Acute Rehospitalizations During Inpatient Rehabilitation for Spinal Cord Injury

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<ul><li><p>edicine and RehabilitationArchives of Physical M</p><p>journal homepage: www.archives-pmr.org</p><p>Archives of Physical Medicine and Rehabilitation 2013;94(4 Suppl 2):S98-105ORIGINAL ARTICLE</p><p>Acute Rehospitalizations During Inpatient Rehabilitationfor Spinal Cord Injury</p><p>Flora M. Hammond, MD,a,b Susan D. Horn, PhD,c Randall J. Smout, MS,c David Chen, MD,d</p><p>Gerben DeJong, PhD,e William Scelza, MD,f Amitabh Jha, MD,f Pamela H. Ballard, MD,e</p><p>Jessica Bloomgarden, MDg</p><p>From aCarolinas Rehabilitation, Charlotte, NC; bIndiana University, Indianapolis, IN; cInstitute for Clinical Outcomes Research, Salt Lake City,UT; dRehabilitation Institute of Chicago, Chicago, IL; eNational Rehabilitation Center, Washington, DC; fCraig Hospital, Englewood, CO; andgMount Sinai School of Medicine, New York, NY.</p><p>Abstract</p><p>Objectives: To investigate frequency of and reasons for readmission to acute care (RTAC) during inpatient rehabilitation after traumatic spinal</p><p>cord injury (SCI), and to identify factors associated with RTAC.</p><p>Design: Prospective observational cohort.</p><p>Setting: Inpatient rehabilitation.</p><p>Participants: Individuals with SCI (NZ1376) consecutively admitted for inpatient rehabilitation; 1032 randomly selected for modeldevelopment; 344 selected for model cross-validation.</p><p>Interventions: Not applicable.</p><p>Main Outcome Measures: RTAC, RTAC reasons, rehabilitation length of stay (LOS), discharge location and FIM, rehospitalization between</p><p>discharge and year 1, and 1-year outcomes: FIM, Craig Handicap Assessment and Reporting Technique, and Patient Health Questionnaire-9.</p><p>Results: Participants (nZ116; 11%) experienced RTAC with a total 143 episodesd96 patients experienced only 1 RTAC, while 14 had 2 RTACs,5 had 3 RTACs, and 1 had 4 RTACs. The most common RTAC reasons were surgery (36%), infection (22%), noninfectious respiratory (14%), and</p><p>gastrointestinal (8%). Mean days SD from rehabilitation admission to first RTAC was 2730 days. Seventy-four (7%) patients had at least1 RTAC for medical reasons and 46 (4%) for surgical reasons. Regression analyses indicated several variables were associated with RTACs:</p><p>greater admission medical severity, lower admission cognitive FIM, pressure ulcer acquired in acute care, and study site. Medical RTACs were</p><p>associated with higher body mass index, lower admission cognitive and motor FIM, payer, and study site. Predictors of surgical RTAC were longer</p><p>time from injury to rehabilitation admission and study site. After controlling for the other variables, the only outcome RTAC influenced was</p><p>longer rehabilitation LOS.</p><p>Conclusions: Approximately 11% of SCI patients experience RTAC during the course of rehabilitation for a variety of medical and surgical</p><p>reasons. RTACs are associated with longer rehabilitation LOS.</p><p>Archives of Physical Medicine and Rehabilitation 2013;94(4 Suppl 2):S98-105</p><p> 2013 by the American Congress of Rehabilitation MedicineData from the Spinal Cord Injury (SCI) Model Systems programdatabase reveals 3 interesting trends over time. First, the averageage of SCI has increased from 28.7 years in the 1973 to 1979Supported in part by National Institute on Disability and Rehabilitation Research, Office of</p><p>Special Education Services, U.S. Department of Education (grant nos. H133A060103,</p><p>H133N060005, H133N060009, H133N060027, and H133N060014).</p><p>No commercial party having a direct financial interest in the results of the research supporting</p><p>this article has or will confer a benefit on the authors or on any organization with which the authors</p><p>are associated.</p><p>0003-9993/13/$36 - see front matter 2013 by the American Congress of Rehttp://dx.doi.org/10.1016/j.apmr.2012.11.051period to 40.7 years since 2005. Second, time from initial injury torehabilitation admission has decreased from an average of 24 daysin the 1973 to 1979 period to only 12 days since 2005.1 And third,the overall average length of stay (LOS) in acute rehabilitation hasdecreased from 74.1 days in 1990 to 60.8 days in 1997.2</p><p>The first of these trends stems from an aging general pop-ulation with conceivably more underlying chronic medicalconditions. The second and third trends stem from changingpolicy and practice patterns. Escalating health care costs requirehabilitation Medicine</p><p>Delta:1_given nameDelta:1_given nameDelta:1_surnameDelta:1_given nameDelta:1_given nameDelta:1_surnameDelta:1_given nameDelta:1_given nameDelta:1_surnameDelta:1_given nameDelta:1_given nameDelta:1_surnameDelta:1_given nameDelta:1_given nameDelta:1_surnameDelta:1_given nameDelta:1_given nameDelta:1_surnamehttp://dx.doi.org/10.1016/j.apmr.2012.11.051http://www.archives-pmr.orghttp://dx.doi.org/10.1016/j.apmr.2012.11.051</p></li><li><p>Rehospitalizations during inpatient rehabilitation for SCI S99those with traumatic SCI to move through acute care hospitali-zation more quickly, and thus, present greater acuity duringinpatient rehabilitation. Additionally, acute inpatient rehabilitationLOS has also shortened over recent years. The shortening of bothacute and rehabilitation LOS places greater pressure on acuteinpatient rehabilitation providers to manage all aspects of medicalcare and rehabilitation in a compressed time frame.