Search

The National Center for Medical Rehabilitation Research recently celebrated its 20th Anniversary. The celebration included a symposium highlighting advances in rehabilitation science over the past 2 decades. The anniversary also reminds us of the challenges that remain in order to strengthen the foundation of disability and rehabilitation research. These challenges have been described in 3 reports published by the Institute of Medicine (IOM) in 1991, 1997, and 2007. Three areas of concern appear across the IOM reports. These include (1) the lack of a comprehensive disability monitoring program, (2) the need for better integration and coordination of federally supported disability research, and (3) funding levels that are inconsistent with the current and projected impacts of disability on individuals, families, and communities. In this commentary we examine the lack of progress in addressing the recommendations contained in the IOM reports. We conclude that renewed efforts by consumers, clinicians, educators, researchers, administrators, and policy makers are needed to achieve the promise of rehabilitation and disability science identified 20 years ago., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Medical necessity is a legal, not medical, term. Depending on the stakeholder's point of view, it may seem less about human need and dispensing medical care and more about a web of rules, rulings, regulations, and manuals, especially for Medicare patients, who use the lion's share of rehabilitation services. In other words, the term medical necessity seems, to some stakeholders, to refer more to what determines payment by Medicare instead of what should be done to determine optimal patient health. Such a perspective on medical necessity has major implications, considering that Medicare pays for most of the rehabilitation treatment in some 1200 inpatient rehabilitation facilities and that its policies determine which patients qualify for admission to an inpatient rehabilitation facility. Medicare's medical necessity policies are often described by inpatient rehabilitation facility administrators and physiatrists as complicated and unfair, as well as being demeaning to the standing of physicians. Ask some physiatrists about their patients meeting Medicare guidelines for medical necessity, and they might bark, "Medical necessity?! That's what I was taught to know!"

Objective: To describe changes in inpatient rehabilitation facility (IRF) outcomes due to the program interruption definitional change, from 30 days to 3 days, in 2002., Design: Secondary data analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database., Setting: Four hundred eleven IRFs that submitted data to the UDSMR database in each of the years 1998 through 2003., Participants: Patient assessment data for 772,584 Medicare fee-for-service beneficiaries., Interventions: None., Main Outcome Measures: The number of IRF patient discharges, percent of IRF patients discharged to the community, percent of IRF patients discharged to acute care, percent of IRF patients with program interruptions, percent of IRF inpatient deaths, and average IRF length of stay (LOS)., Results: IRF outcomes appeared to change because of the program interruption redefinition, with changes varying by impairment group. The largest changes due to the redefinition occurred for patients with traumatic spinal cord injury, including the largest percentage increase in patients (5.16%), the largest decrease in program interruptions (5.14%), the largest increase in acute care discharges (5.04%), and the largest mean decrease in LOS (1.27d). Community discharge showed the largest decrease for patients with Guillain-Barré syndrome (4.03%)., Conclusion: The change in the definition of program interruptions creates the appearance of changes in IRF performance and is important to consider when comparing the preprospective payment system (PPS) and PPS assessment data.

This is the third annual report describing patients discharged from subacute rehabilitation programs in the United States that subscribe to the Uniform Data System for Medical Rehabilitation (UDSmr). The analysis included 39,562 complete records of first admission cases discharged alive from 180 facilities in 1999. Sixty-five percent of the patients were women, and most patients (91%) were white. Sixty-two percent of the patients were 75 yr of age or older. Before the impairment onset, 55% lived with at least one other person. The average total FIM (motor and cognitive) score change for all patients was 21.1 points, and when stratified by rehabilitation impairment group, average scores ranged from 18.3 for patients with pulmonary conditions to 25.3 for patients with a joint replacement. The percentage of patients discharged to a community-based setting ranged from 67% for patients with stroke to 94% for patients with a joint replacement. These data show that patients receiving care in subacute rehabilitation programs show measurable functional improvement and that a high percentage of patients are discharged to community-based settings.

