Factors affecting return to living alone after medical rehabilitation: A cross-validation study.

Objective: To cross validate and extend the authors' finding that cognition is one of the best predictors of return to living alone after medical rehabilitation. Design: A prospective sample of live-alone older medical rehabilitation patients followed from admission to discharge. Logistic regression identified significant predictors of return to living alone, and measures of predictive power were calculated. Setting: Stroke and geriatric units of a free-standing urban medical rehabilitation hospital. Participants: One hundred ninety-four older consecutively admitted medical rehabilitation patients 60 years old or older. Main Outcome Measure: Return to living alone versus discharge to living with others. Results: Consistent with the authors' original findings, both cognition and self-care motor skills were significant predictors of return to living alone. Cognition acted as a suppressor variable, leading to age and education effects only when entered into the regression equation. New variables did not add significantly to prediction. Conclusion: The value of rehabilitation psychologists' role in making cognition-based recommendations about discharge disposition in live-alone older adults is supported by findings from this study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Functional outcome after brain tumor and acute stroke: a comparative analysis

OBJECTIVE: To compare the functional outcome, length of stay, and discharge disposition of patients with brain tumors and those with acute stroke. DESIGN: Case-controlled, retrospective study at a tertiary care medical center inpatient rehabilitation unit. SUBJECTS: Sixty-three brain tumor patients matched with 63 acute stroke patients according to age, sex, and location of lesion. MAIN OUTCOME MEASURES: The functional independence measure (FIM) was measured on admission and discharge. The FIM change and FIM efficiency were also calculated. The FIM was analyzed in three subsets: activities of daily living (ADL), mobility (MOB), and cognition (COG). Discharge disposition and rehabilitation length of stay were compared. RESULTS: Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and stroke populations with respect to total admission FIM, total discharge FIM, change in total FIM, or FIM efficiency. The admission MOB-FIM was found to be higher in the brain tumor group (13.6 vs 11.1, p = .04), whereas the stroke group had a greater change in ADL-FIM score (10.8 vs 8.3, p = .03). The two groups had similar rates of discharge to community at greater than 85%. The tumor group had a significantly shorter rehabilitation length of stay than the stroke group (25 vs 34 days, p < .01). CONCLUSION: Brain tumor patients can achieve comparable functional outcome and rates of discharge to community and have a shorter rehabilitation length of stay than stroke patients.     

Assessment of functional abilities among geriatric patients: A MIMIC model of the functional independence measure.

Objective: To investigate the influence of population heterogeneity among geriatric patients on the factor structure and differential item functioning on the Functional Independence Measure (FIM) and thereby evaluate the appropriateness of using 2 factor composite scores (FIM motor and FIM cognition) among geriatric patients. Design: A specific application of structural equation modeling (i.e., multiple indicators, multiple causes [MIMIC] model) was conducted on FIM admission scores from 718 geriatric rehabilitation patients. Setting: A large urban rehabilitation hospital. Participants: 718 inpatients referred for medical rehabilitation (M?=?77.5 yrs; 62% African American; 68% female). Measurements: All participants' functional abilities were rated on the FIM by trained physical and occupational therapists on admission to the rehabilitation hospital. In addition, all patients completed the Geriatric Depression Scale. Results: Three motor functioning items and 3 cognitive functioning items differed systematically across groups within this geriatric sample (i.e., young-old vs old-old, male vs female, depressed vs nondepressed) even after controlling for group differences on levels of overall motor and cognitive functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors for functional outcome in older rehabilitation patients.

Medical rehabilitation may serve to distinguish older adults capable of independent living from those in need of assistance. Return to independent living was evaluated in 372 older patients, all of whom lived alone before admission. For persons discharged alone, admission performance on the Functional Independence Measure was the only significant predictor of discharge self-care. For those discharged with supervision, age, memory, and depression were also significant predictors of discharge self-care. Thus, older live-alone patients may progress at different rates over rehabilitation, and psychosocial problems may foreshadow loss of independence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system

