levels of fall risk, those with a significant other were less likely to receive OT and PT; significant other status did not explain therapy utilization among patients with low fall risk. Among those with high fall risk, patients with VA insurance and minority patients were more likely to receive PT than those with private insurance and nonminority patients, respectively. Insurance type and minority status did not appear to explain PT utilization among those with lower fall risk. Conclusions Patients with greater comorbidity burden and fall risk were more likely to receive acute care rehabilitation. However, the relation between fall risk and utilization was moderated by insurance type, having a significant other, and race/ethnicity. Understanding the implications of these utilization patterns requires further research.

Objectives To determine the factors associated with acute hospital discharge to the 3 most common postacute settings following total knee arthroplasty (TKA): inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and directly back to the community. Design Retrospective cohort study. Setting Acute care hospitals submitting claims to Medicare. Participants National cohort (N=1,189,286) of 100% Medicare Part A data files from 2009-2011. Interventions Not applicable. Main Outcome Measures Observed rates and adjusted odds of discharge to the 3 main postacute settings based on the clinical and facility level variables: amount of comorbidity, bilateral procedures, and facility TKA volume. Results Using IRF discharge as the reference, patients who received a bilateral procedure had lower odds of both SNF and community discharge, patients with more comorbidity had lower odds for community discharge and higher odds for SNF discharge, and patients who received their TKA from hospitals with lower TKA volumes had lower odds of SNF and community discharge. Conclusions Clinical populations within Medicare beneficiaries may systematically vary across the 3 most common discharge settings following TKA. This information may be helpful for a better understanding on which patient or clinical factors influence postacute care settings following TKA. Additional research including functional status, living situation, and social support systems would be beneficial.

Background While divorce is a social determinant of health among married immigrants in Korea, its association with access to healthcare services is unclear. Given the rapid increase in the number of married immigrants in Korea, research is needed to improve minority groups’ access to healthcare services. Here, we examined healthcare service utilization among married immigrants. Methods We retrieved 11,778 adults from the 2018 Korea National Multicultural Family Survey. We analyzed whether the sex of divorced immigrants is associated with healthcare access using multivariable logistic regression analysis. Further, we analyzed the association between divorce and access to healthcare services among married immigrants using propensity score matching methods. Results There were 691 (5.8%) divorced immigrants in the data set. The married male immigrants had no association between divorce status and healthcare access (adjusted odds ratio [OR] = 1.05, 95% confidence interval [CI] = 0.55–2.03, p = 0.8620). Divorced immigrants were less likely to receive healthcare services than married immigrants (adjusted OR = 1.42, 95% CI = 1.07–1.88). Conclusion Our findings revealed that divorce increases the risk of limited access to healthcare services among married immigrants. Policymakers and healthcare providers should be aware of these potential disparities in this vulnerable minority population.

OBJECTIVE The aim of the study was to investigate sex differences and the impact of social living situation on individual functional independence measure outcomes after stroke rehabilitation. DESIGN A retrospective observational study using Medicare fee-for-service beneficiaries (N = 125,548) who were discharged from inpatient rehabilitation facilities in 2013 and 2014 after a stroke. Discharge individual functional independence measure score, dichotomized as ≥5 and

The biomedical scientific community is in the midst of a significant expansion in how data are used to accomplish the important goals of reducing disability and improving health care. Data science is the academic discipline emerging from this expansion. Data science reflects a new approach to the acquisition, storage, analysis, and interpretation of scientific knowledge. The potential benefits of data science are transforming biomedical research and will lead physical medicine and rehabilitation in exciting new directions. Understanding this transformation will require modifying and expanding the education, training, and research infrastructure that support rehabilitation science and practice.

BACKGROUND In an effort to improve quality and reduce costs, reimbursement for total knee arthroplasty (TKA) and total hip arthroplasty (THA) in the United States is being based on the value of care provided, with adjustments for some qualifying comorbidities, including diabetes in its most severe form and excluding many diabetes codes. The aims of this study were to examine the effects of diabetes on elective TKA or THA complications and readmission risks among Medicare beneficiaries. METHODS Complication (n = 521,230) and readmission (n = 515,691) data were extracted from Medicare files in 2013 and 2014. Diabetes status (no diabetes, controlled-uncomplicated diabetes, controlled-complicated diabetes, and uncontrolled diabetes) was identified with ICD-9 (International Classification of Diseases, 9th Revision) codes. TKA or THA complications and readmission odds based on diabetes status were estimated using logistic regression and adjusted for sociodemographic and clinical characteristics, including comorbidities. RESULTS Compared with no diabetes, the odds ratio (OR) of TKA complications was significantly higher for uncontrolled diabetes (1.29, 95% confidence interval [CI] = 1.06 to 1.57). The OR of THA complications was significantly higher for controlled-complicated diabetes (1.45, 95% CI = 1.17 to 1.80). The OR of readmission was significantly higher for all diabetes groups (1.21 to 1.48 for TKA, 1.20 to 1.70 for THA). CONCLUSIONS Readmission odds were higher in all diabetes categories. The uncontrolled-diabetes group had the greatest TKA readmission and complication odds. The controlled-complicated diabetes group had the greatest THA readmission and complication odds. The findings suggest that including diabetes and associated systemic complications in cost adjustments in alternative payment models for arthroplasty should be considered. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Relying solely on null hypothesis significance testing to investigate rehabilitation interventions may result in researchers erroneously concluding the presence of a treatment effect. Objective We sought to quantify the strength of evidence in favour of rehabilitation treatment effects by calculating Bayes factors (BF10s) for significant findings. Additionally, we sought to examine associations between BF10s, P-values, and Cohen's d effect sizes. Methods We searched the Cochrane Database of Systematic Reviews for meta-analyses with “rehabilitation” as a keyword that evaluated a rehabilitation intervention. We extracted means, standard deviations, and sample sizes for treatment and comparison groups from individual findings within 175 meta-analyses. Investigators independently classified the interventions according to the Rehabilitation Treatment Specification System. We calculated t-statistics, P-values, effect sizes, and BF10s for each finding. We isolated statistically significant findings (P ≤ 0.05); applied evidential categories to BF10s, P-values, and effect sizes; and examined relationships descriptively. Results We analysed 1935 rehabilitation findings. Across intervention types, 25% of significant findings offered only anecdotal evidence in favour of a treatment effect; only 48% indicated strong evidence. This pattern persisted within intervention types and when conducting robustness analyses. Smaller P-values and larger effect sizes were associated with stronger evidence in favour of a treatment effect. However, a notable portion of findings with P-value 0.01 to 0.05 (63%) or a large effect size (18%) offered anecdotal evidence in favour of an effect. Conclusions For a substantial portion of statistically significant rehabilitation findings, the data neither support nor refute the presence of a treatment effect. This was the case among a notable portion of large treatment effects and for most findings with P-value > 0.01. Rehabilitation evidence would be improved by researchers adopting more conservative levels of significance, complementing the use of null hypothesis significance testing with Bayesian techniques and reporting effect sizes.

