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Objective: To evaluate the use of Participation Assessment with Recombined Tools-Objective (PART-O) in spinal cord injury (SCI) and compare it with the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF). Design: Follow-up survey of inception cohort. Setting: Community. Participants: Individuals with SCI, rehabilitated at 2 large SCI Model Systems and enrolled in the SCI Model Systems National Database, who were due for routine follow-up (N = 468: median age at injury, 29; median time post injury, 5 years). Interventions: Not applicable. Main Outcome Measures: PART-0 and CHART-SF. Results: Use of Rasch analysis identified an SCI-specific scoring of PART-0 that demonstrated unidimensionality (first contrast eigenvalue of 1.76) with no misfitting items or disordered steps in any response categories. Person separation and reliability were 2.00 and .80. respectively. Unlike CHART-SF, PART-0 had a relatively normal distribution with no floor or ceiling effects. Test-retest reliability PART-0 administered 2-4 weeks apart was 0.97, with a reliable change index of 3.1 points on a 100-point scale. PART-0 correlated 0.79 with the sum of 3 CHART-SF domains with similar content. The PART-0 scoring was initially validated on a second data set. Conclusions: PART-0 can be used successfully to measure participation in a population of people with SCI. A new method of scoring PART-0 in SCI provides an initially validated, univariate interval measure of participation with good psychometric properties that has advantages over the CHART-SF legacy measure of participation. [ABSTRACT FROM AUTHOR]

Abstract: Whiteneck GG, Gassaway J, Dijkers MP, Lammertse DP, Hammond F, Heinemann AW, Backus D, Charlifue S, Ballard PH, Zanca JM. Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab study. Objective: To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI). Design: Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview. Setting: Inpatient and postdischarge rehabilitation programs. Participants: Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study. Interventions: Not applicable. Main Outcome Measures: Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews. Results: Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services. Conclusions: SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and 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: 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: James R, Gines D, Menlove A, Horn SD, Gassaway J, Smout RJ. Nutrition support (tube feeding) as a rehabilitation intervention. Objective: To describe site variation in use of enteral feeding and its association with stroke rehabilitation outcomes, controlling for a variety of confounding variables. Design: Prospective observational cohort study. Setting: Six inpatient rehabilitation facilities in the United States. Participants: Patients (N=919) from the Post-Stroke Rehabilitation Outcomes Project database with moderate or severe stroke who were discharged to home, community, or skilled nursing facility. Interventions: Not applicable. Main Outcome Measures: Change in total, motor, and cognitive FIM instrument scores and change in severity of illness. Results: Monitoring of nutritional status and the frequency of tube-feeding interventions for patients with moderate and severe stroke varied significantly among sites. Patients with tube feeding had higher severity of illness and lower functioning on admission compared with patients who did not receive tube feeding. However, when we controlled for severity of illness, admission FIM score, and other important covariates, we found that patients with severe strokes who were tube fed for more than 25% of their stay had greater increases in total, motor, and cognitive FIM scores and greater improvement in severity of illness by discharge. Conclusions: Nutrition support (tube feeding) is an effective therapy in rehabilitation service for patients with severe strokes and is associated with greater motor and cognitive improvements, even in patients with the most severe strokes. [Copyright &y& Elsevier]

Abstract: Hatfield B, Millet D, Coles J, Gassaway J, Conroy B, Smout RJ. Characterizing speech and language pathology outcomes in stroke rehabilitation. Objectives: To describe a subset of speech-language pathology (SLP) patients in the Post-Stroke Rehabilitation Outcomes Project and to examine outcomes for patients with low admission FIM levels of auditory comprehension and verbal expression. Design: Observational cohort study. Setting: Five inpatient rehabilitation hospitals. Participants: Patients (N=397) receiving poststroke SLP with admission FIM cognitive components at levels 1 through 5. Interventions: Not applicable. Main Outcome Measure: Increase in comprehension and expression FIM scores from admission to discharge. Results: Cognitively and linguistically complex SLP activities (problem-solving and executive functioning skills) were associated with greater likelihood of success in low- to mid-level functioning communicators in the acute poststroke rehabilitation period. Conclusions: The results challenge common clinical practice by suggesting that use of high-level cognitively and linguistically complex SLP activities early in a patient’s stay may result in more efficient practice and better outcomes regardless of the patient’s functional communication severity level on admission. [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]

Objective To investigate the effect of intensive peer mentoring on patient-reported outcomes of self-efficacy and unplanned hospital readmissions for persons with spinal cord injury/disease (SCI/D) within the first 6 months after discharge from inpatient rehabilitation. Design Randomized controlled trial. Setting Nonprofit inpatient rehabilitation hospital specializing in care of persons with SCI/D and brain injury. Participants Patients (N=158) admitted to the SCI/D rehabilitation program whose discharge location was a community setting. Participants (51% with paraplegia and 49% with tetraplegia) were 73% white and 77% men, with a mean age of 38 years. Interventions Participants in the experimental group received initial consult/introduction with a peer support program liaison and were assigned a peer mentor, who met with the participant weekly throughout the inpatient stay and made weekly contact by phone, e-mail, or in person for 90 days postdischarge. Participants also were encouraged to participate in regularly scheduled peer support activities. Nonexperimental group participants were introduced to peer support and provided services only on request. Main Outcome Measures General Self-efficacy Scale (adapted to SCI/D), project-developed community integration self-efficacy scale, and patient-reported unplanned rehospitalizations. Results Growth rate for self-efficacy in the first 6 months postdischarge was significantly higher for experimental group participants than nonexperimental group participants. Experimental group participants also had significantly fewer unplanned hospital days. Conclusions This study provides evidence that individuals receiving intensive peer mentoring during and after rehabilitation for SCI/D demonstrate greater gains in self-efficacy over time and have fewer days of unplanned rehospitalization in the first 180 days postdischarge. More research is needed to examine the long-term effects of this intervention on health care utilization and the relation between improved health and patient-reported quality of life outcomes. [ABSTRACT FROM AUTHOR]

