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Background The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. Objective The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient’s transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. Methods The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers’ Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers’ burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors’ functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. Results Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. Conclusions This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. Trial Registration ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131 International Registered Report Identifier (IRRID) DERR1-10.2196/21799

BACKGROUND Effective poststroke rehabilitation care can speed patient recovery and minimize patient functional disabilities. Veterans affairs (VA) community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the 2 major sources of institutional long-term care for Veterans with stroke receiving care under VA auspices. OBJECTIVES This study compares rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus those Veterans in VA-contracted CNHs. RESEARCH DESIGN Retrospective observational. SUBJECTS All Veterans diagnosed with stroke, newly admitted to the CLCs or CNHs during the study period who completed at least 2 Minimum Data Set assessments postadmission. MEASURES The outcomes were numbers of days for rehabilitation therapy and restorative nursing care received by the Veterans during their stays in CLCs or CNHs as documented in the Minimum Data Set databases. RESULTS For rehabilitation therapy, the CLC Veterans had lower user rates (75.2% vs. 76.4%, P=0.078) and fewer observed therapy days (4.9 vs. 6.4, P

Objective To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning. Design Retrospective cohort study. Setting Veterans Affairs Medical Centers throughout the United States. Participants Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment. Main Outcome Measure Achievement of physical grade IV or above at final rehabilitation assessment. Results Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, ≤69 years=2, 70-79 years=1, ≥80 years=0; initial physical grade, I=0, II=3, III=4; initial cognitive stage, I or II=0, III=2, IV or V=3, VI or VII=4; absence of renal failure=1; no serious nutritional compromise=3; the type of rehabilitation services received, consultative=0, comprehensive=4; and recovery time between admission and discharge physical grade assessment, 1-2 days=0, 3-7 days=4, and ≥8 days=5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant ( P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score ≥9), second (score = 10-12), third (score = 13-15), and fourth (score >15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively. Conclusion By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.

Huanguang Jia,1 Qinglin Pei,1 Charles T Sullivan,1 Diane C Cowper Ripley,1 Samuel S Wu,1 W Bruce Vogel,1 Xinping Wang,1 Douglas E Bidelspach,2 Jennifer L Hale-Gallardo,1 Barbara E Bates3 1Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL, 2Physical Medicine and Rehabilitation Service, Department of Veterans Affairs, Washington, DC, 3Aleda E. Lutz VA Medical Center, Saginaw, MI, USA Introduction: Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors’ functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans’ health services as well as the geographic variation of the service utilization. Aim: The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care. Methods: This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans’ inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays. Results: The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p

Early childhood caries (ECC) is a significant national problem that disproportionately affects low-income children, and its prevalence is increasing (Tomar and Reeves 2009). ECC has significant short- and long-term adverse consequences (Tinanoff and Reisine 2009). ECC is associated with increased risk of future caries (Gray, Marchment, and Anderson 1991; Reisine, Litt, and Tinanoff 1994; O'Sullivan and Tinanoff 1996), missed school days (Gift, Reisine, and Larach 1992; Hollister and Weintraub 1993), hospitalization and emergency room visits (Sheller, Williams, and Lombardi 1997; Griffin et al. 2000), and, in rare cases, death (Casamassimo et al. 2009). These adverse outcomes are avoidable through ECC preventive services (ECCPS). A randomized clinical trial found that fluoride varnish treatment, combined with parent counseling, can reduce caries by up to 50 percent in high-risk children (Weintraub et al. 2006). National guidelines recommend that children have a dental visit by 12 months of age and receive preventive care at regular intervals thereafter (American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health 2008; American Academy of Pediatric Dentistry 2013). The most common recall interval is 6 months. However, the American Academy of Pediatric Dentistry recommends that children at higher caries risk get check-ups, including topical fluoride application, more often (American Academy of Pediatric Dentistry 2013). Medicaid eligibility has been identified as a risk factor for ECC (American Dental Association 2011). Untreated dental caries occurs among 25 percent of children living in poverty compared with 10.5 percent of children living above poverty (Dye, Li, and Thorton-Evans 2012). Comprehensive dental benefits are required in Medicaid and the Children's Health Insurance Program, which cover 35 percent of all U.S. children (DeNavas-Walt, Proctor, and Smith 2012), but only 31 percent of publicly insured children ages 0–5 years receive dental services (Centers for Medicare and Medicaid Services 2012). Although ECC is largely preventable (Savage et al. 2004; Weintraub et al. 2006; Azarpazhooh and Main 2008), it is difficult to reach preschool aged children for caries prevention. Publicly insured, preschool aged children are more likely to receive medical care than dental care (Bouchery 2012a,b). Consequently, 44 state Medicaid programs have implemented policies to reimburse medical primary care providers (M-PCPs), typically including physicians, physician assistants, and advanced registered nurse practitioners, to provide ECCPS. The specific services reimbursed varies across states but may include an examination of the oral cavity, caries risk assessment, anticipatory guidance, topical fluoride application, and referral to a dental home (American Academy of Pediatrics 2013). Despite widespread adoption, there is little scientific evidence on the effects of M-PCP reimbursement on ECCPS receipt, with published studies from only two states. A North Carolina study examined ECCPS receipt subsequent to policy implementation and found steady growth in the number of medical visits that included ECCPS, but it did not use a pre–post study design to evaluate changes in ECCPS receipt (Rozier et al. 2010). Studies of Wisconsin's Medicaid program, which used pre–post designs, found that M-PCP reimbursement was associated with increased claims rates for fluoride varnish treatment with almost one-half of the increase associated with M-PCPs (Okunseri et al. 2009, 2010). This study extends existing research by analyzing the effect of M-PCP reimbursement on ECCPS receipt for Medicaid-enrolled children in Texas and Florida, which are the second and fourth most populous states, respectively, and account for 15 percent of Medicaid-enrolled children nationally (Kaiser Family Foundation 2013; U.S. Census Bureau 2011). These states are among the most diverse with significant representation of African-American and Hispanic populations (Brewer and Suchan 2001), which disproportionately experience low access to dental care (Edelstein and Chinn 2009). In 2008, the Florida and Texas Medicaid programs implemented M-PCP ECCPS reimbursement for children ages 0–4 years. We used secondary data from these programs to test our central hypothesis that M-PCP reimbursement has improved access to ECCPS. Methodologically, we extend existing research by including a control group of children not subject to M-PCP reimbursement and adopting an analytic strategy that allows us to better isolate the treatment effect by controlling for intrinsic differences between the treatment and control groups, secular time trends, and differential time trends between the two groups. In addition to controlling for standard demographic characteristics, we also control for the children's health status and explicitly incorporate enrollment duration into our model.