OBJECTIVE We examined the association between home health rehabilitation referral and 90-day risk-adjusted hospital readmission after discharge from inpatient rehabilitation facilities among adult patients recovering from stroke (N = 1219). DESIGN A secondary data analysis of the 2005-2006 Stroke Recovery in Underserved Population database. A logistic regression model, multilevel model, and the propensity score inverse probability weighting model were used to evaluate the risk of 90-day rehospitalization between patients with stroke who received a referral for home health rehabilitation and those who did not receive a home health rehabilitation referral at inpatient rehabilitation facility discharge. RESULTS The regression, multilevel, and propensity score inverse probability weighting models indicated that inpatient rehabilitation facility patients with stroke who received home health rehabilitation referral had substantially lower odds of 90-day rehospitalization after inpatient rehabilitation facility discharge compared with those who were not referred to home health (odds ratio = 0.325, 95% confidence interval = 0.138-0.764; odds ratio = 0.340, 95% confidence interval = 0.139-0.832; odds ratio = 0.407, 95% confidence interval = 0.183-0.906, respectively). CONCLUSIONS Our findings suggest the importance of continuation of care (home health) after hospitalization and intense inpatient rehabilitation for stroke. Additional research is needed to establish appropriate use criteria and explore potential underuse of home health services as well as the benefits for follow-up outpatient services for those who do not qualify for home health at inpatient rehabilitation facility discharge.

This cohort study examines the differences between 2 Centers for Medicare & Medicaid Services measures for 30-day rehospitalization after discharge from postacute inpatient rehabilitation., Key Points Question Can Centers for Medicare & Medicaid Services Quality Reporting Program measures detect variation in 30-day hospital readmission rates after postacute inpatient rehabilitation among US inpatient rehabilitation facilities (IRFs)? Findings In this cohort study of 454 378 Medicare fee-for-service beneficiaries discharged from 1162 IRFs submitting claims, risk-standardized potentially preventable readmission rates ranged from 4.3% to 7.3%. Application of the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation resulted in risk-standardized readmission rates above or below the national mean for less than 1% of 1162 Medicare-eligible IRFs. Meaning These findings suggest that the current readmission measure does not distinguish high- and low-performing facilities, and therefore it should not be implemented as part of the IRF quality reporting program., Importance The Improving Medicare Post-Acute Care Transformation Act of 2014 mandated a quality measure of potentially preventable 30-day hospital readmission for inpatient rehabilitation facilities (IRFs). Examining IRF performance nationally may help inform health care quality initiatives for Medicare beneficiaries. Objective To examine variation in Centers for Medicare & Medicaid Services Quality Reporting Program measures for US facility-level risk-adjusted all-cause and potentially preventable hospital readmission rates after inpatient rehabilitation. Design, Setting, and Participants This cohort study of Medicare claims data included 454 378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. Data were analyzed March 23, 2018, through June 24, 2019. Main Outcomes and Measures All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities and the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation. Specifications from the Centers for Medicare & Medicaid Services were followed to identify the cohort, define outcomes, and calculate risk-standardized facility-level rates. Results Among a cohort of 454 378 patients, the mean (SD) age was 76.2 (10.6) years and 263 546 (58.0%) were women. The all-cause readmission rate was 12.3% (95% CI, 12.2%-12.4%), and the potentially preventable readmission rate was 5.3% (95% CI, 5.3%-5.4%). Across 1162 included IRFs, risk-standardized all-cause readmission rates ranged from 10.1% (95% CI, 8.9%-11.6%) to 15.9% (95% CI, 13.6-18.6%) and potentially preventable readmission rates ranged from 4.3% (95% CI, 3.7%-5.4%) to 7.3% (95% CI, 5.7%-8.3%). Using the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities, 16 IRFs (1.4%) had 95% CIs above the national mean rate, 1137 IRFs (97.9%) had 95% CIs containing the national mean rate, and 9 IRFs (0.8%) had 95% CIs below the national mean rate. Using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation, 8 IRFs (0.7%) had 95% CIs above the national mean rate, 1153 IRFs (99.2%) had 95% CIs containing the national mean rate, and 1 IRF (0.1%) had a 95% CI below the national mean rate. Conclusions and Relevance This cohort study found that readmission rates were lower when using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation and further reduced discrimination between facilities compared with the recently discontinued All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities. This finding may indicate there is a lack of room for improvement in readmission rates. Given the rationale of the Centers for Medicare & Medicaid Services for removing measures that fail to discriminate quality performance, this suggests that the current readmission measure should not be implemented as part of the Inpatient Rehabilitation Quality Reporting Program.

Background As defined by Medicare (United States), post-acute rehabilitation services include care provided in inpatient rehabilitation units and facilities, skilled nursing facilities, long-term acute hospitals, and by home health services. Methods We retrospectively evaluated the use of rehabilitation-based post-acute services among Medicare beneficiaries who were hospitalized for lumbar spinal fusion (ICD-9-CM procedure codes 81.04–81.08) in 2012–2014, examined the case-mix for those discharged to rehabilitation- and non-rehabilitation based services, and determined the association between these categories of discharge disposition and 30-day rehospitalization. The independent effect of rehabilitation-based discharge destination on 30-day readmissions was examined with a generalized linear mixed model, first adjusting for patient characteristics and then stratified by clusters that delineated more homogenous clinical profiles. Results Among 261,558 Medicare beneficiaries with lumbar spinal fusion surgery, 50.8% were discharged to a rehabilitation-based post-acute services. Patients discharged to rehabilitation-based services were older and had more comorbidities, and had longer hospital lengths of stays. After adjusting for patient and hospital characteristics, patients discharged to rehabilitation-based post-acute care had increased odds of 30-day rehospitalization than those without discharge to other destinations (OR 1.36; 95%CI = 1.31, 1.40). Analysis of patients by clinical profile clusters found similar results. Conclusions Clinical profiles of Medicare beneficiaries who had lumbar spinal fusion surgery and were discharged to rehabilitation-based post-acute services included more comorbidities than those discharged to non-rehabilitation based settings. Controlling for these differences did not mediate the negative association between use of rehabilitation-based post-acute services and 30-day readmission.

Objective To determine the sociodemographic and clinical characteristics as well as health services use associated with successful community discharge. Data Source Inpatient Rehabilitation Facility-Patient Assessment Instrument and Medicare Provider Analysis and Review files. Study Design We retrospectively examined 167,664 Medicare beneficiaries discharged from inpatient rehabilitation facilities (IRFs) in 2013 to determine the sociodemographic and clinical characteristics as well as health services use associated with successful community discharge. Principal Findings In the multivariable model, sociodemographic (younger age, no disability, social support), clinical (higher motor and cognitive functional status at admission), and health services use (fewer acute care days and longer IRF days) variables were associated with successful community discharge. Conclusions Remaining in the community is an important patient-centered outcome that could complement other postacute rehabilitation quality measures.

Secondary analysis of prospectively collected observational data.To assess the representativeness of the Spinal Cord Injury Model Systems National Database (SCIMS-NDB) of all adults aged 18 years or older receiving inpatient rehabilitation in the United States (US) for new onset traumatic spinal cord injury (TSCI).Inpatient rehabilitation centers in the US.We compared demographic, functional status, and injury characteristics (nine categorical variables comprising of 46 categories and two continuous variables) between the SCIMS-NDB (N = 5969) and UDS-PRO/eRehabData (N = 99,142) cases discharged from inpatient rehabilitation in 2000-2010.There are negligible differences (5%) between SCIMS-NDB patients and the population for 31 of the 48 comparisons. Minor differences (5-10%) exist for age categories, sex, race/ethnicity, marital status, FIM Motor score, and time from injury to rehabilitation admission. Important differences (10%) exist in mean age and preinjury occupational status; the SCIMS-NDB sample was younger and included a higher percentage of individuals who were employed (62.7 vs. 41.7%) and fewer who were retired (10.2 vs. 36.1%).Adults in the SCIMS-NDB are largely representative of the population of adults receiving inpatient rehabilitation for new onset TSCI in the US. However, users of the SCIMS-NDB may need to adjust statistically for differences in age and preinjury occupational status to improve generalizability of findings.

