Patient and Hospital Characteristics Associated with Assessment For Rehabilitation During Hospitalization for Acute Stroke

Transcription

1 Patient and Hospital Characteristics Associated with Assessment For Rehabilitation During Hospitalization for Acute Stroke Lead Author: Janet Prvu Bettger, ScD, FAHA Duke University ; janet.bettger@duke.edu ISC 2012, Wednesday, February 1, 2012, 8:42-8:54 a.m., Room Multidisciplinary Rehab Session, Oral Presentation #21

2 Disclosure Information Author Disclosure Information J. Prvu Bettger: Research Grant - AHRQ L. Kaltenbach, M. Reeves, E.E. Smith, G.C. Fonarow, E.D. Peterson: None L.H. Schwamm: Other; Modest (Chair, AHA GWTG, unpaid) The GWTG-Stroke program is provided by the AHA/ASA. The GWTG-Stroke program DISCLOSURE is currently supported INFORMATION: in part by a charitable contribution from Bristol- Myers Squib/Sanofi Pharmaceutical Partnership and the AHA Pharmaceutical Roundtable. GWTG-Stroke has been funded in the past through support from Boeringher-Ingelheim and Merck.

3 Patient and Hospital Characteristics Associated with Assessment For Rehabilitation During Hospitalization for Acute Stroke? Janet Prvu Bettger, Duke Univ; Lisa Kaltenbach, Duke Clinical Res Inst; Mathew Reeves, Michigan State Univ; Eric E Smith, Univ of Calgary; Gregg C Fonarow, UCLA; Lee H Schwamm, Massachusetts General Hosp; Eric D Peterson, Duke Clinical Res Inst.

4 We know Stroke is a leading cause of serious, long-term disability among adults in the U.S. 3 of 4 stroke survivors are dependent at some level for self-care 15-30% of adult stroke patients report severe disability post-stroke Rogers et al., Circulation 2011

5 We also know: Rehabilitation initiated early following stroke can enhance the recovery process and minimize functional disability Better clinical outcomes when stroke patients receive coordinated, multidisciplinary evaluation and intervention in organized and coordinated inpatient rehabilitation (Evans et al., Lancet 2001; Langhorne & Duncan, Stroke 2001; Prvu Bettger & Stineman, Archives PMR 2007; Teasell et al., Top Stroke Rehabil. 2003

6 Should we be looking at the delivery of rehab in acute care?

7 all acute ischemic and hemorrhagic stroke patients be assessed for rehabilitation services as early as medically and neurologically possible to ensure optimal outcomes AHCPR 1995; Duncan et al., Stroke 2005; Schwamm et al., Stroke 2005

8 Purpose of the study: To examine the degree and determinants of an acute assessment for rehabilitation following acute stroke

9 Overview Prospective cohort of patients with data documented as part of the GWTG-Stroke program initiated and supported by AHA ongoing, voluntary, continuous registry and QI initiative for acute hospitals Outcome Sciences, Inc. = data collection and coordination center DCRI = data analysis center

10 Documentation of Rehab in Acute Care

11 Defined As

12 Study Population Patients admitted to a GWTG-Stroke participating hospital 01/01/08-03/31/11 962,856 stroke admissions from 1540 participating hospitals Excluded: patients with TIA (N=206,217) no stroke related dx (N=18,180) died in-hospital (N=65,680) left AMA, missing d/c code or date (N=13,005) transfers (N=65,280)

13 616,982 eligible stroke admissions from 1523 GWTG-Stroke participating hospitals Median age = 72 years (IQR 60-82) 52% female 70% White 3.5% unable to ambulate prior to stroke Sample

14 Are Stroke Patients Being Assessed For Rehabilitation In The Acute Hospital? Assessed for Rehabilitation N=552,222 Not Assessed for Rehabilitation N=64, % 10.5%

15 Multivariate Model (Strongest Predictors) Characteristics Independently Associated With the Receipt of An Assessment for Rehabilitation Variable OR 95% CI P-value Patient Characteristics Age (per 10-year increase) <.0001 In rehab setting or LTC prior <.0001 Medical History Unable to ambulatory prior to <.0001 admission (ref. = independent) Atrial Fibrillation or Flutter <.0001 Diabetes Mellitus <.0001 Hospital Characteristics Received Care in a Stroke Unit <.0001 C =0.6843

16 Looking a little closer

17 Patient Sociodemographics Variable, Level Assessed for Rehabilitation Not Assessed for Rehabilitation Socio-demographics N=552,223 N=64,760 Age in years, Mean (STD) 69.5 (14.7) 75.5 (15.3) Gender, Female 51.3% 59.0% Race and Ethnicity White 69.2% 76.9% Black or African American 17.0% 10.5% Other Race 13.8% 12.6% Health Insurance* Self Pay/No Insurance 6.6% 3.8% Medicare 40.9% 47.2% Medicaid 8.7% 7.8% Private/VA/Other 43.9% 41.1% Admitted from post-acute or LTC 5.7% 18.5%

