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Abstract: This commentary evaluates the merits of proposals in the United States to create a site-neutral payment system for postacute care for patients with select rehabilitation-related conditions. Under a site-neutral payment system, Medicare would pay providers based on patients' clinical needs, not on the peculiarities of individual postacute settings such as skilled nursing facilities and inpatient rehabilitation facilities. This commentary frames the policy choices by taking into account the research evidence on setting costs and outcomes, the policy tools and preconditions needed for an effective site-neutral payment system, and the overall direction of American health and postacute policy. [Copyright &y& Elsevier]

Abstract: This issue of Archives includes an article by Mallinson et al that compares the outcomes of patients with hip fracture who received rehabilitation services in 3 different postacute settings: skilled nursing facilities, inpatient rehabilitation facilities, or home health. Except in 1 instance, Mallinson found no setting-specific effects and noted that the issue of defining an optimum postacute rehabilitation program is complex and requires more investigation. Mallinson's findings are interesting in their own right but raise a more fundamental issue. This commentary observes that rehabilitation patients typically use multiple postacute settings, not just 1 setting of care, for the same episode of care. This commentary asks whether we should be examining episode outcomes and not just setting-specific outcomes, especially in the face of bundled payment and value-based payment reforms in the Affordable Care Act. [Copyright &y& Elsevier]

Deutscher D, Horn SD, Smout RJ, DeJong G, Putman K. Black-white disparities in motor function outcomes taking into account patient characteristics, nontherapy ancillaries, therapy activities, and therapy interventions. Objective: To assess black-white differences in functional outcomes, controlling for patient characteristics, use of nontherapy ancillaries (NTAs), and use of physical (PT) and occupational therapy (OT) activities and interventions. Design: Multicenter prospective observational cohort study of poststroke rehabilitation. Setting: Six U.S. inpatient rehabilitation facilities. Participants: Patients (N=732) subdivided into case-mix subgroups (CMGs; CMGs 104–107 for moderate strokes [n=397], CMGs 108–114 for severe strokes [n=335]). Interventions: Not applicable. Main Outcome Measure: Discharge Motor FIM. Results: Taking into account patient characteristics, NTAs, and therapy activities, multivariate regressions explained (R 2) 54% and 69% of variation in outcomes between patients with moderate and severe stroke, respectively. Black race was associated with lower outcomes than white race in the severe group. However, race was no longer associated with outcomes after including interventions used within PT and OT activities. Including interventions within therapy activities increased R 2 to 64% and 74% for moderate and severe strokes, respectively. Some PT and OT activities were provided more to blacks than whites and vice versa. Greater intensity sometimes was associated with better and sometimes with poorer functional outcomes. Conclusions: After controlling for interventions within activities, no racial differences were found in functional outcomes at discharge despite racial differences in rehabilitation care, possibly because each racial group received a mixture of interventions that were negatively and positively associated with outcome. Clinicians should provide therapies associated with better outcomes with high and similar intensities for black and white patients poststroke. [Copyright &y& Elsevier]