Objective To examine the effects of facility-level acute–postacute continuity on probability of community discharge and 30-day rehospitalization following inpatient rehabilitation. Data Sources We used national Medicare enrollment, claims, and assessment data to study 541,097 patients discharged from 1,156 inpatient rehabilitation facilities (IRFs) in 2010–2011. Study Design We calculated facility-level continuity as the percentages of an IRF's patients admitted from each contributing acute care hospital. Patients were categorized into three groups: low continuity ( 75 percent from same hospital). The multivariable models included an interaction term to examine the potential moderating effects of facility type (freestanding facility vs. hospital-based rehabilitation unit) on the relationships between facility-level continuity and our two outcomes: community discharge and 30-day rehospitalization. Principal Findings Medicare beneficiaries in hospital-based rehabilitation units were more likely to be referred from a high-contributing hospital compared to those in freestanding facilities. However, the association between higher acute–postacute continuity and desirable outcomes is significantly better in freestanding rehabilitation facilities than in hospital-based units. Conclusions Improving continuity is a key premise of health care reform. We found that both observed referral patterns and continuity-related benefits differed markedly by facility type. These findings provide a starting point for health systems establishing or strengthening acute–postacute relationships to improve patient outcomes in this new era of shared accountability and public quality reporting programs.

To describe impairment-specific patterns in shorter- and longer-than-expected lengths of stay in inpatient rehabilitation, and examine the independent effects of social support on deviations from expected lengths of stay.Retrospective cohort study.Inpatient rehabilitation facilities.Medicare fee-for-service beneficiaries (N=119,437) who were discharged from inpatient rehabilitation facilities in 2012 after stroke, lower extremity fracture, or lower extremity joint replacement.Not applicable.Relative length of stay (actual minus expected). The Centers for MedicareMedicaid Services posts annual expected lengths of stay based on patients' clinical profiles at admission. We created a 3-category outcome variable: short, expected, long. Our primary independent variable (social support) also included 3 categories: family/friends, paid/other, none.Mean ± SD actual lengths of stay for joint replacement, fracture, and stroke were 9.8±3.6, 13.8±4.5, and 15.8±7.3 days, respectively; relative lengths of stay were -1.2±3.1, -1.6±3.7, and -1.7±5.2 days. Nearly half of patients (47%-48%) were discharged more than 1 day earlier than expected in all 3 groups, whereas 14% of joint replacement, 15% of fracture, and 20% of stroke patients were discharged more than 1 day later than expected. In multinomial regression analysis, using family/friends as the reference group, paid/other support was associated (P.05) with higher odds of long stays in joint replacement. No social support was associated with lower odds of short stays in all 3 impairment groups and higher odds of long stays in fracture and joint replacement.Inpatient rehabilitation experiences and outcomes can be substantially affected by a patient's level of social support. More research is needed to better understand these relationships and possible unintended consequences in terms of patient access issues and provider-level quality measures.

To link, classify and describe the content of the Multicenter Benchmarking Study Burn Outcomes Questionnaires (BOQ) using the International Classification of Functioning, Disability and Health (ICF) to determine if the information garnered provides researchers with the data necessary to develop a comprehensive understanding of life after burns.Two ICF linking experts used a standardized linking technique endorsed by the World Health Organization to link all BOQ concepts to the ICF. Linking results were analyzed to determine the comprehensiveness of each of the five measures.The activities and participation component was most frequently addressed followed by the body functions component. Environmental factors are not extensively covered and body structures are not addressed. ICF chapter and category distribution were skewed and varied between assessments. The majority of BOQ items are of the health status perspective.BOQ item composition could be improved with a more even distribution of pertinent ICF topics. Assessment authors may consider addressing the impact of environmental factors on participation. Including body structure concepts would allow investigators to track structural deformation and/or developmental delay. Generally speaking, this data should not be used to examine quality of life outcomes.

The National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Burn Injury Model Systems (BMS) is a nationwide database that uses patient-reported outcome measures to collect data. Though the outcome measures demonstrate good psychometric properties, the question remains whether or not these measures collect data that encompass the entire experience of burn patients over time.Each meaningful concept included in the BMS assessments was linked to the International Classification of Functioning, Disability and Health (ICF) in order to classify and describe the content of each measure. The linking was completed by two experienced coders. The perspective of each assessment was also determined.The body function component was most frequently addressed overall followed by the activities and participation component. The component body structures and environmental factors are not extensively covered in the BMS assessments. ICF chapter and category distribution varied greatly between assessments. The assessments were of the health status perspective.This study suggests a need to revisit the item composition of the BMS assessments to more evenly distribute ICF topics and subtopics that are pertinent to burn injury which will ensure a broader but more precise understanding of burn injury recovery. Implications for Rehabilitation A better understanding of the data collected through the Burn Model Systems (BMS) project may contribute to improve data collection tools and ultimately lead to clinical practice innovations and improvements. Clinicians interested in using BMS data for research purposes can better understand what topics are included and excluded in the collection and what perspectives are addressed. This study highlights the need for burn clinicians around the world to lend their expertise to the WHO for the development of a much needed burn injury International Classification of Functioning, Disability and Health Core Set.

Key Points Question Do rates of successful community discharge after inpatient rehabilitation vary across US facilities and geographic regions? Findings In this cohort study of 487 862 Medicare fee-for-service beneficiaries discharged from 1154 inpatient rehabilitation facilities submitting claims, risk-standardized rates of successful community discharge ranged from 42.9% to 83.6%. Rates were lowest in the Northeast (Massachusetts, 55.9%; New Hampshire, 57.0%) and highest in the West (Oregon, 70.3%; Hawaii, 73.3%). Meaning The observed facility and geographic variations suggest opportunities for improving this important, patient-centered, and nationally reported quality outcome., This cohort study examines facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation among fee-for-service Medicare beneficiaries., Importance The Improving Medicare Post–Acute Care Transformation (IMPACT) Act of 2014 mandated a quality measure of successful community discharge for postacute care services. Examining variation in performance nationally can help identify opportunities for improving patient-centered quality of care. Objective To examine US facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation. Design, Setting, and Participants This retrospective cohort study of Medicare claims data from December 31, 2013, through October 1, 2015, included 1154 inpatient rehabilitation facilities submitting claims to the Centers for Medicare & Medicaid Services and a total of 487 862 Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation facilities. Analyses were performed from December 8, 2017, through September 11, 2018. Main Outcomes and Measures Successful community discharge as defined for the Discharge to Community—Post–Acute Care Inpatient Rehabilitation Facility Quality Reporting Program measure. To be considered a successful community discharge, patients had to discharge from the inpatient rehabilitation facility to the community (ie, home or self-care) and remain there without experiencing an unplanned rehospitalization or dying within the following 31 days. Centers for Medicare & Medicaid Services specifications were followed to identify the cohort, define the outcome, and calculate risk-standardized facility and state rates. Results Among the 487 862 patients included in the cohort, mean (SD) age was 76.4 (10.8) years, and 56.9% were female. The overall rate of successful community discharge after inpatient rehabilitation was 63.7% (95% CI, 63.6%-63.8%). Risk-standardized rates ranged from 42.9% to 83.6% across inpatient rehabilitation facilities. Two hundred sixteen facilities (18.7%) performed significantly better than the mean national rate and 203 (17.6%) performed significantly worse (P