Objectives To study the degree to which initial physical grades and cognitive stages of independence assessed by physical medicine and rehabilitation (PM&R) staff early after hospitalization for acute stroke relate to the decision to either provide rehabilitation in consultation or admission to a specialized rehabilitation unit (SRU) for comprehensive, high-intensity, multidisciplinary rehabilitation. Design An observational study. Setting Early rehabilitation assessment by PM&R staff during patients' acute hospitalization for stroke in 112 Veterans Affairs facilities. Patients The sample included 8,783 veterans who were assessed by PM&R staff. Methods Shortly after hospital admission, functional status was determined according to 7 physical grades and 7 cognitive stages of increasing independence. Patients' physical grades and cognitive stages ranged at initial PM&R assessment from the lowest and most dependent “I” through intermediate “II, III, IV, V, or VI,” and ended with the highest at total independence “VII.” To assess the statistically independent effects of physical grade and cognitive stage, a multivariable generalized estimating equation was applied to account for within Veterans Affairs facilities correlation and to adjust for demographics, stroke type, comorbidities, clinical events before PM&R assessment, and facility-related factors. Main Outcome Measurements The decision to admit patients to an SRU for comprehensive rehabilitation. Results Only 11.2% of those patients assessed after stroke were admitted to an SRU after the acute management phase. After statistical adjustment, patients at the lowest physical grade (I) of independence had a 9-fold increased odds of admission to an SRU compared with those at the highest combined physical grades VI/VII (adjusted odds ratio 9.15, 95% confidence interval 4.31-19.39). In contrast, patients at intermediate cognitive stages of independence were the most likely to be admitted to an SRU. The presence of an SRU within the treating Veterans Affairs facility was strongly related to admission. Conclusions Patients' physical grades and cognitive stages assessed early after stroke are strong determinants of referral for comprehensive rehabilitation.