Horn SD, Deutscher D, Smout RJ, DeJong G, Putman K. Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation. Objective: To describe racial differences in patient characteristics, nontherapy ancillaries, physical therapy (PT), occupational therapy (OT), and functional outcomes at discharge in stroke rehabilitation. Design: Multicenter prospective observational cohort study of poststroke rehabilitation. Setting: Six U.S. inpatient rehabilitation facilities. Participants: Black and white patients (n=732), subdivided in case-mix subgroups (CMGs): CMGs 104 to 107 for moderate strokes (n=397), and CMGs 108 to 114 for severe strokes (n= 335). Interventions: Not applicable. Main Outcome Measure: FIM. Results: Significant black-white differences in multiple patient characteristics and intensity of rehabilitation care were identified. White subjects took longer from stroke onset to rehabilitation admission and were more ambulatory prior to stroke. Black subjects had more diabetes. For patients with moderate stroke, black subjects were younger, were more likely to be women, and had more hypertension and obesity with body mass index greater than or equal to 30. For patients with severe stroke, black subjects were less sick and had higher admission FIM scores. White subjects received more minutes a day of OT, although black subjects had significantly longer median PT and OT session duration. No black-white differences in unadjusted stroke rehabilitation outcomes were found. Conclusions: Reasons for differences in rehabilitation care between black and white subjects should be investigated to understand clinicians' choice of treatments by race. However, we did not find black-white differences in unadjusted stroke rehabilitation outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Hsieh C-H, Gassaway J, Smith P. Long-term outcomes of joint replacement rehabilitation patients discharged from skilled nursing and inpatient rehabilitation facilities. Objective: To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). Design: Postdischarge follow-up interview study at 7.5 months after admission. Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs. Participants: Patients (N=856): 561 with knee replacement and 295 with hip replacement. Interventions: None. Main Outcome Measures: FIM and Short-Form 12-Item Health Survey (SF-12). Results: Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12–related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes. Conclusions: At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Smith P, Gassaway J, DaVanzo JE. Use of rehabilitation and other health care services by patients with joint replacement after discharge from skilled nursing and inpatient rehabilitation facilities. Objective: To compare use of rehabilitation and other health services among patients with knee and hip replacement after discharge from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). Design: Follow-up interview study at 7.5 months after discharge. Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs from across the United States. Participants: Patients (N=856): patients with knee replacement (n=561) and patients with hip replacement (n=295). Interventions: No interventions. Main Outcome Measures: Number of home and outpatient therapy visits, physician visits, emergency room visits, rehospitalizations, and medical complications. Results: After discharge from postacute care, the vast majority of patients received home rehabilitation, outpatient rehabilitation, or both. Patients with knee replacement received an average of 19 home and/or outpatient rehabilitation visits; patients with hip replacement received almost 15 visits. There were no statistically significant differences in rates of emergency room use and rehospitalization except that patients with hip replacement discharged from IRFs had higher rates of rehospitalization than those discharged from freestanding SNFs (15.8% vs 3.1%). Multivariate analyses did not find any SNF/IRF effects. Conclusions: Patients with joint replacement from both SNFs and IRFs receive considerable amounts of follow-up rehabilitation care. Study uncovered no setting effects related to rehospitalization or medical complications. Looking only at care rendered in the initial postacute setting provides an incomplete picture of all care received and how it may affect follow-up outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Horn SD, Smout RJ, Tian W, Putman K, Gassaway J. Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities. Objective: To compare functional outcomes at discharge across postacute settings. Design: Prospective observational cohort study. Setting: Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States. Participants: Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751). Interventions: None; examination of existing practice patterns. Main Outcome Measure: FIM discharge motor score. Results: Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome. Conclusions: As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Hsieh C-H, Gassaway J, Horn SD, Smout RJ, Putman K, James R, Brown M, Newman EM, Foley MP. Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities. Objective: To characterize rehabilitation services for patients with knee and hip replacement in 3 types of postacute facilities in the U.S. Design: Multi-site prospective observational cohort study. Setting: Eight freestanding skilled nursing facilities (SNFs), 1 hospital-based SNF, and 11 inpatient rehabilitation facilities (IRFs). Participants: Patients (N=2158) with knee or hip replacement. Interventions: No new interventions. Main Outcome Measures: Length of stay (LOS), amount and intensity of physical therapy (PT) and occupational therapy (OT), types of therapy activities. Results: Average LOS was about 15 days for freestanding SNF patients, and 9 to 10 days for hospital-based SNF and IRF patients. Freestanding SNFs and IRFs provide about the same number of hours of PT and OT; the hospital-based SNF provided 27% fewer hours. Freestanding SNFs and the hospital-based SNF provided fewer hours a day than did IRFs. Joint replacement patients across all 3 types of facilities spent, on average, 70% to 75% of their PT time in just 2 activities—exercise and gait and spent 56% to 66% of their OT time in 3 activities—exercise, functional mobility, and dressing lower body. Conclusions: Both freestanding SNFs and IRFs provided similar amounts of PT with a similar emphasis on exercise and gait activities. IRFs, however, provided more OT than freestanding SNFs. IRFs had shorter LOSs and more intensive therapy services than freestanding SNFs. Study freestanding SNFs exhibited greater variation in LOS and intensity of therapy than IRFs. [Copyright &y& Elsevier]