OBJECTIVES: Function-related groups based on the Functional Independence Measure have been proposed as a model for a prospective payment system for medical rehabilitation. This study describes discharge destination and motor function outcomes in a sample of patients with stroke from the FIM-FRG STR1 classification. STUDY DESIGN: A retrospective review of 293 cases of stroke from the years 1993 to 1995. The demographic and outcome characteristics of this sample were described. RESULTS/CONCLUSIONS: Forty-five percent of the patients were discharged to home after a mean length of stay of 23.8 days in acute medical rehabilitation. Patients who were discharged home had higher admission and discharge motor FIM scores than those discharged to a subacute facility or long-term care facility, although the correlation between motor FIM score and discharge destination was low to moderate. Median discharge motor FIM scores indicate considerable residual disability in this classification after rehabilitation. Research problems that address methods to improve the usefulness of the FIM-FRG system in a prospective payment system are discussed.     

Predicting discharge and long-term outcome patterns for frail elders.

Objectives: Using the framework of environmental press theory to examine the predictive value o medical rehabilitation team assessments for both functional abilities and long-term living arrangement of early return home and late return home elders. Participants: One hundred thirty-five older adults (72% women, 84% African American; mean age = 73 years) who lived alone prior to hospitalization to medical rehabilitation. Methods: Competency measures were collected during the hospitalization. Living arrangements were determined by phone follow-up at 3, 6, and 18 months after discharge. Multivariate analysis of variance identified early return and late return patient groups. Logistic regression analyses then determined the clinical utility of the prediction model. Chi-square analyses addressed group differences in stability of living arrangements. Results: Medical burden, functional abilities, and cognition were significant predictors of group membership. Among late return patients, 27% continued to live alone at the 18-month follow-up; 59% of the early return patients did so. Conclusions: Interdisciplinary assessments (including psychological measures) completed in the hospital provide valuable data for discharge planning for older medical rehabilitation patients and are clearly... (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Posttraumatic amnesia: its relation to functional outcome

OBJECTIVE: To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS: Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES: Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS: Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION: Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.     

A comparative study of postmortem MR imaging and pathological examination of human brain specimens

OBJECTIVE: To determine typical outcome "benchmarks" for 18 functional tasks in patients undergoing stroke rehabilitation. The benchmarks are intended to serve as points of reference to which the outcomes of patients with similar impairments and degrees of disability can be compared. SUBJECTS: Records from 26,339 stroke patients discharged from 252 inpatient facilities across the United States that submitted 1992 data to the Uniform Data System for Medical Rehabilitation. METHODS: Stroke impairment was detailed as the presence or absence of hemiparesis resulting from stroke and the side(s) of involvement. Within each of five stroke impairment categories, patients were further classified by the Functional Independence Measure-Function-Related Groups (FIM-FRGs) into nine syndromes by degree of disability (admission motor and cognitive FIM scores) and by age. Outcomes were determined for each stroke syndrome at patients' discharge from medical rehabilitation. MAIN OUTCOME MEASURES: Patients' median performance levels on each of the 18 items making up the FIM, length of stay, and community discharge rates. RESULTS: The majority of patients whose admission motor FIM scores were above 37 were able to eat, groom, dress the upper body, and manage bladder and bowel functions independently by discharge. In addition to these tasks, most of those whose motor FIM scores were above 55 were able to dress the lower body, bathe, and transfer onto a chair/bed or toilet. The majority of patients whose initial motor FIM scores were above 62 points and whose cognitive FIM scores were above 30 gained independence in most tasks, including stair climbing and tub transfers. Community discharge rates ranged from 51.6% for the group of patients with the most severe disabilities to 99.2% for the group with the least severe disabilities. CONCLUSION: The clinician can apply these benchmarks to guideline development and quality improvement, and in establishing patient goals.     

Increased serum levels of macrophage colony-stimulating factor (M-CSF) in alpha- and beta-thalassaemia syndromes: correlation with anaemia and monocyte activation

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.     