Amputation is catastrophic and costly, resulting in loss of mobility and independence with the possibility of expensive treatment or being hospitalized for months. In an era of cost containment, policy makers are concerned with maintaining care quality while limiting expenditures.1 Lower extremity amputation accounts for more than $250 million in direct expenditures each year in healthcare costs in the US.2 Thus, understanding the factors associated with cost is critical to informed decision-making about maximizing service cost-efficiency, benefit, and positive outcomes. The objectives of this study were to identify patient- and facility-level factors associated with total inpatient costs and length of stay (LOS) among veterans who underwent lower extremity amputation in Veterans Affairs Medical Centers (VAMCs) nationwide. Our prior work documents the benefits of rehabilitation services in terms of survival, home discharge, receipt of a prescription for a prosthetic limb, and gains in functional improvement among veterans who underwent lower extremity amputation.3, 4 Andersen's Behavioral Model of Health Service Use5 formed the foundation for this work and was used to conceptualize the factors that determine need and lead to the use of health services measured as patients' total inpatient costs and LOS. Demographic factors were considered predisposing, while diagnostic and other clinical information were seen as driving health services need. We recognized that an understanding of the predisposing and need factors associated with total inpatient costs for these patients, including rehabilitation as an integral component of the overall continuum of care, could helps shed light on the quality implications of ongoing pressures to reduce both total inpatient costs and LOS. We hypothesized that there would be similar predisposing and need factors associated with total inpatient costs and LOS, but there could also be some differences among the factors associated with total inpatient costs and LOS. Limited information is available in the literature regarding the factors associated with total inpatient costs and LOS among veterans who undergo lower extremity amputation. Prior studies have shown that greater comorbidity is related to adverse outcomes such as in-hospital mortality and one-year survival,6-10 and that patients with more severe illnesses oftentimes require hospitalizations for a long period of time.6-8, 11 With respect to patients with lower extremity amputations specifically, information is quite limited. Only one study showed that LOS was associated with patients' payer source, amputation level, and injury characteristics.12 We were unable to find more recent studies on factors associated with total inpatient costs or LOS among veterans who underwent lower extremity amputation.

Veterans hospitalized for hip fracture repair may be discharged to one of several rehabilitation settings, but it is not known what factors influence postsurgical discharge setting. The purpose of the study was to examine the patient, facility, and market factors that influence the choice of postsurgical discharge setting. Using a retrospective cohort design, we linked 11,083 veterans who had hip fracture surgeries in a Department of Veterans Affairs (VA) hospital from 1998 to 2005 as assessed by the VA National Surgical Quality Improvement Program dataset with administrative data. The factors associated with five postdischarge settings were analyzed using multinomial logistic regression. We found that few veterans (0.8%) hospitalized for hip fracture were discharged with home health. Higher proportions of veterans were discharged to a nursing home (15.4%), to outpatient rehabilitation (18.8%), to inpatient rehabilitation (16.9%), or to home (48.2%). Patients were more likely to be discharged to nonhome settings for VA-provided rehabilitation if they had total function dependence, had American Society of Anesthesiologists class 4 or 5, had surgical complications prior to discharge, or lived in counties with lower nursing home bed occupancy rates. Future research should compare postsurgical and longer-term morbidity, mortality, and healthcare utilization across these rehabilitation settings.

Hip fractures in the elderly have high rates of mortality and perioperative complications. Both men and COPD patients have worse mortality and complications but this may be due to more co-morbid disease. We assessed mortality and complications in a large cohort (n = 12,646) of men undergoing hip fracture surgery within the Veteran's Health Affairs (VHA) to define the association of COPD to these outcomes after adjusting for other key factors. We looked for opportunities to improve outcomes for COPD patients.Using the VA Surgical Quality Improvement Program (VASQIP), and administrative databases, we determined COPD status, types of co-morbid conditions and surgical factors, and compared these to outcomes of surgical complications, 30-day and one-year mortality for patients who underwent hip fracture repair during 1998 to 2005.COPD was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the COPD was "severe: (indicated by functional disability, previous hospitalization for exacerbation, chronic drug treatment or record of FEV(1)75% predicted), and in 2,736 (21%) cases it was considered "mild" (any previous outpatient visit or hospitalization with a coded diagnosis of COPD). Severe COPD patients had one year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD subjects. Current smoking, use of general anesthesia and delays to surgery were significant modifiable risk factors identified in adjusted models. Osteoporosis was known pre-fracture in only 3% of subjects.COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications. Increased use of regional anesthesia and urgent scheduling of hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.

We examined the cost-effectiveness of a care coordination/home telehealth (CCHT) programme for veterans with diabetes. We conducted a retrospective, pre-post study which compared data for a cohort of veterans ( n=370) before and after the introduction of the CCHT programme for two periods of 12 months. To assess the cost-effectiveness, we converted the patients' health-related quality of life data into Quality Adjusted Life Year (QALY) utility scores and used costs to construct incremental cost-effectiveness ratios (ICERs). The overall mean ICER for the programme at one-year was $60,941, a value within the commonly-cited range of cost-effectiveness of $50,000–100,000. The programme was cost-effective for one-third of the participants. Characteristics that contributed to cost-effectiveness were marital status, location and clinically relevant co-morbidities. By targeting the intervention differently in future work, it may become cost-effective for a greater proportion of patients.