Abstract: Tian W, DeJong G, Brown M, Hsieh C-H, Zamfirov ZP, Horn SD. Looking upstream: factors shaping the demand for postacute joint replacement rehabilitation. Since 1993, the numbers of hip and knee replacements in the United States have increased 2-fold to 3-fold while lengths of stay in acute care have decreased by about half, leading to a significant growth in the use of postacute rehabilitative care for patients with a joint replacement. To document these trends, this article uses secondary analysis of acute hospital discharge survey data and evaluates projections to 2030. This article uses a market approach to identify 3 sets of factors that influence the use of joint replacements: (1) increasing patient demand, (2) increasing supply of practitioners, and (3) the role of fiscal intermediaries. The article reviews underlying epidemiologic trends, growing numbers of orthopedic surgeons performing the procedure, technologic innovations, changing indications for the procedure, changing payer mix, and the effects of payer attempts to contain joint replacement costs. An unintended effect of Medicare payment policy has been to shift costs from acute care to downstream postacute care. Medicare and private health plan reimbursement policies need to take into account this broader perspective and not examine joint replacement care and payment in isolated care settings. Future research and health policy needs to consider the interdependent features of the health care system by linking changes in postacute care with upstream changes both in society at large and in the organization, delivery, and financing of acute care associated with joint replacement. [Copyright &y& Elsevier]

Abstract: DeJong G. The American Congress of Rehabilitation Medicine (ACRM) and rehabilitation research in a changing postacute landscape. The 2007 ACRM presidential address. Postacute rehabilitation is on the threshold of several major changes that have implications for rehabilitation practice and research. The most important of these is the desire of the Centers for Medicare & Medicaid Services to establish a uniform patient assessment method and implement a more setting-neutral prospective payment system across all major postacute settings. The proposed uniform patient assessment instrument will in all likelihood displace the FIM instrument as the industry standard. The rehabilitation research community needs to remain vigilant about the nature, scope, and measurement properties of the proposed uniform patient assessment instrument. A new instrument and setting-neutral payment system may provide new opportunities for service innovation and research. Neurorehabilitation has been one of the strengths of the American Congress of Rehabilitation Medicine (ACRM). ACRM needs to build on this strength and examine more earnestly the rehabilitation interventions and outcomes associated with the increasing prevalence of people with orthopedic and musculoskeletal conditions seen in rehabilitation centers today. ACRM’s ability to do so will depend in part on its ability to join forces with other professional and consumer organizations to increase research funding significantly for each of the major federal agencies that currently fund rehabilitation research. [Copyright &y& Elsevier]

Abstract: Elrod CS, DeJong G. Determinants of utilization of physical rehabilitation services for persons with chronic and disabling conditions: an exploratory study. Objective: To determine which variables influence the receipt of physical rehabilitation services (ie, physical, occupational, speech therapy) for a population of people with chronic and disabling conditions. Design: A convenience sample of 502 adults with cerebral palsy (CP), multiple sclerosis (MS), and spinal cord injury (SCI), drawn from diverse parts of the United States. Setting: Respondents were surveyed in the general community. Participants: Persons (91% under the age of 65y) with CP, MS, or SCI who responded to the 1999 component of a national longitudinal survey. Interventions: Not applicable. Main Outcome Measures: Self-reported need for physical rehabilitation services. Bivariate and multivariate analyses were used to examine variables that influenced utilization of services. Results: Some 53% of respondents did not receive self-reported needed physical rehabilitation services. Respondents who had Medicaid were more likely than those with Medicare or private insurance to receive physical rehabilitation services. Respondents having a lower household income and poorer health were less likely to receive services. Conclusions: Our findings indicate that health care funding sources provide widely disparate coverage for physical rehabilitation services to persons with 3 specific chronic and disabling conditions. Policy-makers and health plan administrators should re-evaluate their coverage of physical rehabilitation services designed to enhance quality of life and reduce the burden of lost independence. [Copyright &y& Elsevier]