Evaluating the FONE FIM: Part II. Concurrent validity & influencing factors

The "motor" (activities of daily living) component of the FONE FIM, the telephone version of the Functional Independence Measure (FIM) was evaluated in a cohort of 132 patients who had been discharged to home from a geriatric inpatient assessment and rehabilitation program. In the current study, Rasch person ability measures were derived from telephone assessments 5 weeks after discharge and in-home assessments 1 week later. Concordance between the modes was shown to be satisfactory for the Rasch measures based on intraclass correlation coefficients. However, the telephone mode consistently generated lower estimates than did the observational mode. This was due to the fact that the telephone mode underestimated motor function for the majority of patients who were at higher levels of cognition and motor function, but overestimated for patients who were at lower levels of cognition and motor function. At the item level, concordance, as determined by Kappa statistics, was better when the FONE FIM responses came from the patient rather than proxy respondents, and when the assessments were done by more experienced rather than less experienced raters. Based on these findings, a mixed strategy, the telephone mode for patients capable of responding to the FONE FIM and in-home assessments for those who are incapable, is recommended.     

Depression and Activities of Daily Living Predict Rehospitalization Within 6 Months of Discharge From Geriatric Rehabilitation.

Objective: Examine baseline predictors of rehospitalization over the first 18 months postdischarge. Study Design: Prospective longitudinal study. Participants and setting: Consecutive admissions (n = 194) to an urban medical rehabilitation hospital over the age of 60 and living alone prior to rehabilitation. Main Outcome Measure: Rehospitalization over 3 time periods (0-3 months, 3-6 months, 6-18 months postdischarge). Results: Rehospitalization during the initial 3 months postdischarge was predicted by baseline limitations in activities of daily living (ADLs). Patients with depression at baseline were more likely to be rehospitalized during the 3- to 6-month period than were nondepressed patients. No significant predictors of rehospitalization were detected for the 6- to 18-month period. Conclusions: ADL limitations and depression are significant prognostic indicators of postdischarge outcome in geriatric rehabilitation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital

OBJECTIVE: The study examined predictors of discharge against medical advice (AMA) and outcomes of psychiatric patients with AMA discharges, as measured by poorer symptom ratings at discharge and higher rates of rehospitalization. METHODS: A total of 195 patients discharged AMA from general hospital psychiatric units were compared retrospectively with 2,230 regularly discharged patients. AMA status was defined as signing out against medical advice, being absent without leave, or being administratively discharged. All patients received standardized assessments within 24 hours of admission and at discharge. Demographic characteristics, psychiatric history, DSA-IV psychiatric and substance use diagnoses, and scores on an expanded 32-item version of the Psychiatric Symptom Assessment Scale were compared. RESULTS: The groups did not differ in primary psychiatric diagnoses. Patients discharged AMA were significantly less likely to be Caucasian or to be functionally impaired due to physical illness. They were more likely to live alone, have a substance use diagnosis, use more psychoactive substances, and have more previous hospitalizations. Patients discharged AMA had significantly shorter lengths of stay, higher rehospitalization rates, and more severe symptoms at discharge, even when length of stay was taken into account. The differences between the groups in male gender and young age were better accounted for by a greater likelihood of substance abuse in these groups. CONCLUSIONS: The results suggest a profile of patients who may be discharged AMA. Such patients have worse outcomes and are more likely to be high utilizers of inpatient resources. Aggressive identification of patients likely to be discharged AMA and early discharge planning for appropriate outpatient treatment are recommended.     

Trunk control test as an early predictor of stroke rehabilitation outcome

BACKGROUND AND PURPOSE: The aim of this study was to investigate the construct and predictive validity of the Trunk Control Test (TCT) in postacute stroke patients by comparing TCT scores at admission and discharge with the Functional Independence Measure (FIM) scores. METHODS: Forty-nine patients participated in the study. The TCT examines four movements: rolling from a supine position to the weak side (T1) and to the strong side (T2), sitting up from a lying-down position (T3), and sitting balance (T4). The FIM is an 18-item scale (13 motor [motFIM] and 5 cognitive [cognFIM]) used to determine the level of dependence of patients in daily life. RESULTS: Thirty-six patients (73%) increased their TCT overall score at discharge. The TCT item-total correlations were high, both at admission and discharge (P < .0001). The individual TCT items were intercorrelated. Furthermore, the homogeneity of the TCT was confirmed by a high Cronbach's index. High correlations were found between admission and discharge scores in the different tests (TCT, FIM, and motFIM; P < .0001) and between TCT at admission and FIM (P < .0001) and motFIM (P < .0001) at admission. TCT at admission alone explained 71% of the variance in motFIM at discharge. CONCLUSIONS: The TCT showed a good sensitivity to change in assessing recovery of stroke patients. The high item-total correlation and Cronbach's alpha value of the TCT suggest that there is one homogeneous construct underlying the item list. The TCT construct validity was confirmed by the correlation between this test and the FIM scores. TCT at admission predicted motFIM at discharge even better than motFIM at admission alone. Possibly, the TCT captures basic motor skills that foreshadow the recovery of more complex behavioral skills described by the FIM.     