For the Department of Veterans Affairs (VA), traumatic brain injury (TBI) is a significant problem facing active duty military personnel, veterans, their families, and caregivers. The VA has designated TBI treatment as one of its physical medicine and rehabilitation special emphasis programs, thereby providing a comprehensive array of treatment services to those military personnel and veterans with TBI. Timely treatment of TBI is critical in achieving maximal recovery, and being in geographical proximity to a medical center with specialized TBI treatment services is a major determinant of whether such treatment is utilized. We present a mixed integer programming model for locating TBI treatment units in the VA. This model was developed for the VA Rehabilitation Strategic Healthcare Group to assist in locating new TBI treatment units. The optimization model assigns TBI treatment units to existing VA medical centers while minimizing the sum of patient treatment costs, patient lodging and travel costs, and the penalty costs associated with foregone treatment revenue and excess capacity utilization. We demonstrate our model with VA TBI admission data from one of the VA's integrated service networks, and discuss the expected service and cost implications for a range of TBI treatment unit location options.

Our objective was to determine the relationship between receipt of a prescription for a prosthetic limb and three-year mortality post-surgery among veterans with lower extremity amputation. We conducted a retrospective observational study that included 4,578 veterans hospitalized for lower extremity amputation and discharged in Fiscal Years 2003 and 2004. The outcome was time to all-cause mortality from the amputation surgical date up to the 3-year anniversary of the surgical date. There were 1,300 (28.4%) veterans with lower extremity amputations who received a prescription for a prosthetic limb within a year after the surgical amputation. About 46% (n=2086) died within three-years of the surgical anniversary. Among those who received a prescription for a prosthetic limb, only 25.2% died within 3 years of the surgical anniversary. After adjustment, veterans who received a prescription for a prosthetic limb were less likely to die after the surgery than veterans without a prescription with a hazard ratio of 0.68 (95% CI, 0.60-0.77). Findings demonstrated that veterans with lower extremity amputations who received a prescription for a prosthetic limb within a year after the surgical amputation were less likely to die within three years of the surgical amputation after controlling for patient-, treatment-, and facility-level characteristics.

Comprehensive rehabilitation services postacute stroke have been shown efficacious in European trials; however, their effectiveness in everyday practices in the United States is unknown. We compared outcomes of veteran patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services postacute stroke using propensity scores. Outcomes included change in patients' physical and cognitive independence after rehabilitation, discharge to home as opposed to other settings, and 1-yr posthospital discharge survival. Of the 2,963 patients in the study, 683 (23.1%) received comprehensive rehabilitation while the remaining patients received consultative services. We found, after propensity adjustment, that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 (95% confidence interval [CI]: 9.1 to 16.5) more points of physical independence on a 78-point scale and gained 1.5 (95% CI: 0.8 to 2.2) more points of cognitive independence on a 30-point scale. The likelihoods of discharge to home from the hospital (odds ratio [OR] = 1.61, 95% CI: 1.07 to 2.44) and 1-yr posthospital discharge survival (OR = 1.79, 95% CI: 1.25 to 2.56) were significantly higher among those who received comprehensive rehabilitation. Among patients hospitalized for acute stroke, comprehensive rehabilitation services are associated with greater recovery of physical and cognitive independence, improved home discharge likelihood, and improved 1-yr survival.

To develop a prognostic index for achievement of modified independence (Functional Independence Measure grade VI) after completion of either comprehensive or consultative rehabilitation after stroke.Retrospective cohort study.Veterans Affairs Medical Centers (VAMCs) throughout the United States.Data included 5316 patients with stroke discharged from VAMCs who received rehabilitation services while hospitalized and who were physically dependent at initial assessment. The index was derived with use of 60% of the sample and validated in the remaining 40% of the sample. Points derived from the β coefficients of a multivariable logistic model were added to scores that were associated with the probability of recovery.Recovery to modified independence or above at final rehabilitation assessment, defined as when patients no longer need physical assistance with eating; grooming; dressing the upper and lower body; toileting; sphincter management; bed to chair, toilet, and tub transfers; and walking/wheelchair use and when they require no more than supervision with bathing or climbing stairs.Seven independent predictors were identified through logistic regression in the derivation sample: initial physical grade (I or II = 0 points; III = 2 points; IV = 4 points; V = 5 points), initial cognitive stage (I or II = 0 points; III = 2 points; IV = 3 points, V or VI = 4 points; VII =5 points), type of rehabilitation (consultative = 0 points; comprehensive = 4 points), age (60 years = 3 points; 60-79 years = 2 points; ≥80 years = 0 points), time from initial to final physical grade assessment (1-2 days = 0 points; ≥3 days = 2 points), absence of urinary procedures (3 points), and absence of diabetes with complications (1 point). The following proportions of patients recovered to physical grade VI for the first, second, third, and fourth quartile scores, respectively: 0.59% (score ≤9), 3.87% (score = 9-11), 14.19% (score = 12-15), and 37.38% (score ≥16).Functional recovery to physical grade VI can be predicted on the basis of patients' initial status after a stroke occurs and the type of rehabilitation services to be provided by using a simple scoring system.