Abstract: McNaughton H, DeJong G, Smout RJ, Melvin JL, Brandstater M. A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities. Objective: To compare stroke rehabilitation practice and outcomes between New Zealand (NZ) and the United States. Design: Prospective observational cohort study. Setting: Seven inpatient rehabilitation facilities (IRFs) in the United States and NZ. Participants: Consecutive convenience sample of 1161 patients in 6 U.S. IRFs and 130 in 1 NZ IRF (age, >18y) after acute stroke. Interventions: Not applicable. Main Outcome Measures: Change in FIM score and discharge destination. Results: NZ participants were older than U.S. participants (mean: 74.1y vs 66.0y, respectively; P<.001). Measures of initial stroke severity were higher for U.S. participants. Mean rehabilitation length of stay (LOS) was shorter for U.S. participants (18.6d vs 30.0d, P<.001), but physical and occupational therapy time per patient was considerably higher despite the shorter LOS. U.S. therapists were involved in more active therapies for more of the time. Outcomes were better for U.S. participants, with fewer discharged to institutional care (13.2% vs 21.5%, P=.006) and larger changes in FIM scores. Conclusions: U.S. participants with acute stroke who were selected for rehabilitation had better outcomes than NZ participants, despite shorter stays in the rehabilitation facility. U.S. participants had more intensive input from physiotherapists and occupational therapists, which may explain some of the larger increases in FIM scores. This suggests that further studies with tighter controls on case mix may add additional information on the effects of therapy intensity on patients with stroke. [Copyright &y& Elsevier]

Abstract: Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Objective: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients. Design: Prospective observational cohort study. Setting: Five U.S. inpatient rehabilitation facilities. Participants: Poststroke rehabilitation patients (N=830; age, >18y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database. Interventions: Not applicable. Main Outcome Measures: Discharge total, motor, and cognitive FIM scores and discharge destination. Results: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes. Conclusions: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Horn SD, Smout RJ, Ryser DK. The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes. Objective: To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes. Design: Prospective observational cohort study. Setting: Three IRFs in the United States. Participants: Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs. Interventions: Not applicable. Main Outcome Measures: Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination. Results: The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities. Conclusions: For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study’s findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS. [Copyright &y& Elsevier]

Abstract: Richards LG, Latham NK, Jette DU, Rosenberg L, Smout RJ, DeJong G. Characterizing occupational therapy practice in stroke rehabilitation. Objectives: To describe how occupational therapy (OT) activities during stroke inpatient rehabilitation vary by admission functional status and over time and how time spent in these various activities relates to functional status at discharge. Design: Observational cohort study. Setting: Six inpatient rehabilitation hospitals in the United States. Participants: People (N=713) receiving 4 to 19 hours of poststroke OT. Interventions: Not applicable. Main Outcome Measures: Patients were categorized by number of 4-hour blocks of OT received and by admission upper-extremity (UE) dressing score on the FIM instrument. In each group, the percentage of time spent in 16 activities and the percentage of patients who received each activity were calculated. The amount of time in activities was compared for those patients scoring 1 or 2 at admission who achieved at least a level of supervision for UE dressing (a score of ≥5) using Wilcoxon 2-sample tests. Results: The majority of OT time was spent in impairment-focused activities (37.5%) or training basic activities of daily living (31.9%). Treatment progressed to more advanced activities over time (eg, less bed mobility, more home management), yet little time was spent on community integration or leisure activities and with very few patients. Successful patients received more higher-level activities, whereas unsuccessful patients received larger amounts of basic-level activities. Conclusions: OT activities focused on a combination of remediating impairments and retraining specific functional tasks, at the ability level of each individual patient, and provided higher-level activities as patients improved their function. More time in higher-level activities was related to greater success in rehabilitation. However, higher-level activities remain the least common activities provided during inpatient rehabilitation. [Copyright &y& Elsevier]