Objective The aim of the study was to examine whether receipt of testosterone replacement therapy was associated with reduced 30-day rehospitalization after postacute care among older men with testosterone deficiency. Design, patients, and methods We conducted a retrospective cohort study using a 5% national sample of Medicare beneficiaries. We identified 1290 nonsurgical inpatient postacute care discharges between January 1, 2007, and October 31, 2014, for male patients, 66 yrs or older, with a previous diagnosis of testosterone deficiency. Multivariable logistic regression was used to calculate odds ratios and 95% confidence intervals for 30-day postacute care rehospitalization related to receipt of testosterone replacement therapy. Results In older men with testosterone deficiency, receipt of testosterone replacement therapy was not associated with rehospitalization (odds ratio = 0.87, 95% confidence interval, 0.59-1.29) in the 30 days after postacute care discharge. These findings persisted after adjustment for quintile of propensity scores (odds ratio = 0.90, 95% confidence interval = 0.62-1.30). Conclusion Testosterone replacement therapy was not associated with reduced rehospitalization after postacute care discharge in older men with testosterone deficiency. Further research in this population should examine the effects of testosterone replacement therapy on functional recovery and community independence.

Background Medicare data from acute hospitals do not contain information on functional status. This lack of information limits the ability to conduct rehabilitation-related health services research. Objective The purpose of this study was to examine the associations between 5 comorbidity indexes derived from acute care claims data and functional status assessed at admission to an inpatient rehabilitation facility (IRF). Comorbidity indexes included tier comorbidity, Functional Comorbidity Index (FCI), Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Hierarchical Condition Category (HCC). Design This was a retrospective cohort study. Methods Medicare beneficiaries with stroke, lower extremity joint replacement, and lower extremity fracture discharged to an IRF in 2011 were studied (N=105,441). Data from the beneficiary summary file, Medicare Provider Analysis and Review (MedPAR) file, and Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) file were linked. Inpatient rehabilitation facility admission functional status was used as a proxy for acute hospital discharge functional status. Separate linear regression models for each impairment group were developed to assess the relationships between the comorbidity indexes and functional status. Base models included age, sex, race/ethnicity, disability, dual eligibility, and length of stay. Subsequent models included individual comorbidity indexes. Values of variance explained (R2) with each comorbidity index were compared. Results Base models explained 7.7% of the variance in motor function ratings for stroke, 3.8% for joint replacement, and 7.3% for fracture. The R2 increased marginally when comorbidity indexes were added to base models for stroke, joint replacement, and fracture: Charlson Comorbidity Index (0.4%, 0.5%, 0.3%), tier comorbidity (0.2%, 0.6%, 0.5%), FCI (0.4%, 1.2%, 1.6%), Elixhauser Comorbidity Index (1.2%, 1.9%, 3.5%), and HCC (2.2%, 2.1%, 2.8%). Limitation Patients from 3 impairment categories were included in the sample. Conclusions The 5 comorbidity indexes contributed little to predicting functional status. The indexes examined were not useful as proxies for functional status in the acute settings studied.

Objective. This study explored the experiences and needs of older adults during and following Hurricane Ike. Method. Two focus group interviews were conducted among older adults who lived in or around Galveston Island before Hurricane Ike. Nine older adults (six women and three men) participated in two focus group sessions. These qualitative interviews were audio recorded, transcribed, and analyzed using thematic content analyses. Results. The findings of this study reveal the need for continuity in health care services, medications, psychological support, social and family support, community-level services, and information among older adults. Conclusions. The contribution of factors such as health care continuity and psychological support reinforces the importance of specific postdisaster resources to meet the needs of older adults following hurricanes. These results suggest the importance of designing hurricane preparedness guidelines specifically for older adults.

Objective Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. Design Retrospective cohort study. Setting Acute care hospitals. Participants Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. Measurements 90-day unplanned readmissions. Results The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. Conclusions We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care.

Objective:To examine the longitudinal association between levels of lower extremity performance (LEP) and health-related quality of life (HRQoL) in older Mexican Americans aged 72 years or older participating in the Hispanic Established Population for the Epidemiological Study of the Elderly (2000-2006). Method: LEP was measured in 621 non-institutionalized participants with the Short Physical Performance Battery (SPPB). Participants were divided into high (SPPB score 10-12), intermediate (SPPB score 7-9), and low (SPPB score 0-6) groups based on LEP. HRQoL was assessed using the Medical Outcomes Study Short Form (SF-36), which includes a Physical Composite Scale (PCS) and a Mental Composite Scale (MCS). Results: Participants in the high LEP group had slower rates of decline in the PCS, and those in the intermediate LEP group had slower rates of decline in the MCS score over time. Discussion: Increased LEP was associated with slower rates of decline in physical and mental HRQoL in older Mexican Americans.

Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.

Objectives To determine the association between patients' functional status at discharge from inpatient rehabilitation and 30-day potentially preventable hospital readmissions. A secondary objective was to examine the conditions resulting in these potentially preventable readmissions. Design Retrospective cohort study. Setting Inpatient rehabilitation facilities submitting claims to Medicare. Participants National cohort (N=371,846) of inpatient rehabilitation discharges among aged Medicare fee-for-service beneficiaries in 2013 to 2014. The average age was 79.1±7.6 years. Most were women (59.7%) and white (84.5%). Interventions Not applicable. Main Outcome Measures (1) Observed rates and adjusted odds of 30-day potentially preventable hospital readmissions after inpatient rehabilitation and (2) primary diagnoses for readmissions. Results The overall rate of any 30-day hospital readmission after inpatient rehabilitation was 12.4% (n=46,265), and the overall rate of potentially preventable readmissions was 5.0% (n=18,477). Functional independence was associated with lower observed rates and adjusted odds ratios for potentially preventable readmissions. Observed rates for the highest versus lowest quartiles within each functional domain were as follows: self-care: 3.4% (95% confidence interval [CI], 3.3–3.5) versus 6.9% (95% CI, 6.7–7.1), mobility: 3.3% (95% CI, 3.2–3.4) versus 7.2% (95% CI, 7.0–7.4), and cognition: 3.5% (95% CI, 3.4–3.6) versus 6.2% (95% CI, 6.0–6.4), respectively. Similarly, adjusted odds ratios were as follows: self-care: .70 (95% CI, .67–.74), mobility: .64 (95% CI, .61–.68), and cognition: .84 (95% CI, .80–.89). Infection-related conditions (44.1%) were the most common readmission diagnoses followed by inadequate management of chronic conditions (31.2%) and inadequate management of other unplanned events (24.7%). Conclusions Functional status at discharge from inpatient rehabilitation was associated with 30-day potentially preventable readmissions in our sample of aged Medicare beneficiaries. This information may help identify at-risk patients. Future research is needed to determine whether follow-up programs focused on improving functional independence will reduce readmission rates.

Background To compare different methods for identifying a long term care (LTC) nursing home stay, distinct from stays in skilled nursing facilities (SNFs), to the method currently used by the Center for Medicare and Medicaid Services (CMS). We used national and Texas Medicare claims, Minimum Data Set (MDS), and Texas Medicaid data from 2011-2013. Methods We used Medicare Part A and B and MDS data either alone or in combination to identify LTC nursing home stays by three methods. One method used Medicare Part A and B data; one method used Medicare Part A and MDS data; and the current CMS method used MDS data alone. We validated each method against Texas 2011 Medicare-Medicaid linked data for those with dual eligibility. Results Using Medicaid data as a gold standard, all three methods had sensitivities > 92% to identify LTC nursing home stays of more than 100 days in duration. The positive predictive value (PPV) of the method that used both MDS and Medicare Part A data was 84.65% compared to 78.71% for the CMS method and 66.45% for the method using Part A and B Medicare. When the patient population was limited to those who also had a SNF stay, the PPV for identifying LTC nursing home was highest for the method using Medicare plus MDS data (88.1%). Conclusions Using both Medicare and MDS data to identify LTC stays will lead to more accurate attribution of CMS nursing home quality indicators. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2318-9) contains supplementary material, which is available to authorized users.