Objective: To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs. Design: Retrospective observational study. Setting: Veterans Affairs facilities nationwide. Participants: Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (NZ12,565). Intervention: Not applicable. Main Outcome Measure: Discharge location after hospitalization. Results: There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]Z1.23; 95% confidence interval [CI]Z1.11e1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (ORZ.04; 95% CIZ.03e.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (ORZ.61; 95% CIZ.50e.74) or other central nervous system hemorrhage (ORZ.78; 95% CIZ.63e.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (ORZ1.36; 95% CIZ1.07e1.73) were more likely to return home. Evidence of congestive heart failure (ORZ.85; 95% CIZ.76e.95), fluid and electrolyte disorders (ORZ.86;95% CIZ.77e.96),internalorgan procedures and diagnostics (ORZ.87; 95% CIZ.78e.97), and serious nutritionalcompromise (ORZ.49; 95% CIZ.40e.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge. Conclusions: We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning. Archives of Physical Medicine and Rehabilitation 2014;95:1277-82

Background Behavioral symptoms accompanying dementia are associated with increased health care costs, reduced quality of life and daily functioning, heightened family caregiver burden, and nursing home placement. Standard care typically involves pharmacologic agents, but these are, at best, modestly effective, carry serious risks, including mortality, and do not address behavioral symptoms families consider most distressful and which may prompt nursing home placement. Given dementia’s devastating effects and the absence of an imminent cure, the Veterans Administration has supported the development and testing of new approaches to manage challenging behaviors at home. Methods/Design The Tailored Activity Program – Veterans Administration is a Phase III efficacy trial designed to reduce behavioral symptoms in Veterans with dementia living with their caregivers in the community. The study uses a randomized two-group parallel design with 160 diverse Veterans and caregivers. The experimental group receives a transformative patient-centric intervention designed to reduce the burden of behavioral symptoms in Veterans with dementia. An occupational therapist conducts an assessment to identify a Veteran’s preserved capabilities, deficit areas, previous roles, habits, and interests to develop activities tailored to the Veteran. Family caregivers are then trained to incorporate activities into daily care. The attention-control group receives bi-monthly telephone contact where education on topics relevant to dementia is provided to caregivers. Key outcomes include reduced frequency and severity of behavioral symptoms using the 12-item Neuropsychiatric Inventory (primary endpoint), reduced caregiver burden, enhanced skill acquisition, efficacy using activities, and time spent providing care at 4 months; and long-term effects (8 months) on the Veteran’s quality of life and frequency and severity of behavioral symptoms, and caregiver use of activities. The programs’ impact of Veterans Administration cost is also examined. Study precision will be increased through face-to-face research team trainings with procedural manuals and review of audio-taped interviews and intervention sessions. Discussion The Tailored Activity Program – Veterans Administration is designed to improve the quality of life of Veterans with dementia and lessen the burden of care on caregivers. Activities are tailored to reflect the Veteran’s preserved capabilities and interests to enhance active engagement, while not taxing areas of cognition that are most impaired. Trial registration ClinicalTrials.gov, NCT01357564

Background Stroke mortality has been found to be much higher among residents in the stroke belt region than in the rest of United States, but it is not known whether differences exist in the quality of stroke care provided in Department of Veterans Affairs medical centers in states inside and outside this region. Objective We compared mortality and inpatient stroke care quality between Veterans Affairs medical centers inside and outside the stroke belt region. Methods Study patients were veterans hospitalized for ischemic stroke at 129 Veterans Affairs medical centers. Inpatient stroke care quality was assessed by 14 quality indicators. Multivariable logistic regression models were fit to examine differences in quality between facilities inside and outside the stroke belt, adjusting for patient characteristics and Veterans Affairs medical centers clustering effect. Results Among the 3909 patients, 28·1% received inpatient ischemic stroke care in 28 stroke belt Veterans Affairs medical centers, and 71·9% obtained care in 101 non-stroke belt Veterans Affairs medical centers. Patients cared for in stroke belt Veterans Affairs medical centers were more likely to be younger, Black, married, have a higher stroke severity, and less likely to be ambulatory pre-stroke. We found no statistically significant differences in short- and long-term post-admission mortality and inpatient care quality indicators between the patients cared for in stroke belt and non-stroke belt Veterans Affairs medical centers after risk adjustment. Conclusions These data suggest that a stroke belt does not exist within the Veterans Affairs health care system in terms of either post-admission mortality or inpatient care quality.