Abstract: Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke. Objective: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables. Design: Observational cohort study of 200 consecutive poststroke rehabilitation patients in each of 6 inpatient rehabilitation facilities. Setting: Six U.S. inpatient rehabilitation hospitals. Participants: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records. Interventions: Not applicable. Main Outcome Measures: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS). Results: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108–114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104–107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS. Conclusions: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS. [Copyright &y& Elsevier]

Abstract: Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results. Objectives: To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP). Design: Prospective observational cohort study. Setting: Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand. Participants: Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs). Interventions: Not applicable. Main Outcome Measures: Change in FIM score, change in severity of illness, and discharge destination. Results: For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4. Conclusions: This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability. [Copyright &y& Elsevier]

Abstract: Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the “black box” of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs. [Copyright &y& Elsevier]

Abstract: DeJong G, Horn SD, Conroy B, Nichols D, Healton EB. Opening the black box of poststroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. This article introduces the journal’s supplement devoted to the methods and findings of the 7-site Post-Stroke Rehabilitation Outcomes Project (PSROP), a study designed to provide a very granular in-depth understanding of stroke rehabilitation practice and how practice is related to outcomes. The article summarizes current knowledge about the effectiveness of poststroke rehabilitation, outlines where the PSROP fits into the broader traditions of stroke rehabilitation outcomes research, underscores the study’s methodologic innovations, and summarizes the scope of the articles that follow. [Copyright &y& Elsevier]

Abstract: Objective: To examine the association between inpatient and postdischarge rehabilitation services and function, life satisfaction, and community participation 1 year after spinal cord injury (SCI). Design: Prospective, observational. Setting: Six rehabilitation facilities. Participants: Patients with SCI (N=1376). Interventions: None. Main Outcome Measures: Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART), motor FIM (mFIM), and return to work/school at 1 year post-SCI. Results: Demographic and injury characteristics explained 49% of the variance in mFIM and 9% to 25% of the variance in SWLS and CHART social integration, mobility, and occupation scores. Inpatient rehabilitation services explained an additional 2% of the variance for mFIM and 1% to 3% of the variance for SWLS and CHART scores. More time in inpatient physical therapy (PT) was associated with higher mFIM scores; more time in inpatient therapeutic recreation (TR) and social work and more postdischarge nursing (NSG) were associated with lower mFIM scores. More inpatient PT and TR and more postdischarge PT were associated with higher mobility scores; more inpatient psychology (PSY) was associated with lower mobility scores. More postdischarge TR was associated with higher SWLS; more postdischarge PSY services was associated with lower SWLS. Inpatient TR was positively associated with social integration scores; postdischarge PSY was negatively associated with social integration scores. More postdischarge vocational counseling was associated with higher occupation scores. Differences between centers did not explain additional variability in the outcomes studied. Conclusions: Inpatient and postdischarge rehabilitation services are weakly associated with life satisfaction and societal participation 1 year after SCI. Further study of the type and intensity of postdischarge services, and the association with outcomes, is needed to ascertain the most ... [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine the association between inpatient and postdischarge rehabilitation services and function, life satisfaction, and community participation 1 year after spinal cord injury (SCI). Design: Prospective, observational. Setting: Six rehabilitation facilities. Participants: Patients with SCI (N=1376). Interventions: None. Main Outcome Measures: Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART), motor FIM (mFIM), and return to work/school at 1 year post-SCI. Results: Demographic and injury characteristics explained 49% of the variance in mFIM and 9% to 25% of the variance in SWLS and CHART social integration, mobility, and occupation scores. Inpatient rehabilitation services explained an additional 2% of the variance for mFIM and 1% to 3% of the variance for SWLS and CHART scores. More time in inpatient physical therapy (PT) was associated with higher mFIM scores; more time in inpatient therapeutic recreation (TR) and social work and more postdischarge nursing (NSG) were associated with lower mFIM scores. More inpatient PT and TR and more postdischarge PT were associated with higher mobility scores; more inpatient psychology (PSY) was associated with lower mobility scores. More postdischarge TR was associated with higher SWLS; more postdischarge PSY services was associated with lower SWLS. Inpatient TR was positively associated with social integration scores; postdischarge PSY was negatively associated with social integration scores. More postdischarge vocational counseling was associated with higher occupation scores. Differences between centers did not explain additional variability in the outcomes studied. Conclusions: Inpatient and postdischarge rehabilitation services are weakly associated with life satisfaction and societal participation 1 year after SCI. Further study of the type and intensity of postdischarge services, and the association with outcomes, is needed to ascertain the most effective use of therapy services after SCI. [Copyright &y& Elsevier]