Background The focus of health care reform is shifting from all-cause to potentially preventable readmissions. Potentially preventable within-stay readmission rates is a measure recently adopted by the Centers for Medicare and Medicaid Services for the Inpatient Rehabilitation Facility Quality Reporting Program. Objective We examined the patient-level predictors of potentially preventable within-stay readmissions among Medicare beneficiaries receiving care in inpatient rehabilitation facilities. We also studied the reasons for readmissions and the risk-standardized variation across states. Design Retrospective cohort study. Setting Inpatient rehabilitation facilities. Patients Medicare fee-for-service beneficiaries receiving inpatient rehabilitation after hospitalization in 2012-2013 (N = 345,697). Methods Medicare claims were reviewed to identify potentially preventable readmissions occurring during inpatient rehabilitation. Main Outcome Measures (1) Observed rates and odds of potentially preventable within-stay readmissions by patient sociodemographic and clinical characteristics, (2) risk-standardized state rates, and (3) primary diagnoses for hospital readmissions. Results The overall rate of potentially preventable within-stay readmissions was 3.5% (n = 11,945). Older age, male gender, hospitalizations during the previous 6 months, longer hospital lengths of stay, intensive care unit use, and number of comorbidities were associated with increased odds. Dual eligibility and disability status were not associated with increased odds. Greater functional scores at rehabilitation admission were associated with lower odds. Rates and odds varied across rehabilitation impairment groups. Risk-standardized state rates ranged from 3.1% to 4.1%. Readmissions for conditions reflecting inadequate management of infections (36.8%) were the most frequent and readmissions for inadequate injury prevention (6.1%) least frequent. Conclusions Potentially preventable within-stay readmissions may represent a target for inpatient rehabilitation care improvement. Our findings highlight the need for care coordination across providers. Future research should focus on care processes that reduce patients' risk of these potentially preventable rehospitalizations. Level of Evidence II

Objectives Examine the effects of postacute discharge setting on unplanned hospital readmissions following total knee arthroplasty (TKA) in older adults. Design Secondary analyses of 100% Medicare (inpatient) claims files. Setting Acute hospitals across the United States. Participants Medicare fee-for-service beneficiaries ≥66 years of age who were discharged from an acute hospital following TKA in 2009-2011 (n = 608,031). Measurements The outcome measure was unplanned readmissions at 30, 60, and 90 days. The independent variable of interest was postacute discharge setting: inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), or community. Covariates included demographic, clinical, and facility-level factors. The top 10 reasons for readmission were tabulated for each discharge setting across the 3 consecutive 30-day time periods. Results A total of 32,226 patients (5.3%) were re-admitted within 30 days. Compared with community discharge, patients discharged to IRF and SNF had 44% and 40% higher odds of 30-day readmission, respectively. IRF and SNF discharge settings were also associated with 48% and 45% higher odds of 90-day readmission, respectively, compared with community discharge. The largest increase in readmission rates occurred within the first 30 days of hospital discharge for each discharge setting. From 1 to 30 days, postoperative and post-traumatic infections were among the top causes for readmission in all 3 discharge settings. From 31 to 60 days, postoperative or traumatic infections remained in the top 5-7 reasons for readmission in all settings, but they were not in the top 10 at 61 to 90 days. Conclusions Patients discharged to either SNF or IRF, in comparison with those discharged to the community, had greater likelihood of readmission within 30 and 90 days. The reasons for readmission were relatively consistent across discharge settings and time periods. These findings provide new information relevant to the delivery of postacute care to older adults following TKA.

The effect of physical activity on cognitive function in older adults from minority and disadvantaged populations is not well understood. This study examined the longitudinal association between physical activity and cognition in older Mexican Americans. The study methodology included a prospective cohort with longitudinal analysis of data from the Hispanic Established Populations for the Epidemiologic Study of the Elderly. General linear mixed models were used to assess the associations and interactions between physical activity and cognitive function over 14 years. Community-based assessments were performed in participants' homes. Physical activity was recorded for 1,669 older Mexican Americans using the Physical Activity Scale for the Elderly. Cognition was measured using the Mini-Mental State Examination (MMSE) and separated into memory and nonmemory components. A statistically significant positive association was observed between levels of physical activity and cognitive function after adjusting for age, sex, marital status, education, and comorbid health conditions. There was a statistically significant difference in MMSE scores over time between participants in the third (β = 0.11, standard error (SE) = 0.05) and fourth (β = 0.10, SE = 0.2) quartiles of physical activity and those in the first. The protective effect of physical activity on cognitive decline was evident for the memory component of the MMSE but not the nonmemory component after adjusting for covariates. Greater physical activity at baseline was associated with less cognitive decline over 14 years in older Mexican Americans. The reduction in cognitive decline appeared to be related to the memory components of cognitive function.

This article complements a series of six impairment-specific reports of multi-year data from the Uniform Data System for Medical Rehabilitation database (UDSMR® database) providing national benchmarking information for follow-up information on key rehabilitation outcomes. The current report includes follow-up data on a subset of patients with stroke, traumatic brain injury, lower extremity fracture, lower extremity joint replacement, traumatic spinal cord injury, or debility who received inpatient rehabilitation services from 2002 through 2010 in facilities that subscribed to the UDSMR. Recent reports published in this journal contain the admission and discharge benchmark information for patients in these rehabilitation impairment categories.1–6 An earlier report containing follow-up information from 1994–1996 was also published in this journal.7 Following a debilitating illness or injury, patients and family members universally desire recovery of functional independence to enable a return to community living. Traditionally, inpatient providers have had no established need and few if any resources to document patient outcomes and experiences following discharge. The Affordable Care Act8 contains several provisions (e.g. readmission reduction, bundled payments, and care coordination) that expand provider accountability beyond the immediate stay. In other words, the financial incentives (penalties) included in these provisions have heightened the interest of upstream providers in the downstream care and longer-term outcomes their patients experience. Implicit in this expanded episode-of-care framework are the needs and impacts of family caregivers and the understanding that longer-term recovery of health status and independence are largely a function of a person’s combined formal and informal care networks.9 Our goal for this report was to display yearly aggregated summaries of select rehabilitation outcomes in a natural, meaningful sequence (admission, discharge, follow-up) for patients within the six largest impairment groups receiving inpatient medical rehabilitation services. We believe this information can serve as a valuable resource for all stakeholders working to improve the long-term outcomes, care transitions, and/or care coordination for persons requiring intensive post-acute rehabilitation services.

To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation.Retrospective cohort design.Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States.Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007.Not applicable.Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS).Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days.Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.