Background Some studies have found that older individuals are not as likely as their younger counterparts to be treated with some guideline-based stroke therapies. We examined whether age-related differences in inpatient quality of care exist among US veterans with ischemic stroke. Methods This was a retrospective study of a national sample of veterans admitted to 129 Veterans Affairs medical centers for ischemic stroke during fiscal year 2007. Inpatient stroke care quality was examined across 14 inpatient processes of care, including dysphagia screening, National Institutes of Health Stroke Scale (NIHSS) score documentation, thrombolysis, deep venous thrombosis prophylaxis, antithrombotic therapy by hospital day 2 and at discharge, early ambulation, fall risk assessment, pressure ulcer risk assessment, rehabilitation needs assessment, atrial fibrillation management, lipid management, smoking cessation counseling, and stroke education. Results Among the 3939 veterans with ischemic stroke, the mean age was 67.8 years (standard deviation, 11.5). The overall performance rate was >70% for 10 of the 14 quality indicators. In unadjusted analyses, older patients were less likely to receive lipid management, smoking cessation, NIHSS documentation, and early ambulation compared with younger patients; conversely, older patients were more likely to receive dysphagia screening and stroke education. After adjusting for demographic, clinical, and hospital level characteristics, the age-related differences in processes of care were less consistent; however, the youngest patients were more likely to receive smoking cessation counseling and the oldest patients were less likely to receive lipid management. Conclusions Risk-adjusted inpatient stroke care quality varies little with age for veterans admitted to a Veterans Affairs medical center for acute ischemic stroke.

Amputation of the lower extremity can be both psychologically and physically traumatic. It can present significant limitations to a person's self-image, self-care, and mobility. Patients must deal with the aftermath, the loss of part or the whole limb. Rehabilitation can help patients learn functional skills assisting in the adjustment to lower extremity amputation. There is a continuum of care that is needed after the surgery, including treatment during the surgical hospitalization and potentially after discharge from the hospital. Rehabilitation is a long difficult process and is an important component that can impact the long-term outcomes of amputees. The goal of rehabilitation during the immediate postoperative period is to return the individual to a lifestyle as functional as possible, and an early emphasis on rehabilitation can focus on preparing the individuals who are candidates for a prosthesis.1 For those patients who are not candidates for prosthetic rehabilitation, the goals may be more modest and may include mobility and activities of daily living independence at the wheelchair level. These patients often remain independent, which highlights the importance of training at the wheelchair level particularly among those who may not be prosthetic candidates.2 The stroke literature has documented the benefits of a standardized multidisciplinary high intensity approach to rehabilitation,3 but it has not been until recently that there is evidence of benefits of inpatient rehabilitation following lower extremity amputation. Dillingham and colleagues applied Medicare claims data to compare inpatient rehabilitation facility (IRF) outcomes to those of other post-acute care settings among dysvacular amputees receiving rehabilitation. After statistically controlling for initial patient characteristics, 1-year survival was significantly increased in those who received IRF care compared to those admitted to nursing homes or directly discharged home, as was the receipt of a prosthesis. Also, the number of non-amputation-related hospital admissions and re-amputations were reduced in patients discharged to IRFs relative to other settings.4 Among trauma-related amputees, typically a comparatively younger population, the number of nights in inpatient rehabilitation correlated with better vocational outcomes, improved role functioning, increased vitality, and decreased pain.1 Our studies among veterans with lower extremity amputations have also shown the benefits of receiving inpatient rehabilitation. In the Department of Veterans Affairs (VA), there are two types of inpatient rehabilitation services. Consultative services occur while patients remain on general medical or surgical bed sections, while specialized rehabilitation occurs on specialized rehabilitation bed units (SRUs). Compared to veterans who had no evidence of inpatient rehabilitation services, patients who received either consultative or specialized rehabilitation were more likely to be discharged home following the surgical amputation and survive to their one year amputation anniversary.5 We further demonstrated that patients who received rehabilitation services on SRUs had incremental benefits over those who received only consultative services. Patients treated on a SRU were more likely to be discharged home following the surgical hospitalization, receive a prescription for a prosthetic limb within one year post amputation, and show improvement in physical functioning at rehabilitation discharge using the Functional Independence Measure (FIM™).6 Those two studies showed benefits of rehabilitation services during the time immediately following the surgical amputation but prior to the surgical hospital discharge date. While conducting these studies, we learned that there is a high variability of the receipt of rehabilitation service, and we are uncertain of the determinants in the variability. Rehabilitation can be offered during a variety of times, in various places, and include a variety of service types. Thus, the Time, Place, and Type (TPT) framework was developed to gain a better understanding of these three inter-connected components as related to alternative patterns or pathways of care.5, 7 The timing of rehabilitation can be prior to the surgical amputation (preoperative), during the time period after the surgical amputation but prior to the surgical hospitalization discharge date (immediate postoperative), or after the surgical discharge date (late). Place can be inpatient, outpatient, nursing home, or home. Type of inpatient rehabilitation can be either consultative services on regular bed sections or specialized services on SRUs. In a subsequent study, we learned that patients who were admitted onto a SRU were more likely to have waited longer to have their first rehabilitation assessment after surgery and had moderate physical and cognitive disabilities during the immediate postoperative time period compared to those with the most or least severe disabilities. Patients who received only consultative rehabilitation during this time period were more likely to have previous amputation complications, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities.8 The next step would be to determine who and why patients need additional rehabilitation after receiving services during the immediate postoperative time period. This study addresses different elements of the TPT framework focusing on the receipt of inpatient rehabilitation services during both the immediate postoperative and late time periods. The objective of this paper was to determine what patient- and facility-level characteristics drive a late (timing) specialized (type) inpatient (place) rehabilitation episode among those veterans who already received immediate postoperative rehabilitation services, either consultative or specialized. We were unable to find other studies that looked at factors associated with the second inpatient stay in such veterans or non-veterans with lower extremity amputations.