</p><p>Less clear is the frequency of readmission to acute care(RTAC) among individuals with traumatic SCI in the course ofinpatient rehabilitation, reasons for such RTACs, patient charac-teristics and care features associated with such readmissions, andassociations between RTACs and the patients outcomes. Under-standing these factors may help identify those at greatest risk anduncover interventions and practices that may help avert RTACs.</p><p>Studies have reported on the major causes of rehospitalizationsamong those with chronic SCI, but they have focused primarily onthose who have already completed their inpatient SCI rehabilita-tion program. The most common reasons for rehospitalizationshave consistently included disorders of the genitourinary tract (ie,urinary tract infections), respiratory complications, gastrointes-tinal (GI) disorders, and disorders of the skin and integumentarysystems (primarily complications related to pressure ulcers).3-5</p><p>The studies of specific factors contributing to RTACs duringSCI rehabilitation care have not been reported in the literature.</p><p>In 1999, Chen et al6 reported on the most common medicalcomplications experienced by persons with new SCI during acuterehabilitation who were treated within the SCI Model Systemsprogram. However, the study was unable to differentiate whetherthe medical condition developed during the acute care or acuterehabilitation phase of care after injury. Moreover, the data relatedto acute care complications had a limited look-back period,because the main data source, the SCI Model Systems database,started to collect such data only in the previous 2 years. Chen6 didnot explore patient characteristics or health-related factors thatmay have increased the risks for developing these complications,nor did they delve into the setting of care in which these medicalconditions were treated (acute care vs rehabilitation) or the impactthat they had on the rehabilitation course and outcome.</p><p>The full impact of RTAC episodes remains unknown. Anec-dotally, we know that an RTAC can disrupt rehabilitation progress,create emotional stress on the patient and family, increase healthcare costs, and undermine patient outcomes. Concurrently, payersand quality monitoring organizations look to readmissions withinthe first 30 days after acute care discharge as a quality-of-careindicator denoting substandard care. In a recent literature reviewof acute care hospital admissions (for any diagnosis, not just SCI),it was estimated that 9% to 48% of acute care rehospitalizationsare related to substandard care during acute care hospitalization.7</p><p>Of note, this study examined readmissions primarily after acuteList of abbreviations:</p><p>AIS ASIA Impairment Scale</p><p>ASIA American Spinal Injury Association</p><p>BMI body mass index</p><p>CHART Craig Handicap Assessment and Reporting Technique</p><p>CSI Comprehensive Severity Index</p><p>GI gastrointestinal</p><p>HL Hosmer-Lemeshow</p><p>LOS length of stay</p><p>RTAC readmission to acute care</p><p>SCI spinal cord injury</p><p>www.archives-pmr.orgcare to community discharge as opposed to acute care to inpatientrehabilitation specifically. Adequate preparation for acute caredischarge to inpatient rehabilitation may differ from the needs foracute care discharge to the community. The medical preparationand needs of the SCI population in transition from acute care toacute inpatient rehabilitation and during inpatient rehabilitationremain unclear. Many RTACs may be planned events, forexample, readmissions for a planned surgery and not related tomedical complications that develop or worsen during the acutephase of rehabilitation.</p><p>The aim of this article is to describe the medical complicationsthat precipitate an RTAC during inpatient rehabilitation for SCI byassessing the incidence of and reasons for RTACs and the factorsassociated with RTACs. A secondary aim is to evaluate the rela-tion between RTACs and outcome at rehabilitation discharge and1 year postinjury.</p><p>Methods</p><p>The SCIRehab Project is a multicenter, 5-year investigationrecording and analyzing the details of the SCI inpatient rehabili-tation process for 1032 patients. The introductory article in thissupplement of SCIRehab project articles describes the studydesign, including use of practice-based evidence researchmethods, inclusion criteria, data sources, and the analysis plan.8,9</p><p>Briefly, the SCIRehab sites included 6 inpatient rehabilitationfacilities: Craig Hospital, Englewood, CO; Shepherd Center,Atlanta, GA; Rehabilitation Institute of Chicago, Chicago, IL;Carolinas Rehabilitation, Charlotte, NC; Mount Sinai MedicalCenter, New York, NY; and National Rehabilitation Hospital,Washington, DC. Institutional review board approval was obtainedat each center. Participants were 12 years of age, gave (or theirparent/guardian gave) informed consent, and were admitted to thefacilitys SCI unit for initial rehabilitation after traumatic SCI.