Compare 5 comorbidity indices to predict community discharge and functional status following post-acute rehabilitation.This was a retrospective study of Medicare beneficiaries with stroke, lower-extremity fracture, and joint replacement discharged from inpatient rehabilitation in 2011 (N = 105,275). Community discharge and self-care, mobility, and cognitive function were compared using the Charlson, Elixhauser, Tier, Functional Comorbidity, and Hierarchical Condition Category comorbidity indices.Of the patients, 64.4% were female, and 84.6% were non-Hispanic white. Mean age was 79.3 (SD, 7.5) years. Base regression models including sociodemographic and clinical variables explained 56.6%, 42.2%, and 23.0% of the variance (R) for discharge self-care; 47.4%, 30.9%, and 18.6% for mobility; and 62.0%, 55.3%, and 37.3% for cognition across the 3 impairment groups. R values for self-care, mobility, and cognition increased by 0.2% to 3.3% when the comorbidity indices were added to the models. The base model C statistics for community discharge were 0.58 (stroke), 0.61 (fracture), and 0.62 (joint replacement). The C statistics increased more than 25% with the addition of discharge functional status to the base model. Adding the comorbidity indices individually to the base model resulted in C-statistic increases of 1% to 2%.Comorbidity indices were poor predictors of community discharge and functional status in Medicare beneficiaries receiving inpatient rehabilitation.

Date Presented 4/19/2018 This poster describes an inpatient rehabilitation facility (IRF) study examining the relationship between facility-level factors and 30-day unplanned readmission rates among Medicare beneficiaries. Identifying factors related to care process at the organization and region levels could potentially improve the quality of IRF care. Primary Author and Speaker: Chih–Ying Li Additional Authors and Speakers: Amol Karmarkar, Kenneth Ottenbacher, Yong–Fang Kuo, Yu–Li Lin, James Graham

Background We examined activity-specific patterns and child,family and environmental correlates of participation restriction in nine community-based activities among preschoolers with disabilities who have received Part C early intervention services. Methods Data were gathered from a subsample of 1509 caregivers whose children (mean age = 67.7 months) had enrolled in the National Early Intervention Longitudinal Study (NEILS) and completed a 40-min computerized telephone interview or 12-page mailed survey.Data were analysed on cases with complete data on the variables of interest.Bivariate relationships were examined between variables,including patterns of co-reporting participation difficulties for pairs of community activities. Results Caregivers were more than twice as likely to report difficulty in one activity (20%) than difficulties in 2‐3,4‐5,or 6‐9 activities.Co-reporting paired difficulties was strong for activities pertaining to neighbourhood outings but less conclusive for community-sponsored activities and recreation and leisure activities.Our data show strong and positive associations between child functional limitations in mobility,toileting,feeding,speech,safety awareness,and friendships and participation difficulty in 7‐9 activities.Lower household income was associated with participation difficulty in 7 out of 9 activities and difficulty managing problematic behaviour was strongly associated with participation difficulty in all 9 activities.Each of the three environmental variables (limited access to social support,transportation and respite) was associated with participation restrictions in all nine activities. Conclusion Results provide practitioners with detailed descriptive knowledge about modifiable factors related to the child,family and environment for promoting young children’s community participation,as well information to support development of a comprehensive assessment tool for research and intervention planning to promote community participation for children enrolled in early intervention.

Objective To examine changes in facility-level risk-standardized rehospitalization rankings for postacute inpatient rehabilitation facilities after modifying two model parameters. Data Sources We used national Medicare enrollment, claims, and assessment data to study 522,260 patients discharged from inpatient rehabilitation in fiscal years 2010–2011. Study Design We calculated risk-standardized 30-day unplanned rehospitalization rates for 1,135 inpatient rehabilitation facilities using four approaches. The first model replicated the current postacute risk-standardization methodology and included patients discharged from acute hospitals up to 30 days prior to postacute admission and excluded patients transferred directly back to acute hospitals following rehabilitation. Our alternative models excluded patients with delayed admissions (>1 day between acute discharge and postacute admission) and counted direct transfers back to acute as rehospitalizations. Principal Findings Excluding patients with delayed admissions and counting direct transfers back to acute care as rehospitalizations substantially impacted rankings of more than half the postacute providers: 29 percent had better and 27 percent had worse quintile rankings. Conclusions Changing the timeframes for duration to admission and rehospitalization will have profound effects on postacute provider quality performance ratings. Reporting rehospitalization rates is an important issue with the explicit goal of improving the quality of postacute care. Research is needed to understand and minimize potential unintended consequences of this quality metric.

Objective To examine trajectories of functional recovery after rehabilitation for traumatic brain injury (TBI). Design Prospective study. Setting Inpatient rehabilitation hospitals in the Uniform Data System for Medical Rehabilitation. Participants A subset of individuals receiving inpatient rehabilitation services for TBI from 2002 to 2010 who also had postdischarge measurement of functional independence (N=16,583). Interventions Inpatient rehabilitation. Main Outcomes Measures Admission, discharge, and follow-up data were obtained from the Uniform Data System for Medical Rehabilitation. We used latent class mixture models to examine recovery trajectories for both cognitive and motor functioning as measured by the FIM instrument. Results Latent class models identified 3 trajectories (low, medium, high) for both cognitive and motor FIM subscales. Factors associated with membership in the low cognition trajectory group included younger age, male sex, racial/ethnic minority, Medicare or Medicaid (vs commercial or other insurance), comorbid conditions, and greater duration from injury date to rehabilitation admission date. Factors associated with membership in the low motor trajectory group included older age, racial/ethnic minority, Medicare or Medicaid coverage, comorbid conditions, open head injury, and greater duration to admission. Conclusions Standard approaches to assessing recovery patterns after TBI obscure differences between subgroups with trajectories that differ from the overall mean. Select demographic and clinical characteristics can help classify patients with TBI into distinct functional recovery trajectories, which can enhance both patient-centered care and quality improvement efforts.

Objectives To model 12-month rehospitalization risk among Medicare beneficiaries receiving inpatient rehabilitation for spinal cord injury (SCI) or traumatic brain injury (TBI) and to create 2 (SCI- and TBI-specific) interactive tools enabling users to generate monthly projected probabilities of rehospitalization on the basis of an individual patient's clinical profile at discharge from inpatient rehabilitation. Design Secondary data analysis. Setting Inpatient rehabilitation facilities. Participants Medicare beneficiaries receiving inpatient rehabilitation for SCI (n=2587) or TBI (n=10,864). Interventions Not applicable. Main Outcome Measures Monthly rehospitalization (yes/no) based on Medicare claims. Results Results are summarized through computer-generated interactive tools, which plot individual level trajectories of rehospitalization probabilities over time. Factors associated with the probability of rehospitalization over time are also provided, with different combinations of these factors generating different individual level trajectories. Four case studies are presented to demonstrate the variability in individual risk trajectories. Monthly rehospitalization probabilities for the individual high-risk TBI and SCI cases declined from 33% to 15% and from 41% to 18%, respectively, over time, whereas the probabilities for the individual low-risk cases were much lower and stable over time: 5% to 2% and 6% to 2%, respectively. Conclusions Rehospitalization is an undesirable and multifaceted health outcome. Classifying patients into meaningful risk strata at different stages of their recovery is a positive step forward in anticipating and managing their unique health care needs over time.