Objectives: To document patient, program characteristics, and therapy service provision in subacute rehabilitation across 3 types of facilities that provide subacute rehabilitation, to examine the determinants of therapy intensity, and to evaluate the contribution of rehabilitation services to functional gains., Design: A retrospective study linking administrative billing data and patients' functional assessment records., Setting: Twenty facilities part of the Uniform Data System for Medical Rehabilitation (UDSMR) subacute database, Participants: A total of 1976 billing records of patients with stroke, orthopedic, and debility impairments, discharged in 1996 and 1997, were retrieved and linked with the FIM trade mark instrument ratings from UDSMR subacute database., Interventions: Not applicable., Main Outcomes Measures: Total therapy intensity and Rasch-transformed FIM domain gains (ie, gains in self-care, mobility, cognition)., Results: Therapy intensity was mostly determined by impairment and facility type, although variances explained by the predictors were small. Patients in all 3 impairment groups made functional gains; gains were related weakly, although significantly, to therapy intensity and rehabilitation duration after controlling for other variables., Conclusions: The provision of rehabilitation therapies varied across facilities. Skilled nursing facilities with subacute rehabilitation units tended to provide more therapies than subacute units in acute or rehabilitation hospitals., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

This is the 10th annual report describing patients discharged from comprehensive medical rehabilitation programs in the United States that subscribe to the Uniform Data System for Medical Rehabilitation. The analysis included 298,973 complete records of first admission cases discharged alive from 676 facilities in 1999. The data show that patients receiving care in comprehensive rehabilitation programs show measurable functional improvement and that a high percentage of patients are discharged to community-based settings.

Objective: To develop an index that weights diagnostic information (International Classification of Diseases, 9th revision, Clinical Modification, or ICD-9-CM codes) by the extent to which it is expected to affect functional status and inpatient rehabilitation length of stay (LOS)., Design: Eleven nationally prominent physiatrists assigned ICD-9-CM codes to ordinal categories by expected effect on functional recovery. A resulting functional diagnostic complexity index score was calculated for each patient by combining the ranked values of each ICD-9-CM code in the discharge record. Analyses were stratified across the 20 rehabilitation impairment categories (RICs) of the Functional Independence Measure-Function Related Groups., Data: Patients (182,254) discharged from 465 inpatient rehabilitation units in larger hospitals and free-standing rehabilitation hospitals in 1995., Results: High degrees of diagnostic complexity were associated with low levels of functional independence at admission within each of 20 RICs (Spearman R = .06 to .25). Depending on RIC, patients in the highest (compared with the lowest) complexity category had up to a 35% increase in rehabilitation LOS after accounting for the primary medical reason for rehabilitation and severity of disabilities at admission., Conclusion: This prototype index of medical complexity offers a promising approach for analyzing the cumulative effects of diagnoses on patients' initial functional status and rehabilitation LOS.

Objective: To determine if diagnostic information provided in the form of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes improves rehabilitation length of stay (LOS) prediction when used in combination with the Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system., Design: Various models characterizing diagnostic information using ICD-9-CM codes were created that included individual ICD-9-CM codes and groupings of those codes by organ or etiology involved. Each method was evaluated using linear regression with the natural logarithm of LOS as the dependent variable. Separate validation data sets were held back to quantify the incremental effect of diagnosis when combined with the FIM-FRG classification system., Setting: Records from 252 rehabilitation facilities and hospital units across the nation., Patients: Analyses were undertaken using 82,646 records from patients discharged in 1992., Results: The addition of ICD-9-CM diagnostic information to the FIM-FRG classification system increased the variance explained by a maximum of 1.9%, from 31.5% to 33.4%., Conclusions: Refinement of the FIM-FRGs to include ICD-9-CM diagnoses does not appear warranted on the basis of the small increase in the percentage of explained variance in LOS. We believe the lack of improved prediction with the addition of ICD-9-CM codes relates primarily to incomplete coding practices and to the effect of patients' diagnoses being absorbed in variables as already expressed by the FIM-FRG system. Although ICD-9-CM codes, overall, did not greatly improve LOS prediction, they appeared to have some impact in certain impairment categories.

Objective: To evaluate the range, distribution, and unidimensionality of the items included in Version Five of the Functional Independence Measure (FIM) Mastery Test, a 54-item written examination used to determine FIM rating proficiency by professionals who administer the instrument., Study Design: Rasch analysis of the test results of 6,645 clinicians who took the FIM Mastery Test in 1996., Results: Overall, clinicians performed well on the test. When the mean item difficulty was centered at 50, and the test scores were calibrated to range from 0 to 100 logits, the mean person ability level was 77 logits. Fit statistics indicated that the test was unidimensional, measuring a common theme. While the item separation index value was 17, 22 items were not efficient in determining the clinicians' ability levels. Analysis of the logit values by the correct response showed that descriptions of Total Assistance (Level 1) and Complete Independence (Level 7) were easiest for clinicians to score correctly., Conclusion: The examination measures the common theme of FIM knowledge in a consistent manner. Further, the results suggest that the FIM Mastery Test may be shortened, perhaps by eliminating one of the three case studies, and improved by adding more challenging questions. In addition, FIM training should focus on distinguishing among levels 2 through 6, since clinicians had more difficulty identifying these levels.