Abstract: Objective: To compare patient and injury characteristics, rehabilitation services, and outcomes between people incurring traumatic spinal cord injury (SCI) at younger and older ages. Design: Multisite prospective observational cohort study. Setting: Six acute rehabilitation facilities. Participants: Patients (N=866) aged ≥16 years admitted to participating centers for their initial rehabilitation after SCI. Interventions: Not applicable. Main Outcome Measures: Motor FIM scores at discharge and 1 year postinjury, discharge location, and postacute clinical pathways. Results: Patients were divided into 4 age-at-injury groups: 16 to 29, 30 to 44, 45 to 60, and >60 years of age. Older adults (>60y) incurring SCI were more likely to be married, retired/unemployed, on Medicare, and to have attained more education. Their injuries mostly resulted from falls and were incomplete in nature. The oldest group had the highest severity of illness, lowest admission and discharge motor FIM scores, and longer rehabilitation stay. They received relatively less rehabilitation than younger groups. They spent proportionately more time in occupational therapy working on preparatory activities and less time on self-care activities during inpatient rehabilitation. In the aged >60 years group, 80% went home at discharge; 17.2% were discharged to a nursing home. Younger groups were less likely to go to a nursing home. Admission motor FIM was the most significant predictor of motor FIM at discharge and 1-year anniversary across age groups. But the age groups differed significantly in patient and treatment factors that explained their respective outcomes. Conclusions: Older injured individuals experienced a different clinical pathway from younger patients. The present study suggests the need for development of a rehabilitation program tailored specifically to older adults. [Copyright &y& Elsevier]

Abstract: Objective: To examine the association between body weight, therapy participation, and functional outcomes among people with spinal cord injury (SCI). Design: Multisite prospective observational cohort study. Setting: Six acute rehabilitation facilities. Participants: Patients (N=1017) aged ≥12 years admitted for their initial rehabilitation after SCI. Interventions: Not applicable. Main Outcome Measure: Motor FIM at inpatient rehabilitation discharge and 1 year postinjury. Results: Underweight and overweight/obese patients consisted of 2 different clusters of SCI patients. Underweight patients were more likely to be younger, black, less educated, single, have Medicaid as a primary payer, and more likely to have had a cervical level injury because of violence and vehicular-related events than their overweight and obese counterparts. We found few significant differences in hours of therapy during inpatient rehabilitation across weight groups. Among patients with C5-8 ASIA Impairment Scale (AIS) grades A, B, and C injuries, underweight patients received fewer hours of physical therapy per week than patients with a healthy weight (P=.028). Obese patients with paraplegia AIS grades A, B, and C received more hours of occupational therapy during their rehabilitation stay (P<.001) than other weight groups. A higher percentage of underweight patients had pressure ulcers during inpatient rehabilitation in C5-8 AIS grades A, B, and C and paraplegia AIS grades A, B, and C groups. Only in the paraplegia AIS grades A, B, and C group did we find a significant association between weight groups and discharge motor FIM score. Regression models showed that among C1-4 AIS grades A, B, and C patients, the overweight group had better 1-year follow-up motor FIM scores than other weight groups. Conclusions: Patients who had an unhealthy body weight, that is, being underweight or obese, often have therapy participation and profiles different from those deemed healthy, or just overweight. For patients with paraplegia AIS grades A, B, and C, being overweight or obese was associated with diminished motor FIM outcomes at discharge from rehabilitation. The relation between body weight status, therapy participation, and outcomes are not consistent among study group participants. [Copyright &y& Elsevier]