Within the Veterans Health Administration (VHA), the top tier of postacute rehabilitation care is provided in acute rehabilitation bedservice units (ARBUs). The next level of care is provided in subacute rehabilitation bedservice units (SRBUs). We fitted reduced-form and structural models to explain VHA cost differences between ARBUs and SRBUs across time and for the individual cost components. We included sociodemographic variables, time since stroke onset, care facility, and the Functional Independence Measure at admission as explanatory variables. The multivariable results indicate that total index stay costs are lower in ARBUs by almost $6,000 (or approximately 25%) compared with SRBUs. Moreover, the lower costs observed in ARBUs in this study combined with the higher rates of guideline compliance and improved outcomes in ARBUs found in previous work suggest that stroke rehabilitation in an ARBU may be more cost-effective than stroke rehabilitation in an SRBU.

Berlowitz DR, Hoenig H, Cowper DC, Duncan PW, Vogel WB. Impact of comorbidities on stroke rehabilitation outcomes: does the method matter? Objectives To examine the impact of comorbidities in predicting stroke rehabilitation outcomes and to examine differences among 3 commonly used comorbidity measures—the Charlson Index, adjusted clinical groups (ACGs), and diagnosis cost groups (DCGs)—in how well they predict these outcomes. Design Inception cohort of patients followed for 6 months. Setting Department of Veterans Affairs (VA) hospitals. Participants A total of 2402 patients beginning stroke rehabilitation at a VA facility in 2001 and included in the Integrated Stroke Outcomes Database. Interventions Not applicable. Main Outcome Measures Three outcomes were evaluated: 6-month mortality, 6-month rehospitalization, and change in FIM score. Results During 6 months of follow-up, 27.6% of patients were rehospitalized and 8.6% died. The mean FIM score increased an average of 20 points during rehabilitation. Addition of comorbidities to the age and sex models improved their performance in predicting these outcomes based on changes in c statistics for logistic and R 2 values for linear regression models. While ACG and DCG models performed similarly, the best models, based on DCGs, had a c statistic of .74 for 6-month mortality and .63 for 6-month rehospitalization, and an R 2 of .111 for change in FIM score. Conclusions Comorbidities are important predictors of stroke rehabilitation outcomes. How they are classified has important implications for models that may be used in assessing quality of care.

Background and Purpose— Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. Methods— Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. Results— The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). Conclusions— Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

Background and Purpose— Evidence for ethnic disparities in stroke incidence, severity, and mortality has continued to mount in recent years. However, the picture for disparities in acute management and rehabilitation remains more ambiguous. The objective of this report is to summarize current evidence from stroke epidemiology and studies focusing on disparities in stroke care and disability, suggesting courses for action. Methods— A comprehensive search of current literature on ethnic/racial variation in stroke incidence, mortality, and severity, as well as acute and postacute patient care was performed. Results— Recent evidence unambiguously reaffirms a greater burden of disease in stroke, greater mortality, and greater severity of strokes for blacks. Evidence for disparities in acute and postacute care is less conclusive, as is the evidence for disparities among other ethnic groups. Evidence for health disparities in stroke care across settings, regions, and the continuum of care varies considerably. Conclusions— Minority ethnic groups have higher rates or more severe stroke, but variations in prognosis for clinical outcomes other than mortality remain less certain. There is considerable need for more studies that take into account regional ethnic variations in treatment and outcomes, and for better documentation of stroke outcomes among groups in addition to blacks. Dealing with ethnic disparities in stroke will be served by sustained attention to quality improvement in high-impact areas in stroke care, complemented by initiatives that promote cultural competence.