Objective: To present a new version (2.0) of the Functional Independence Measure-Function Related Group (FIM-FRG) case-mix measure., Data Source/study Setting: 85,447 patient discharges from 252 freestanding facilities and hospital units contained in the 1992 Uniform Data System for Medical Rehabilitation., Study Design: Patient impairment category, functional status at admission to rehabilitation, and patient age were used to develop groups that were homogeneous with respect to length of stay. Within each impairment category patients were randomly assigned to one data set to create the system (through recursive partitioning) or a second set for validation. Clinical and statistical criteria were used to increase the percentage of patients classified, expand the impairment categories of FIM-FRGs Version 1.1, and evaluate the incremental predictive ability of coexisting medical diagnoses. Predictive stability over time was evaluated using 1990 discharges., Principal Findings: In Version 2.0, the percentage of patients classified was increased to 92 percent. Version 2.0 includes two new impairment categories and separate groups for patients admitted to rehabilitation for evaluation only. Coexisting medical diagnoses did not improve LOS prediction. The system explains 31.7 percent of the variance in the logarithm of LOS in the 1992 validation sample, and 31.0 percent in 1990 discharges., Conclusions: FIM-FRGs Version 2.0 includes more specific impairment categories, classifies a higher percentage of patient discharges, and appears sufficiently stable over time to form the basis of a payment system for inpatient medical rehabilitation.

Objective: To determine which factors related to departments of physical medicine and rehabilitation (PM&R) might contribute to the academic productivity of members of the teaching staff of those departments, and to develop an instrument that measures them., Design: Prospective, inception cohort., Setting: University medical center, academic PM&R departments., Participants: PM&R academic departments., Intervention: Over a 6-year period, seven PM&R departments volunteered to use this instrument to measure academic productivity at 2-year intervals. Rasch analysis was applied to the generated data., Main Outcome Measure: Measurable items that were included in questions of the scale fell into six categories: research funding and/or experience; scholarly productivity; equipment and facilities; quality of the training program for resident physicians; continuing education efforts in research methodologies and professional organizational participation; and departmental leadership. Rasch analysis was applied to evaluate a new outcome instrument to measure academic productivity in PM&R departments., Results: Twenty-eight of the original 42 questions survived the Rasch analysis and were retained. Questions were dropped either because they did not fit the Rasch analysis (4 of 42 questions) or because application of the Rasch analysis demonstrated that they were inappropriately or outstandingly easy (10 of 42 were inappropriately or outstandingly easy)., Conclusion: This shortened instrument of 28 questions fits the Rasch analysis, has questions that evently range from easy to very difficult, and addresses six measurable categories that are correlates of PM&R departmental influences on the academic productivity of the PM&R teaching staff.

The authors present a modular set of patient classification systems designed for medical rehabilitation that predict resource use and outcomes for clinically similar groups of individuals. The systems, based on the Functional Independence Measure, are referred to as Function-Related Groups (FIM-FRGs). Using data from 23,637 lower extremity fracture patients from 458 inpatient medical rehabilitation facilities, 1995 benchmarks are provided and illustrated for length of stay, functional outcome, and discharge to home and skilled nursing facilities (SNFs). The FIM-FRG modules may be used in parallel to study interactions between resource use and quality and could ultimately yield an integrated strategy for payment and outcomes measurement. This could position the rehabilitation community to take a pioneering role in the application of outcomes-based clinical indicators.