The role of cognition in predicting activities of daily living and ambulation functioning in the oldest old rehabilitation patients.

Examined what demographic, medical, cognitive, and affective measures predicted activities of daily living (ADL) and ambulation for 60 geriatric rehabilitation inpatients (aged 85 yrs or older) at discharge. Ss completed the Geriatric Depression Scale, Dementia Rating Scale (DRS), and Functional Independence Measure. Cognition, as measured by the DRS, was the only significant predictor of both ADL and ambulation scores. Gender was correlated with ADL skills, indicating that women attained higher ADL scores, while men did better on ambulation skills. DRS scores accounted for 8% of ADL variance and 16% of ambulation variance, above and beyond demographic and medical variables. Depression was a poor predictor of functional skills among this sample, few of whom were depressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Classifying rehabilitation inpatients by expected functional gain

OBJECTIVES: To create a more suitable payment system for medical rehabilitation, the authors developed a companion classification system to the original functional independence measure-function-related groups (FIM-FRGs), which classify patients having similar lengths of stay in a rehabilitation hospital or inpatient unit. The companion system presented here groups patients according to their gains in functional status during the rehabilitation stay. METHODS: Data from 84,492 patients discharged from 252 rehabilitation facilities in 1992 were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The gain-FRGs system used four predictor variables: (1) diagnosis leading to disability, admission scores on the (2) motor and (3) cognitive subscales of the FIM, and (4) patient age. RESULTS: The gain-FRGs system contained 74 patient groups and explained 21% of the variation in functional gain for patients in a different set of records withheld for validation. CONCLUSIONS: The gain-FRGs system should be considered for prospective payment systems because it gives the provider an incentive to improve patient outcomes, which is missing in a payment system based on FIM-FRGs alone.     

Analysis of Likert scale data in disability and medical rehabilitation research.

Many clinical evaluations are subjective, resulting in ordinal level measurements. A widely used example in medical rehabilitation is the Functional Independence Measure (FIM), which provides a measure of disability. The FIM is an 18-item, 7-point Likert scale ranging from complete dependence to complete independence. Parametric statistics are commonly used for the analysis of ordinal data. However, Likert scales often lead to violation of many underlying assumptions. This study examined the comparative power of the t test with the Wilcoxon rank-sum test using real pretest/posttest data sets measured on an ordinal scale. FIM scores were obtained on 714 geriatric patients at admit and discharge from a rehabilitation hospital. A Fortran 77 program was written to sample with replacement from each admit and discharge data distribution. Results indicated the Wilcoxon rank-sum test outperformed the t test for almost every sample size and alpha level examined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The possibility of preserving the causative agent of plague in soil in resting (nonculturable) form

The purpose of this study was to find criteria characteristic for patients in need of care and social services. The criteria should serve as a guideline for patients and staff to facilitate care planning before discharge. The sample consisted of 49 patients, born before 1925, in need of emergency inpatient treatment, admitted to medical- or orthopaedic wards. Data of the patient's self care needs were collected by interviews, assessment of self care status and need of treatment. The patients could be divided into three groups depending on type of discharge. Group A (n = 27) discharged home, group B (n = 7) discharged to geriatric clinic and group C (n = 15) discharged and in need of further care and social services. Criteria indicating the patients further assistance from the community were in group C (medical- and orthopaedic wards) deficit in daily living activities and locomotion. Group B had an increased need of support from the physiotherapist and the occupational therapist, in locomotion as well as daily living activities The physician's assessment showed that the criteria behind the decision "no further medical treatment appropriate" and "ready for discharge" were not related to medical impairment but to lack of self care, need of care, rehabilitation and social services.