Abstract: Objectives: To investigate frequency of and reasons for readmission to acute care (RTAC) during inpatient rehabilitation after traumatic spinal cord injury (SCI), and to identify factors associated with RTAC. Design: Prospective observational cohort. Setting: Inpatient rehabilitation. Participants: Individuals with SCI (N=1376) consecutively admitted for inpatient rehabilitation; 1032 randomly selected for model development; 344 selected for model cross-validation. Interventions: Not applicable. Main Outcome Measures: RTAC, RTAC reasons, rehabilitation length of stay (LOS), discharge location and FIM, rehospitalization between discharge and year 1, and 1-year outcomes: FIM, Craig Handicap Assessment and Reporting Technique, and Patient Health Questionnaire-9. Results: Participants (n=116; 11%) experienced RTAC with a total 143 episodes—96 patients experienced only 1 RTAC, while 14 had 2 RTACs, 5 had 3 RTACs, and 1 had 4 RTACs. The most common RTAC reasons were surgery (36%), infection (22%), noninfectious respiratory (14%), and gastrointestinal (8%). Mean days ± SD from rehabilitation admission to first RTAC was 27±30 days. Seventy-four (7%) patients had at least 1 RTAC for medical reasons and 46 (4%) for surgical reasons. Regression analyses indicated several variables were associated with RTACs: greater admission medical severity, lower admission cognitive FIM, pressure ulcer acquired in acute care, and study site. Medical RTACs were associated with higher body mass index, lower admission cognitive and motor FIM, payer, and study site. Predictors of surgical RTAC were longer time from injury to rehabilitation admission and study site. After controlling for the other variables, the only outcome RTAC influenced was longer rehabilitation LOS. Conclusions: Approximately 11% of SCI patients experience RTAC during the course of rehabilitation for a variety of medical and surgical reasons. RTACs are associated with longer rehabilitation LOS. [Copyright &y& Elsevier]

Abstract: Objective: To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization. Design: Prospective observational cohort study. Setting: Six geographically dispersed rehabilitation centers in the U.S. Participants: Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey. Interventions: Not applicable. Main Outcome Measures: Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations. Results: More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034–2.279), having Medicaid as the main payer (95% CI, 1.303–2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960–.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized—from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered. Conclusions: Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources. [Copyright &y& Elsevier]

Abstract: Objective: To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status. Design: Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury. Setting: Inpatient rehabilitation and community follow-up at 6 SCI treatment centers. Participants: Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation. Interventions: Not applicable. Main Outcome Measures: Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI). Results: Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school. Conclusions: Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account. [Copyright &y& Elsevier]

Abstract: Horn SD, DeJong G, Deutscher D. Practice-based evidence research in rehabilitation: an alternative to randomized controlled trials and traditional observational studies. Sound rigorous methods are needed by researchers and providers to address practical questions about risks, benefits, and costs of interventions as they occur in routine clinical practice such as: Are treatments used in daily practice associated with intended outcomes? For whom does an intervention work best? With limited clinical resources, what are the best interventions to use for specific types of patients? Answers to such questions can help clinicians, patients, researchers, and health care administrators learn from, and improve, real-world everyday clinical practice. In this article, we describe existing research designs to demonstrate clinical usefulness and comparative effectiveness of rehabilitation treatments. We compare randomized controlled trials and observational cohort studies of various types, including those that use instrumental variables or propensity scores to control for potential patient or treatment selection effects. We argue that practice-based evidence (PBE) study designs include features that address limitations inherent in both randomized trials and traditional observational studies, and also reduce the need for instrumental variables and propensity scores methods. We give examples of how PBE designs have been used in various rehabilitation areas to determine better treatments for specific types of patients. [Copyright &y& Elsevier]