Objective: To develop a patient classification system that groups patients achieving similar functional outcome scores by discharge from medical rehabilitation., Design: Patient groups were developed using a recursive partitioning algorithm and clinical input. Results were validated in a separate set of patient records., Setting: Two hundred fifty-two free-standing rehabilitation hospitals and distinct part units that participate in the Uniform Data System for Medical Rehabilitation., Patients: The 84,492 rehabilitation inpatients discharged in 1992 were grouped into 20 impairment categories., Main Outcome Measure: Discharge score on the motor subscale of the Functional Independence Measure (FIM)., Results: In the Discharge Motor FIM-Function Related Groups (DMF-FRGs) system, patients are first classified into one of 20 impairment categories and then into FRGs by their admission motor FIM scores. Some FRGs are also subdivided on the basis of admission cognitive FIM scores and age. The entire system consists of 139 patient groups that explain 63% of the variation in motor FIM discharge scores in the validation data set. Nontraumatic brain injury and joint replacement DMF-FRGs are provided as examples., Conclusion: Clinicians can use the DMF-FRGs to identify groups of patients whose motor FIM scores at discharge are below, within, or above nationally established ranges of values for the purpose of outcomes management, guideline development, and quality improvement. The DMF-FRGs can also be considered in the design of an outcome-based payment system for medical rehabilitation.

This study evaluates the relationship of functional severity to patterns of functional gain and length of stay (LOS) for patients discharged from medical rehabilitation. It further compares differences in patterns between summed and Rasch transformed subscales of the Functional Independence Measure (FIM). Two different schemes of the FIM-Function Related Groups (FIM-FRGs) are used to define groups of patients who present with similar degrees of functional severity. The first scheme was developed using summed admission motor and cognitive FIM subscores (FIM-FRGs). The second scheme was developed by transforming these same motor and cognitive FIM subscores into logits (Logit FIM-FRGs), thus making FIM scores more equal-interval. The study included 32,494 patients who were discharged from 123 facilities that submitted data to the Uniform Data System for Medical Rehabilitation (UDSMR) and involved the separate evaluation of 18 different rehabilitation impairment categories. Motor FIM gain was calculated for each FRG in both schemes as the patient's discharge motor FIM score minus the admission motor FIM score. There were four patterns of motor FIM gain and two patterns of LOS across rehabilitation impairment. The most common pattern in both schemes was linear trend, for which median gains and LOS were highest for patients in the most disabled FRGs and lowest for patients in the least disabled FRGs. Gain patterns differed across impairment and across the two schemes. The motor FIM gain distributions provide clinicians with a range of typical functional outcomes for patients admitted to medical rehabilitation. This descriptive approach provides clinicians and administrators with a simple way to compare the motor FIM gain and LOS patterns of patients teated in local facilities with broad-based norms. This sample includes about one-quarter of rehabilitation facilities nationwide, thus representing population standards for facilities participating in the UDSMR. Suggestions are made on how to use these norms most appropriately for both facility and patient comparison.

The stability of the musculoskeletal form of the Medical Rehabilitation Follow Along (MRFA) instrument was examined in 47 patients receiving outpatient rehabilitation services. The MRFA instrument was designed to provide information on quality of daily living, including physical function, pain, satisfaction, and emotional/psychological well-being. The instrument consists of thirty questions and can be administered as an interview or a written questionnaire. The MRFA instrument was developed using Rasch analysis procedures and is an extension of previous research involving the Functional Assessment Screening Questionnaire. Forty-seven patients completed the musculoskeletal form of the MRFA on two occasions separated by an interval of 1 to 7 days. The stability of responses was examined using the intraclass correlation coefficient (ICC) and kappa. ICC values for the sections of the MRFA instrument examining quality of daily living and physical functioning ranged from 0.74 to 0.97. ICC values for items assessing pain and feelings of well-being were more variable, ranging from 0.36 to 0.93. The kappa values displayed a similar pattern. The overall stability of the MRFA instrument was found to be adequate for gathering screening information in outpatient settings. Additional research is necessary to confirm the findings of this investigation and extend the results to a larger outpatient population.

The Uniform Data System for Medical Rehabilitation (UDSmr) provides a method for uniform assessment of the severity of patient disability and the outcomes of medical rehabilitative care. The effectiveness and efficiency of medical rehabilitation services may be analyzed using the Functional Independence Measure (FIM), the functional assessment component of the UDS, and other data. Program evaluation models based on the UDSMR and the FIM are useful for measuring resource cost of disability.