</p><p>Patient, injury, and outcome variables</p><p>Trained data abstractors collected patient and injury data frompatient medical records. The International Standards of Neuro-logical Classification of SCI10 were used to describe the motor leveland completeness of injury. Patients with American Spinal InjuryAssociation (ASIA) Impairment Scale (AIS) grade D were groupedtogether regardless of injury level. Patients with AIS grades of A, B,and C were grouped together and separated by motor level todetermine the remaining 3 injury groups: high tetraplegia (C1-4),low tetraplegia (C5-8), and paraplegia (T1 and below). These injurycategories were selected because they were each large enough foranalysis and created groupings thought to have relatively homog-enous functional ability within groups and clear differencesbetween groups. Height and weight were collected to calculatebody mass index (BMI).</p><p>The Comprehensive Severity Index (CSI), the studys principalseverity measure, was used to score the extent of deviation fromnormal physiological status for each medical complication andcomorbidity present during the first 3 days after rehabilitationadmission.11 Higher CSI scores denote increased medical severity.We also assessed several medical conditions that occurred duringacute care prior to the initial rehabilitation admission and theirpossible association with RTAC: deep venous thrombosis, leukocy-tosis, pneumonia, pressure ulcers, sepsis, and urinary tract infection.</p><p>The FIM was used to describe a patients independence inmotor and cognitive abilities at rehabilitation admission and</p><p>http://www.archives-pmr.org</p></li><li><p>S100 F.M. Hammond et aldischarge and 1 year postinjury. All FIM data were Rasch-adjusted, as described in the first article in this supplement.8</p><p>Participation in mobility, occupation, and social interaction at1 year postinjury was assessed by various subscales of the CraigHandicap Assessment and Reporting Technique (CHART).12 Thepresence of depression at 1 year was measured by the PatientHealth Questionnaire-9,13 although it is important to note thatpositive responses to the Patient Health Questionnaire-9 itemsmay be present because of SCI or other reasons and may notalways represent depression per se. The LOS in rehabilitationexcluded days during which the patient was returned to acute care.</p><p>Definition of RTAC</p><p>All interruptions of inpatient rehabilitation requiring readmissionto an acute care hospital were considered to represent an RTAC. Foreach such event, the dates of interruption and reason(s) wereabstracted from the medical chart. In many instances, multiplereasons were listed along with the presenting signs, symptoms, anddiagnoses recorded by the clinical team. In such cases, we reviewedthe data and selected the 1 primary reason that best represented thecause for the RTAC episode. Hence, no RTAC episode is countedmore than once, and only 1 reason is represented even whenmultiple causes may have prompted the RTAC. Because the unit ofanalysis is the patient, a patient with 1 or multiple RTACs is countedonly once in the RTAC group. The RTAC reasons were grouped intoeither surgery or 1 of the following medical categories: infection(eg, pneumonia, aspiration pneumonia, urinary tract infection,sepsis, skin infection), respiratory (eg, pneumothorax, respiratoryfailure, pleural effusion, tracheal stenosis, anaphylaxis), GI, venousthromboembolism, cardiac (eg, congestive heart failure, chest pain,arrhythmia), mental status change, neurologic, anemia, orthostatichypotension, pain, and unknown.</p><p>Data analysis</p><p>The sample (NZ1376) was divided by random selection intoa primary analysis dataset with 75% of the cases (nZ1032) anda validation set with the other 25% (nZ344). Stratification wasused to ensure equal representation by level/completeness of injury,treatment center, and availability of follow-up interview data.Statistical tests showed no significant differences between thedevelopment and validation subgroups on any dependent or inde-pendent variable used in the regression models. All analyses wereinitially performed using the development dataset. For ordinaryleast-squares regressions, the adjusted R2 reduces the unadjusted R2</p><p>to take into account the number of predictors in the model. Theadjusted R2 value indicates the strength of the model or the amountof variation explained in the outcome by the independent variables,and values range from 0 (no prediction) to 1 (perfect prediction);values that are closer to 1 indicate better models. The models werevalidated by calculating the R2 for the 25% dataset using only thestatistically significant predictors from the original model anddetermining the reduction in R2 (relative shrinkage) that occurred.A relative shrinkage of 0.2 is considered a poor validation.</p><p>For logistic regression, discrimination was assessed by usingthe area under the receiver operator characteristic curve (c) toevaluate how well the model distinguished patients who did notachieve a specified...</p></li></ul>

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