Background Individuals with a strong sense of coherence (SOC), which considers one's ability to respond to stressors by the appropriate use of adaptive coping resources, can avoid breakdown when confronted with stress. This study examined the associations between SOC, perceived burden (caregiver's perception of the effect of caregiving-related stress) and depressive symptoms of informal caregivers (family members and involved friends) of stroke survivors one-month after the stroke. Methods One-hundred and four ethnically diverse veterans who were hospitalized after experiencing an acute stroke and their informal caregivers were enrolled in the study prior to discharge. One-month after being discharged from one of five Veterans Affairs Medical Centers in Florida and Puerto Rico, comprehensive data was collected and analyzed. Results Multiple regression analyses showed that greater SOC was associated with both lower burden (p

The development of a national program to assure access to prenatal care for all women, regardless of income, is believed to be an effective means of reducing low birthweight and neonatal mortality in the U.S. Yet scarce empirical evidence concerning the effectiveness of large-scale prenatal care programs is available. This paper summarizes an evaluation of a statewide public prenatal care program xohich grew out of the federal Improved Preg- nancy Outcome (IPO) project. Using linked birth and infant death-certificate data, andIPOprogram records from a four-year period (1985-1988), this study compares the neonatal mortality rates of participan ts of Florida s IPO program with those of a matched comparison group. The results indicate an inverse relationship between IPO participation and the risk of neonatal mortality in a low-income population. These findings suggest that large-scale prenatal care programs can be effective in improving birth outcomes.

Misclassification of race and ethnicity in administrative data may produce misleading results if it is overlooked or ignored. In this study, we examined the racial/ethnic classifications of 1,084 veterans with stroke in Florida who received inpatient and outpatient services within the Department of Veterans Affairs (VA) healthcare system and who were also eligible for Medicare between 2000 and 2001. We compared the reliability of racial/ethnic classifications between VA inpatient data, VA outpatient data, and Medicare data. Our results showed that (1) the rate of unknown racial/ethnic classification in VA outpatient and inpatient data was high, (2) minimizing the unknowns by substituting known values from other data when available would greatly enhance the overall and individual classification reliability, (3) black and white classifications in the VA data had stronger agreement with Medicare data, and (4) Medicare data may under-represent Hispanic patients. Key words: administrative data, ethnicity, Department of Veterans Affairs, Medicare, race, racial/ethnic classification, reliability, Social Security Administration, stroke, validity, veterans. INTRODUCTION Stroke is one of the leading causes of death and major cause of serious and long-term disability in the United States population [1] as well as in the veteran population [2-3]. Numerous studies have shown racial/ ethnic disparities in stroke. In a recent study using a continuous annual household-based survey of the United States population from 1999 to 2001, McGruder et al. reported that racial/ethnic disparities existed in stroke prevalence, risk behaviors, and medical history [4]. In a recent selective review of literature published between 1991 and 2003, Stansbury et al. provided a broad perspective on race/ethnicity across the continuum of stroke care [5]. Their review confirmed the increased stroke incidence and mortality among black Americans and demonstrated the higher prevalence of hypertension among black and Hispanic patients and atrial fibrillation among non-Hispanic white stroke patients. Within the Department of Veterans Affairs (VA) healthcare system, Jones et al. examined racial variation and initial stroke severity among 982 veteran patients who received acute stroke care [6]. Using the Canadian Neurological Scale, Jones et al. showed that unadjusted scores were significantly lower for black patients than for white patients (7.96 vs 9.32, p = 0.04), which indicated greater stroke severity among black patients. Reports on racial/ethnic disparities in the use of stroke-related procedures and services showed mixed results. In an earlier study among a national sample of veterans with ischemic stroke, Oddone et al. reported that the likelihood of angiography for black patients was 47 percent that of white patients and Hispanic patients were only 75 percent as likely as non-Hispanic white patients to receive the procedure [7]. On the contrary, Goldstein et al. found no significant differences between white and nonwhite patients in the use of a variety of stroke-related procedures and services among 1,073 veterans diagnosed with acute ischemic stroke [8]. In two separate studies on racial/ethnic disparities in poststroke rehabilitation outcomes, Horner et al. showed that black veteran patients had greater residual physical deficits from stroke than white patients [9] and that low-income black veteran patients experienced poorer functional recovery over a 12-month period [10]. Most of these studies were based on data extracted from the VA inpatient and/or outpatient databases. Less, however, is known about the agreement of racial/ethnic classification for stroke patients between the VA inpatient and outpatient databases and Medicare data. Although the overall veteran population has been declining, VA healthcare enrollees have been increasing. The number of veteran patients age 65 and over is projected to increase rapidly in the next 10 years. …