The Functional Independence Measure-Function Related Groups (FIM-FRGs) were developed to classify medical rehabilitation inpatients into homogeneous groups based on length of stay (LOS). Patients are first grouped into clinically relevant rehabilitation impairment categories, then by functional status, as expressed by the FIM, and in certain cases by patient age. The statistical approach used to form the final groupings was a recursive partitioning algorithm applied to the FIM scores and patient age within impairment category. This analysis compares four FIM-FRG classification schemes developed from four scale sets that combine FIM items differently: (1) use of the 18 FIM items as separate variables, (2) the combination of FIM items into six clinical subscales, (3) the combination of the six clinical subscales into motor and cognitive subscales, and (4) the combination of all FIM items into a single scale. The FIM-FRG schemes explain similar amounts of variance in the logarithm of LOS and contain approximately equal numbers of FRGs. The motor and cognitive subscale scheme is recommended for use in payment, however, this scheme and the other schemes have additional uses. Each FRG scheme provides different insight into the clinical relationship between disability and LOS.

This article presents basic findings, concepts and methods in medical outcomes research. Epidemiologic outcomes research begins with the daily life of patients or populations and searches for antecedents. Clinical outcomes research begins with an intervention and examines effects. Both are needed. Issues and methodologies in medical rehabilitation outcomes research are examined, and topics for the forth-coming series are sketched. Medical rehabilitation can make substantial advances in understanding its effectiveness in the near future if it will undertake the needed comparative outcomes research.

Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.

This study describes development of a functional assessment instrument used to screen ambulatory care patients who have difficulty performing daily activities. Sample selection occurred in 2 stages. In the first stage, an interdisciplinary team used clinical selection criteria in order to screen patients into 2 groups: group 1, those likely to have functional limitations; and group 2, those not likely to have functional limitations. Using clinical selection criteria for a 3-week period in an ambulatory primary care setting, it was found that 20% of the outpatients seen fell into group 1. In the second stage, a randomly selected subsample of 194 persons was used, with 97 in group 1, and 97 in group 2. The Functional Assessment Screening Questionnaire (FASQ) was tested using this second sample. The FASQ was found to discriminate between the 2 groups, with those in group 1 having a significantly greater number of functional difficulties than those in group 2. An analysis was conducted to investigate which diagnostic problems were more likely to be associated with patients reporting functional limitations. Fourteen diagnostic patient problems found to be significantly more limiting than for the total sample were identified. The factor structure of the FASQ was examined and a format for clinically integrating the FASQ factors was offered.

In view of current emphasis on evaluation of benefits derived from rehabilitation programs, it is important that there be easily replicated measures for demonstrating the efficiency and effectiveness of services provided, as well as for transmitting information on patient functional status when transferring service responsibilities from one agency or facility to another. The authors used the PULSES profile and the Barthel index to measure severity of disability and to monitor rehabilitation progress in a heterogeneous sample of 307 severely disabled persons in 10 comprehensive medical rehabilitation centers, geographically selected. Gains in functional independence were registered for up to 2 years after admission. Cutting points of PULSES score totals or Barthel score totals distinguished the degree of severity of disability. The 2 scoring modalities appear valid, reliable, and sensitive for describing functional abilities and change over a period of time. They can be applied both to medical records and direct observations, and staff of medical facilities can readily be trained in their use.

Functional assessment measures of patients in a rehabilitation hospital were used to predict vocational status 18 months after discharge. The Granger adapted version of the Barthel index and the PULSES profile were administered to 118 disabled persons at discharge. Their total scores were correlated with vocational status measured by a scale of 1 to 6, ranging from unemployment to full-time employment. Analysis of data reveals that the Barthel index and sex (female) predicted vocational status 18 months after discharge (p < 0.05). PULSES showed no significant correlation with vocational status. Further analysis indicates that in a stepwise regression of independent variables on vocational status, the best predictors were the Barthel index, sex (female), age (the younger are more likely to pursue a vocation), contacts with state rehabilitation counselor, and contacts with Tufts counselor. Further studies are needed to examine specific subgroups of the physically impaired population seen by medical centers and state rehabilitation agencies.

The World Health Organization model of disablement was applied to patients 2 years after admission to rehabilitation centres. Various established measures were also applied. This study confirmed the usefulness of the concept of impairment, disability and handicap, as well as the applicability of the scoring methods in predicting rehabilitation outcome.

An on-stream method for describing patients' functional abilities is used to develop analyses of medical rehabilitation outcomes. Outcomes are the changes in status between admission, discharge and follow-up. Standardized observation and reporting make it possible to compare one date with another, one case with another or one agency or facility with another to determine program characteristics, effectiveness and efficiency.