PubMed Health⌕ Search

Biomedical subjects

Gerben DeJong

Publications and source records attributed to Gerben DeJong.

13 recordsLinked to original sources
PubMed2006

Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.

BACKGROUND AND PURPOSE: To assess whether poststroke rehabilitation outcomes and reimbursement for Medicare beneficiaries differ across inpatient rehabilitation facilities (IRFs) and skilled nursing facility (SNF) subacute rehabilitation programs. METHODS: Clinical data were linked with Medicare claims for 58,724 Medicare beneficiaries with a recent stroke who completed treatment in 1996 or 1997 in IRFs and subacute rehabilitation SNFs that subscribed to the Uniform Data System for Medical Rehabilitation. Outcome measures were discharge destination, discharge FIM ratings and Medicare Part A reimbursement during the institutional stay. RESULTS: IRF patients that were more likely to have a community-based discharge, compared with rehabilitation SNF patients, were patients with mild motor disabilities and FIM cognitive ratings of 23 or greater (adjusted odds ratio [AOR]=2.19; 95% CI: 1.52 to 3.14), patients with moderate motor disabilities (AOR=1.98; 95% CI: 1.49 to 2.61), patients with significant motor disabilities (AOR=1.26; 95% CI: 1.01 to 1.57) and patients younger than 82 with severe motor disabilities (AOR=1.43; 95% CI: 1.25 to 1.64). IRF patients with significant and severe motor disabilities achieved greater motor function of 2 or more FIM units compared with rehabilitation SNF patients. Medicare Part A payments for IRFs were higher than rehabilitation SNF payments across all subgroups. CONCLUSIONS: For most patients, poststroke rehabilitation in the more costly and intensive IRFs resulted in higher functional outcomes compared with care in a SNF-based rehabilitation program. IRF and SNF outcomes were similar for patients with minimal motor disabilities and patients with mild motor disabilities and significant cognitive disabilities. Cost-effectiveness analyses require considering the costs of the full episode of care.

Aged↗
PubMed2005

The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes.

UNLABELLED: DeJong G, Horn SD, Smout RJ, Ryser DK. The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes. OBJECTIVE: To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes. DESIGN: Prospective observational cohort study. SETTING: Three IRFs in the United States. PARTICIPANTS: Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination. RESULTS: The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities. CONCLUSIONS: For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study's findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS.

Activities of Daily Living↗
PubMed2005

Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results.

UNLABELLED: Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results. OBJECTIVES: To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP). DESIGN: Prospective observational cohort study. SETTING: Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand. PARTICIPANTS: Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in FIM score, change in severity of illness, and discharge destination. RESULTS: For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4. CONCLUSIONS: This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.

Activities of Daily Living↗
PubMed2005

A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities.

UNLABELLED: McNaughton H, DeJong G, Smout RJ, Melvin JL, Brandstater M. A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities. OBJECTIVE: To compare stroke rehabilitation practice and outcomes between New Zealand (NZ) and the United States. DESIGN: Prospective observational cohort study. SETTING: Seven inpatient rehabilitation facilities (IRFs) in the United States and NZ. PARTICIPANTS: Consecutive convenience sample of 1161 patients in 6 U.S. IRFs and 130 in 1 NZ IRF (age, >18 y) after acute stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in FIM score and discharge destination. RESULTS: NZ participants were older than U.S. participants (mean: 74.1 y vs 66.0 y, respectively; P<.001). Measures of initial stroke severity were higher for U.S. participants. Mean rehabilitation length of stay (LOS) was shorter for U.S. participants (18.6d vs 30.0 d, P<.001), but physical and occupational therapy time per patient was considerably higher despite the shorter LOS. U.S. therapists were involved in more active therapies for more of the time. Outcomes were better for U.S. participants, with fewer discharged to institutional care (13.2% vs 21.5%, P=.006) and larger changes in FIM scores. CONCLUSIONS: U.S. participants with acute stroke who were selected for rehabilitation had better outcomes than NZ participants, despite shorter stays in the rehabilitation facility. U.S. participants had more intensive input from physiotherapists and occupational therapists, which may explain some of the larger increases in FIM scores. This suggests that further studies with tighter controls on case mix may add additional information on the effects of therapy intensity on patients with stroke.

Activities of Daily Living↗
PubMed2005

Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial.

Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the "black box" of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs.

Clinical Trials as Topic↗
PubMed2005

Timing of initiation of rehabilitation after stroke.

UNLABELLED: Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke. OBJECTIVE: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables. DESIGN: Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities. SETTING: Six U.S. inpatient rehabilitation hospitals. PARTICIPANTS: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS). RESULTS: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS. CONCLUSIONS: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS.

Activities of Daily Living↗
PubMed2005

Characterizing occupational therapy practice in stroke rehabilitation.