Background Information regarding the association of comorbidity indices with readmission risk for older adults receiving postacute care is limited. The purpose of this study was to compare the discriminatory ability of five comorbidity indices in predicting 30-day all-cause hospital readmission following discharge to the community from postacute inpatient rehabilitation facilities (IRF). Methods The sample included Medicare fee-for-service beneficiaries with stroke, lower extremity joint replacement, and fracture, discharged from IRF in 2011 (N = 75,582). Logistic regression models were used to predict 30-day all-cause readmission. Impairment-specific base models included demographic characteristics and length of stay. Subsequent models included individual comorbidity indices: Tier, Charlson, Elixhauser, functional comorbidity index (FCI), and the hierarchical condition category (HCC). We then added discharge functional status to each model. Results were compared using C-statistics. Results Thirty-day readmission rates following discharge from an IRF ranged from 6.5% (joint replacement) to 14% (stroke). The C-statistics were 0.53, 0.56, and 0.55 for the base models in the stroke, joint replacement, and fracture groups, respectively. Adding the Tier, Charlson, FCI, or Elixhauser variables increased the C-statistics by 0.03-0.07 across the three impairment categories. Adding the HCC increased the C-statistics by 0.06-0.09. With the addition of discharge functional status in the model, the C-statistics further increased by 0.06-0.09. Conclusions Comorbidity indices were weakly associated with 30-day readmission in older adults discharged from postacute inpatient rehabilitation. Adding patient-level functional status to the comorbidity indices further improved the discriminatory ability to predict readmission in our sample.

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood.To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care.This was a retrospective cohort study.Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013.Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406).Not applicable.Thirty-day unplanned rehospitalization following post-acute rehabilitation.The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %).The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care.

© 2015, Springer Science+Business Media New York. Background: Abdominal obesity is a risk factor for Barrett’s esophagus independent of GERD symptoms, but little is understood about the biological mechanisms between obesity and the carcinogenic pathway of esophageal adenocarcinoma. Aims: To evaluate whether ghrelin and leptin may partially explain the association between obesity and Barrett’s esophagus. Methods: We conducted a case–control study using patients with a new diagnosis of Barrett’s esophagus (cases) and two control groups frequency matched to cases for age, gender, and geographic region: (1) patients with gastroesophageal reflux disease (GERD) and (2) a sample of the general population. We generated odds ratios using logistic regressions to evaluate quartiles of serum ghrelin or serum leptin, adjusting for known risk factors for Barrett’s esophagus. We evaluated potential interaction variables using cross products and ran stratified analyses to generate stratum-specific odds ratios. Results: A total of 886 participants were included in the analysis. Higher ghrelin concentrations were associated with an increased risk of Barrett’s esophagus, when compared to the population controls, but not the GERD controls. Ghrelin concentrations were not associated with the frequency of GERD symptoms, but ghrelin’s relationship with Barrett’s esophagus varied significantly with the frequency of GERD symptoms. Leptin concentrations were positively associated with at least weekly GERD symptoms among the population controls and were inversely associated with Barrett’s esophagus only among the GERD controls. Adjusting for waist circumference did not change the main associations. Conclusion: Higher levels of ghrelin were associated with an increased risk of Barrett’s esophagus among the general population. In contrast, leptin was positively associated with frequent GERD symptoms, but inversely associated with the risk of Barrett’s esophagus among the GERD controls.

Background & Aims Abdominal obesity and increasing body mass index are risk factors for esophageal adenocarcinoma and its main precursor, Barrett's esophagus; however, there are no known biological mechanisms for these associations or regarding why only some patients with gastroesophageal reflux disease develop Barrett's esophagus. We evaluated the association between Barrett's esophagus and multimers of an adipose-associated hormone, adiponectin. Methods We conducted a case-control study evaluating the associations between adiponectin (total, high-molecular-weight, and low-/medium-molecular-weight) and Barrett's esophagus within the Kaiser Permanente Northern California population. Patients with a new diagnosis of Barrett's esophagus (cases) were matched to patients with gastroesophageal reflux disease (GERD) without Barrett's esophagus and to population controls. Results Complete serologic and epidemiologic data were available for 284 cases, 294 GERD controls, and 285 population controls. Increasing adiponectin levels were a risk factor for Barrett's esophagus among patients with GERD (total adiponectin fourth vs first quartile odds ratio [OR], 1.96; 95% confidence interval [CI], 1.17–3.27; high-molecular-weight adiponectin OR, 1.65; 95% CI, 1.00-2.73; low-/medium-molecular-weight adiponectin OR, 2.18; 95% CI, 1.33–3.56), but not compared with population controls. The associations were significantly stronger among patients reporting frequent GERD symptoms and among smokers ( P values interaction Conclusions Adiponectin levels are associated positively with the risk of Barrett's esophagus among patients with GERD and among smokers, but not among population controls without GERD symptoms. Higher adiponectin concentrations either independently may contribute to the aberrant healing of esophageal injury into Barrett's esophagus or be a marker for other factors.

Objective: Examine the relationship between frailty and falls. Method: A total of 847 Mexican Americans from the Hispanic Established Population for the Epidemiological Study of the Elderly were evaluated. The outcome variable was fall occurrence. Some predictor variables included were frailty, sociodemographic variables, functional and health status, and prior falls. Results: Those who fell were more likely to be women, not married, had prior falls, more functional problems and poorer health. The incidence rate ratio (IRR) for falls was 1.9 for nonfrail individuals and 3.2 for frail individuals. Prefrail individuals had 1.36 higher odds of falls (95% CI [1.11, 1.67]), individuals with prior falls had 1.26 higher odds of falls (95% CI [1.15, 1.37]), and those with poor balance had 1.49 higher odds of falls (95% CI [1.15, 1.95]) over the 2 years ( p < .01). Discussion: Frailty increases the odds of falls in older Mexican Americans. Interventions tailored to reduce fall incidence and improve health care quality for older Mexican Americans are needed.

SIR—The adverse effects of low mobility in older hospitalised persons are well documented [1, 2]. The amount of time patients are limited to a bed or chair is an independent predictor of functional decline even after controlling for illness severity [3]. Ambulation is a potentially simple intervention to reduce low mobility in-hospital. A number of factors, however, can interact to influence how much a patient actually walks. Identifying factors associated with varied levels of ambulation would help clinicians identify older patients at risk for low levels of mobility. Although, previous studies have investigated perceived barriers to ambulation during hospitalisation from the perspectives of older patients and their primary nurses and physicians [4], no study has examined relevant factors using direct measures of ambulatory activity such as step counts. We recently demonstrated that accelerometer technology can be used to collect continuous information on patient mobility in hospitalised older persons [5]. For this study, our objective was to identify subgroups of patients with shared clinical profiles who differed with respect to mean daily ambulation.

OBJECTIVE The aim of this study was to provide benchmarking information for a large national sample of patients receiving inpatient rehabilitation because of a hip fracture. DESIGN A secondary data analysis of records from 893 medical rehabilitation facilities located in the United States that contributed information to the Uniform Data System for Medical Rehabilitation from January 2000 through December 2007 was performed. Variables analyzed included demographic information (age, sex, marital status, race/ethnicity, prehospital living setting, and discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, International Classification of Diseases, Ninth Revision, codes for admitting diagnosis, comorbidities), and Functional Status Information (FIM instrument ratings at admission and discharge, FIM efficiency, and FIM gain). RESULTS Descriptive statistics from 303,594 patients showed length of stay decreasing from a mean (SD) of 14.5 (7.9) days to 13.3 (5.5) days over the 8-yr study period. FIM total admission and discharge ratings also decreased. Mean admission ratings decreased from 72.5 (14.5) to 59.9 (15.7). Mean discharge ratings decreased from 95.8 (18.1) to 86.0 (19.8). FIM change per day remained relatively stable; mean for the entire sample was 2.1 (1.6). The percentage of persons discharged to the community also decreased across the study period, ranging from 77.8% in 2000 to 70.0% in 2007. All results are likely influenced by various policy changes affecting classification and/or documentation processes. CONCLUSIONS National rehabilitation data from persons with hip fracture in 2000-2007 indicate that patients are spending less time in inpatient rehabilitation care than in previous years and are experiencing improvements in functional independence during their stay. In addition, most patients are discharged to the community after inpatient rehabilitation.