18 Preadmission Clinical History Medical History (Obtained On Admission) Assessed for Rehabilitation N=552,222 Not Assessed for Rehabilitation N=64,760 Pre-stroke ambulatory status* Unable to ambulate 2.8% 9.5% Ambulating with person assist 4.7% 8.8% Ambulating independently 80.1% 62.1% Previous Stroke/TIA 32.1% 35.7% Atrial Fibrillation or Flutter 16.6% 26.3% CAD or Prior MI 26.4% 29.6% Diabetes Mellitus 33.3% 28.5% Dyslipidemia 43.0% 38.7% Heart Failure 7.7% 12.0% Hypertension 81.3% 79.6% Peripheral Vascular Disease 4.7% 5.8% Smoker 20.6% 13.0%

19 Status on Admission Stroke Symptoms resolved on admission* Assessed for Rehabilitation N=552,222 Not Assessed for Rehabilitation N=64,760 Ambulatory status at admission* Unable to ambulate 18.6% 33.2% Ambulating with person assist 16.3% 7.0% Ambulating independently 24.0% 16.6% Stroke symptoms resolved* 5.4% 5.0% 1st NIHSS total score, Mean (STD)* 6.5 (6.8) 13.9 (10.5) *Missing data

20 Variable, Level Hospital Characteristics Assessed for Rehabilitation N=552,222 Not Assessed for Rehabilitation N=64,760 Care Delivery % % NIHSS Total Score Documented Patient had a Stroke Consult* Received Care in a Stroke Unit* Received Thrombolytic Therapy Comfort care measures only Length of Stay, Mean # of days (STD) 6.2 (7.34) 5.6 (6.9) Structural Characteristics % % Hospital Beds, Mean # (STD)* (337.1) (336.3) Geographic Region of the Country West South Midwest Northeast Hospital Type, Academic* Urban Designation by RUCA Codes

21 Discharge Disposition Referred for Rehabilitation at Discharge Assessed for Rehabilitation N=552,222 Not Assessed for Rehabilitation N=64,760 No rehabilitation (discharge home no services) Discharged to Post-acute care: (inpatient rehabilitation unit or facility) (26.0) (2.3) (skilled nursing facility or (20.4) (13.7) Medicare equivalent subacute unit [swing bed]) (0.3) (0.2) (home with home health) (11.5) (2.8) (long term acute hospital) (1.2) (1.0) No rehabilitation: discharge to hospice discharge to long-term care

22 CONCLUSIONS Nearly all patients had documentation of an assessment for rehabilitation or that rehabilitation services were provided Care in a stroke unit increased the likelihood of an assessment Older age and hx of afib. decreased the likelihood Patients admitted from LTC or post-acute care or who were unable to ambulate prior their stroke admission were half as likely to be assessed

23 PRACTICE IMPLICATIONS What does assessed for rehabilitation mean? Patients who have had an ischemic or hemorrhagic stroke with resultant impairments and limitations in activities, as identified on the brief assessment, should be referred to rehabilitation services for an assessment of rehabilitation needs. 1. Assess function 2. Refer to rehab Duncan, Stroke Rehab Clinical Practice Guidelines, 2005

24 Measurement of Practice Improve clarity in coding instructions for acute hospitals documenting rehab assessment E.g., transfer or referral to rehab assessment of rehab need was completed Standardize the assessment process (physician or nursing assessment of function refer for assessment by rehab team stroke team makes an informed decision about acute care goals/needs and appropriate post-acute services) Determine optimal methods for supporting acute hospitals toward evidence-based care

25 POLICY IMPLICATIONS Several U.S. stroke initiatives require documentation of a rehabilitation assessment Paul Coverdell National Acute Stroke Registry (2004) The Joint Commission for acute hospital stroke center certification (2006) Endorsed by the National Quality Forum (2008) AHA GWTG-Stroke hospital-based data registry and quality improvement program (2008) Inclusion/exclusion for each differs slightly and differs from clinical recommendations In this study: 89.5% could easily have been 96% (e.g., inclusion of d/c to rehab, exclude d/c to hospice)

26 POLICY IMPLICATIONS (continued) Opportunity exists for all acute stroke quality initiatives to achieve consensus on defining an evidence-based quality measure that will best support patient-centered outcomes and appropriate use of rehabilitation services both in the hospital and after discharge. More stringent and specific measures needed Function assessed (mobility, self-care, communication & cognition) Referred to rehab team Time to receipt of rehabilitation Future measure to evaluate quality of rehab in acute care

27 FUTURE RESEARCH Identify indicators of referral to rehab team Determine what is an assessment for rehab Differentiate who receives rehab in acute care only, post-acute only, or both Examine how decisions made in acute care impact patient and health system outcomes

28 ACKNOWLEDGEMENTS Special thanks to AHA for supporting the analyses Thanks to the statistical team and mentorship at DCRI Support Dr. Prvu Bettger from the AHRQ Comparative Effectiveness Research Mentored Scholar Program (K12HS019479, PI: Oddone).