UNLABELLED: Richards LG, Latham NK, Jette DU, Rosenberg L, Smout RJ, DeJong G. Characterizing occupational therapy practice in stroke rehabilitation. OBJECTIVES: To describe how occupational therapy (OT) activities during stroke inpatient rehabilitation vary by admission functional status and over time and how time spent in these various activities relates to functional status at discharge. DESIGN: Observational cohort study. SETTING: Six inpatient rehabilitation hospitals in the United States. PARTICIPANTS: People (N=713) receiving 4 to 19 hours of post-stroke OT. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patients were categorized by number of 4-hour blocks of OT received and by admission upper-extremity (UE) dressing score on the FIM instrument. In each group, the percentage of time spent in 16 activities and the percentage of patients who received each activity were calculated. The amount of time in activities was compared for those patients scoring 1 or 2 at admission who achieved at least a level of supervision for UE dressing (a score of >or=5) using Wilcoxon 2-sample tests. RESULTS: The majority of OT time was spent in impairment-focused activities (37.5%) or training basic activities of daily living (31.9%). Treatment progressed to more advanced activities over time (eg, less bed mobility, more home management), yet little time was spent on community integration or leisure activities and with very few patients. Successful patients received more higher-level activities, whereas unsuccessful patients received larger amounts of basic-level activities. CONCLUSIONS: OT activities focused on a combination of remediating impairments and retraining specific functional tasks, at the ability level of each individual patient, and provided higher-level activities as patients improved their function. More time in higher-level activities was related to greater success in rehabilitation. However, higher-level activities remain the least common activities provided during inpatient rehabilitation.

Activities of Daily Living↗
PubMed2005

Opening the black box of post-stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes.

DeJong G, Horn SD, Conroy B, Nichols D, Healton EB. Opening the black box of post-stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. This article introduces the journal's supplement devoted to the methods and findings of the 7-site Post-Stroke Rehabilitation Outcomes Project (PSROP), a study designed to provide a very granular in-depth understanding of stroke rehabilitation practice and how practice is related to outcomes. The article summarizes current knowledge about the effectiveness of post-stroke rehabilitation, outlines where the PSROP fits into the broader traditions of stroke rehabilitation outcomes research, underscores the study's methodologic innovations, and summarizes the scope of the articles that follow.

Clinical Trials as Topic↗
PubMed2005

Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?

UNLABELLED: Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? OBJECTIVE: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients. DESIGN: Prospective observational cohort study. SETTING: Five U.S. inpatient rehabilitation facilities. PARTICIPANTS: Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total, motor, and cognitive FIM scores and discharge destination. RESULTS: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes. CONCLUSIONS: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.

Activities of Daily Living↗
PubMed2005

Outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs for Medicare beneficiaries with hip fracture.

OBJECTIVE: We sought to assess whether outcomes and reimbursement differ for Medicare beneficiaries with hip fracture when treated in an inpatient rehabilitation facility (IRF) compared with a skilled nursing facility (SNF) subacute rehabilitation program. PARTICIPANTS: Clinical data were linked with Medicare claims for 29,793 Medicare fee-for-service beneficiaries with a recent hip fracture who completed treatment in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation. OUTCOME MEASURES: We measured discharge destination, change in motor FIM rating, and Medicare Part A reimbursement. RESULTS: For patients with moderate-to-severe and severe disabilities, case mix groups (CMGs) 704 and 705, the percentage of patients discharged to the community from IRFs was lower than for patients treated in subacute rehabilitation SNFs, after controlling for covariates. Adjusted odds ratios were 0.71 (95% confidence interval 0.55-0.92) for CMG 704 and 0.72 (95% confidence interval 0.63-0.83) for CMG 705. For patients in the 3 other CMGs, no significant differences were detected. Improvement in motor functional status was roughly equivalent for patients treated in IRFs and those treated in the subacute rehabilitation programs across all 5 CMGs, after controlling for covariates. Medicare Part A payments for IRFs were significantly higher than SNF payments across all CMGs. CONCLUSION: SNF-based subacute rehabilitation was less costly and outcomes were in most, but not all, instances similar or better than IRF-based rehabilitation for Medicare fee-for-service beneficiaries who had a recent hip fracture.

Aged↗
PubMed2005

Medicare reform and the American devolution.

The Medicare Modernization Act of 2003 (MMA'03) did more than introduce a prescription drug benefit for Medicare beneficiaries; it also laid the groundwork for several far-reaching changes in the Medicare program. These changes must be considered in the context of the "American devolution"--a much larger shift in American health and social policy that is changing how Americans manage their health and wealth as more tasks and responsibilities devolve to individuals in managing their personal affairs and their lives in the workplace. The devolution presents a special challenge to those who have diminished capacities for self-direction, including many stroke survivors who are especially dependent on the Medicare program for their rehabilitation and management of their diminished health status. This article calls for a massive investment in information technology and brokerage that will enable all Americans to effectively navigate the brave new world that the changes in the Medicare program portend.

Aged↗
PubMed2004

Use of outcomes information in acute inpatient rehabilitation.

OBJECTIVE: To describe the ways in which rehabilitation outcomes information is used in the acute inpatient rehabilitation industry and the industry's views on the topic of public disclosure of rehabilitation outcomes information. DESIGN: A mixed-methods approach, featuring data from 39 informational telephone interviews with rehabilitation industry stakeholders followed by a survey of 95 randomly sampled acute inpatient rehabilitation provider organizations. RESULTS: Both the informational interviews and survey findings revealed that there is currently little stakeholder demand for functional outcomes information. Outcomes information is primarily used within provider organizations to track the effectiveness of rehabilitation services. There is general consensus among rehabilitation provider organizations in favor of public disclosure of outcomes information. CONCLUSIONS: Outcomes information is not routinely shared with rehabilitation stakeholders (i.e., payers and consumers). Rehabilitation providers and industry stakeholders generally express favorable attitudes toward public disclosure of outcomes information. Stakeholders' perceptions of current barriers and facilitators of outcomes information provide insight into the steps that can be taken toward greater transparency in the rehabilitation industry.

Activities of Daily Living↗