Objective Peer support is an important adjunct to clinical care for people with disabilities, and may help address barriers to community reintegration. Peers offer positive role models and the benefit of learning from shared experiences of living with disability. Despite potential benefits, peer support is not consistently integrated in the rehabilitation process. This presentation describes three interventions recommended by patients, and directed by peer mentors, to promote successful community transition after rehabilitation for traumatic spinal cord injury (SCI). The interventions were one-to-one peer mentoring, a peer-directed patient education program, and a patient-centered Internet portal, providing access to peers, educational materials, and healthcare professionals for continuation of care post-discharge. The initiatives were undertaken to improve patient engagement in the care process, and to instill self-efficacy in their ability to effectively manage their own care needs. Experimental and quasi-experimental studies were undertaken to evaluate the impact of the three interventions. Material/Patients and methods The research setting is a large hospital specializing in neurorehabilitation of traumatic SCI or brain injuries. Research participants were patients admitted for neurorehabilitation after SCI. Approximately 500 SCI patients are admitted annually. In study one, 158 patients were randomized to receive usual care or to receive intensive one-to-one peer mentoring during and after their hospital stay. Over 40 former patients were trained as certified peer mentors. Peers met with patients at least one hour per week throughout the hospital stay. Additional face-to-face or telephone contacts were continued for up to 90 days post-discharge. In study two, 208 patients participated in a trial comparing traditional, didactic, nurse-directed education to a novel, peer-directed and patient-focused education program emphasizing transformative learning. The new program was implemented step-wise over three class topics–bowel and bladder care, skin care, and managing health concerns common in SCI, in order to evaluate the effects on patient engagement and healthcare outcomes. Study three involves working with peer mentors to design and build an internet portal to provide a constant connection for the patient to healthcare professionals, personalized health information, educational resources, and peer support. An interrupted time-series analysis will evaluate the impact of the portal on self-efficacy at discharge and healthcare outcomes up to 6 months post-discharge. Results Results of these interventions have been dramatic in improving patient engagement and self-efficacy to manage their own care needs. Significant reductions in secondary complications and hospital readmissions post-discharge have also been noted. Discussion/Conclusion Peer-directed self-management strategies appear to be effective and cost-effective in promoting successful community reintegration. Moreover, these strategies have contributed to a broader change in the organization's culture of patient-centered care and rehabilitation. [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 ... [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To describe the application of practice-based evidence (PBE) methodology to spinal cord injury (SCI) rehabilitation in the SCIRehab study, and to summarize associations of patient characteristics and treatment interventions to outcomes. Design: Prospective observational study. Setting: Six SCI rehabilitation centers. Participants: Patients with traumatic SCI (N=1376) admitted for first rehabilitation. Interventions: Not applicable. Main Outcome Measures: FIM and residence at discharge, and FIM, residence, Craig Handicap Assessment and Reporting Technique, work/school status, Patient Health Questionnaire-9, Diener Satisfaction with Life Scale, rehospitalization, and presence of pressure ulcers at 1 year postinjury. Results: Patient demographic and injury characteristics explained significant variation in rehabilitation outcomes, particularly functional outcomes. Regression modeling also identified a large number of significant associations with outcomes when total time in each discipline was modeled and when models were developed for each discipline, examining time spent in the many specific interventions provided by each discipline. Conclusions: The application of PBE methodology in the SCIRehab study provided extensive information about the process of inpatient SCI rehabilitation. While patient demographic and injury characteristics explain substantial variation in rehabilitation outcomes, particularly functional outcomes, significant relations also were found between the type and quantity of treatment interventions delivered by each rehabilitation discipline and a broad range of outcomes. [Copyright &y& Elsevier]

Abstract: Comparative effectiveness research (CER) has been receiving much attention (and government funding) in recent years, stemming from dissatisfaction with much medical and health care research, which does not produce actionable evidence that can be used by clinicians, patients, and policymakers. Rehabilitation research has been characterized by similar weaknesses and by often inadequate research designs. The SCIRehab study of the outcomes of inpatient spinal cord injury rehabilitation is one of a small number of rehabilitation practice-based evidence (PBE) studies in recent years that allows for the comparison of interventions by all disciplines for relevant real-life outcomes. This introduction to a series of articles resulting from the SCIRehab project discusses the need for and the nature of CER, and places the SCIRehab study and other PBE studies in the light of CER. After a description of the highlights of the analyses in this supplement, we provide a preliminary evaluation of SCIRehab, counting the articles and presentations from the study, the resources that went into this vast project, and the lessons learned that may benefit future rehabilitation PBE investigators. [Copyright &y& Elsevier]

Abstract: Hospice has become a major component of end-of-life care, but little scientific information is available to guide clinicians in knowing when the use of hospice is appropriate, in knowing how to measure the impact of its care, and in knowing which hospice interventions lead to the best outcomes. The National Hospice Outcomes Project (NHOP) arose from the need to identify patient factors and hospice interventions that are associated with better end-of-life outcomes. Clinical Practice Improvement (CPI) methodology allowed us to generate a large comprehensive database that could identify scientifically hospice interventions associated with better outcomes for specific patient populations. The complex interplay of patients, medical and complementary treatments, and families can be evaluated. This paper describes an overview of the research methods used for the NHOP, describes the project''s 13 clinical sites and study population of 1,306 patients, and presents some basic findings from the study. [Copyright &y& Elsevier]