OBJECTIVE: To compare stroke rehabilitation practice and outcomes between New Zealand (NZ) and the United States. DESIGN: Prospective observational cohort study. SETTING: Seven inpatient rehabilitation facilities (IRFs) in the United States and NZ. PARTICIPANTS: Consecutive convenience sample of 1161 patients in 6 U.S. IRFs and 130 in 1 NZ IRF (age, >18 y) after acute stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in FIM score and discharge destination. RESULTS: NZ participants were older than U.S. participants (mean: 74.1 y vs 66.0 y, respectively; P<.001). Measures of initial stroke severity were higher for U.S. participants. Mean rehabilitation length of stay (LOS) was shorter for U.S. participants (18.6d vs 30.0 d, P<.001), but physical and occupational therapy time per patient was considerably higher despite the shorter LOS. U.S. therapists were involved in more active therapies for more of the time. Outcomes were better for U.S. participants, with fewer discharged to institutional care (13.2% vs 21.5%, P=.006) and larger changes in FIM scores. CONCLUSIONS: U.S. participants with acute stroke who were selected for rehabilitation had better outcomes than NZ participants, despite shorter stays in the rehabilitation facility. U.S. participants had more intensive input from physiotherapists and occupational therapists, which may explain some of the larger increases in FIM scores. This suggests that further studies with tighter controls on case mix may add additional information on the effects of therapy intensity on patients with stroke. Copyright © 2005 by Elsevier Science (USA). [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients. DESIGN: Prospective observational cohort study. SETTING: Five U.S. inpatient rehabilitation facilities. PARTICIPANTS: Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total, motor, and cognitive FIM scores and discharge destination. RESULTS: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes. CONCLUSIONS: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes. Copyright © 2005 by Elsevier Science (USA). [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes. DESIGN: Prospective observational cohort study. SETTING: Three IRFs in the United States. PARTICIPANTS: Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination. RESULTS: The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities. CONCLUSIONS: For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study's findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS. Copyright © 2005 by Elsevier Science (USA). [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe how occupational therapy (OT) activities during stroke inpatient rehabilitation vary by admission functional status and over time and how time spent in these various activities relates to functional status at discharge. DESIGN: Observational cohort study. SETTING: Six inpatient rehabilitation hospitals in the United States. PARTICIPANTS: People (N=713) receiving 4 to 19 hours of post-stroke OT. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patients were categorized by number of 4-hour blocks of OT received and by admission upper-extremity (UE) dressing score on the FIM instrument. In each group, the percentage of time spent in 16 activities and the percentage of patients who received each activity were calculated. The amount of time in activities was compared for those patients scoring 1 or 2 at admission who achieved at least a level of supervision for UE dressing (a score of >or=5) using Wilcoxon 2-sample tests. RESULTS: The majority of OT time was spent in impairment-focused activities (37.5%) or training basic activities of daily living (31.9%). Treatment progressed to more advanced activities over time (eg, less bed mobility, more home management), yet little time was spent on community integration or leisure activities and with very few patients. Successful patients received more higher-level activities, whereas unsuccessful patients received larger amounts of basic-level activities. CONCLUSIONS: OT activities focused on a combination of remediating impairments and retraining specific functional tasks, at the ability level of each individual patient, and provided higher-level activities as patients improved their function. More time in higher-level activities was related to greater success in rehabilitation. However, higher-level activities remain the least common activities provided during inpatient rehabilitation. Copyright © 2005 by Elsevier Science (USA). [ABSTRACT FROM AUTHOR]

OBJECTIVE: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables. DESIGN: Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities. SETTING: Six U.S. inpatient rehabilitation hospitals. PARTICIPANTS: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS). RESULTS: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS. CONCLUSIONS: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS. Copyright © 2005 by Elsevier Science (USA). [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP). DESIGN: Prospective observational cohort study. SETTING: Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand. PARTICIPANTS: Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in FIM score, change in severity of illness, and discharge destination. RESULTS: For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4. CONCLUSIONS: This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability. Copyright © 2005 by Elsevier Science (USA). [ABSTRACT FROM AUTHOR]