Background Walking speed norms and several risk thresholds for poor health outcomes have been published for community-dwelling older adults. It is unclear whether these values apply to hospitalized older adults. Objective The purpose of this study was to determine the in-hospital walking speed threshold that best differentiates walking-independent from walking-dependent older adults. Design This was a cross-sectional study. Methods This study recruited a convenience sample of 174 ambulatory adults aged 65 years and older who had been admitted to a medical-surgical unit of a university hospital. The participants' mean (SD) age was 75 (7) years. Fifty-nine percent were women, 66% were white, and more than 40% were hospitalized for cardiovascular problems. Usual-pace walking speed was assessed over 2.4 m. Walking independence was assessed through self-report. Several methods were used to determine the threshold speed that best differentiated walking-independent patients from walking-dependent patients. Approaches included a receiver operating characteristic (ROC) curve, sensitivity and specificity, and frequency distributions. Results The participants' mean (SD) walking speed was 0.43 (0.23) m/s, and 62% reported walking independence. Nearly 75% of the patients walked more slowly than the lowest community-based risk threshold, yet 90% were discharged home. Overall, cut-point analyses suggested that 0.30 to 0.35 m/s may be a meaningful threshold for maintaining in-hospital walking independence. For simplicity of clinical application, 0.35 m/s was chosen as the optimal cut point for the sample. This threshold yielded a balance between sensitivity and specificity (71% for both). Limitations The limitations of this study were the small size of the convenience sample and the single health outcome measure. Conclusions Walking speeds of older adults who are acutely ill are substantially slower than established community-based norms and risk thresholds. The threshold identified, which was approximately 50% lower than the lowest published community-based risk threshold, may serve as an initial risk threshold or target value for maintaining in-hospital walking independence.

OBJECTIVE: To examine how similar summary scores of physical functioning using the FIM can represent very different patient clinical profiles. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012 and 2013. PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation (N=765,441). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: We used patients’ scores on items from the Functional Independence Measure (FIM) to quantify their level of independence in both self-care and mobility domains. We then identified patients as requiring “No Physical Assistance” at discharge from inpatient rehabilitation using a rule and score-based approach. RESULTS: Among those patients with FIM self-care and mobility summary scores suggesting no physical assistance needed, we found physical assistance was in fact needed frequently in bathroom related activities (e.g., continence, toilet and tub transfers, hygiene, clothes management) and with stairs. In other words, it was not uncommon for actual performance to be lower than what may be suggested by a summary score in those domains. CONCLUSIONS: Further research is needed into creating clinically meaningful descriptions of summary scores from combined performances on individual items of physical functioning.

Objectives The objectives of this study were to determine the association between patients’ functional status at discharge from skilled nursing facility (SNF) care and 30-day potentially preventable hospital readmissions, and to examine common reasons for potentially preventable readmissions. Design Retrospective cohort study. Setting SNFs and acute care hospitals submitting claims to Medicare. Participants National cohort of Medicare fee-for-service beneficiaries discharged from SNF care between July 15, 2013, and July 15, 2014 (n = 693,808). Average age was 81.4 (SD 8.1) years, 67.1% were women, and 86.3% were non-Hispanic white. Measurements Functional items from the Minimum Data Set 3.0 were categorized into self-care, mobility, and cognition domains. We used specifications for the SNF potentially preventable 30-day postdischarge readmission quality metric to identify potentially preventable readmissions. Results The overall observed rate of 30-day potentially preventable readmissions following SNF discharge was 5.7% (n = 39,318). All 3 functional domains were independently associated with potentially preventable readmissions in the multivariable models. Odds ratios for the most dependent category versus the least dependent category from multilevel models adjusted for patients’ sociodemographic and clinical characteristics were as follows: mobility, 1.54 (95% confidence interval [CI] 1.49–1.59); self-care, 1.50 (95% CI 1.44–1.55); and cognition, 1.12 (95% CI 1.04–1.20). The 5 most common conditions were congestive heart failure (n = 7654, 19.5%), septicemia (n = 7412, 18.9%), urinary tract infection/kidney infection (n = 4297, 10.9%), bacterial pneumonia (n = 3663, 9.3%), and renal failure (n = 3587, 9.1%). Across all 3 functional domains, septicemia was the most common condition among the most dependent patients and congestive heart failure among the least dependent. Conclusions Patients with functional limitations at SNF discharge are at increased risk of hospital readmissions considered potentially preventable. Future research is needed to determine whether improving functional status reduces risk of potentially preventable readmissions among this vulnerable population.

To investigate the effects of facility-level factors on 30-day unplanned risk-adjusted hospital readmission after discharge from inpatient rehabilitation facilities (IRFs).Study using 100% Medicare claims data, covering 269,306 discharges from 1094 IRFs between October 2010 and September 2011.IRFs with at least 30 discharges.A total number of 1094 IRFs (N=269,306) serving Medicare fee-for-service beneficiaries.Not applicable.Risk-standardized readmission rate (RSRR) for 30-day hospital readmission.Profit status was the only provider-level IRF characteristic significantly associated with unplanned readmissions. For-profit IRFs had a significantly higher RSRR (13.26±0.51) than did nonprofit IRFs (13.15±0.47) (P.001). After controlling for all other facility characteristics (except for accreditation status because of its collinearity with facility type), for-profit IRFs had a 0.1% point higher RSRR than did nonprofit IRFs, and census region was the only significant region-level characteristic, with the South showing the highest RSRR of all regions (type III test, P=.005 for both).Our findings support the inclusion of profit status on the IRF Compare website (a platform including IRF comparators to indicate quality of services). For-profit IRFs had a higher RSRR than did nonprofit IRFs for Medicare beneficiaries. The South had a higher RSRR than did other regions. The RSRR difference between for-profit and nonprofit IRFs could be due to the combined effects of organizational and regional factors.

Reistetter TA, Graham JE, Deutsch A, Granger CV, Markello S, Ottenbacher KJ . Utility of functional status for classifying community versus institutional discharges after inpatient rehabilitation for stroke. Objective To evaluate the ability of patient functional status to differentiate between community and institutional discharges after rehabilitation for stroke. Design Retrospective cross-sectional design. Setting Inpatient rehabilitation facilities contributing to the Uniform Data System for Medical Rehabilitation. Participants Patients (N=157,066) receiving inpatient rehabilitation for stroke from 2006 and 2007. Interventions Not applicable. Main Outcome Measure Discharge FIM rating and discharge setting (community vs institutional). Results Approximately 71% of the sample was discharged to the community. Receiver operating characteristic curve analyses revealed that FIM total performed as well as or better than FIM motor and FIM cognition subscales in differentiating discharge settings. Area under the curve for FIM total was .85, indicating very good ability to identify persons discharged to the community. A FIM total rating of 78 was identified as the optimal cut point for distinguishing between positive (community) and negative (institution) tests. This cut point yielded balanced sensitivity and specificity (both=.77). Conclusions Discharge planning is complex, involving many factors. Identifying a functional threshold for classifying discharge settings can provide important information to assist in this process. Additional research is needed to determine if the risks and benefits of classification errors justify shifting the cut point to weight either sensitivity or specificity of FIM ratings.