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Biomedical subjects

M G Stineman

Publications and source records attributed to M G Stineman.

At least 19 recordsLinked to original sources
PubMed2001

The story of function-related groups--please, first do no harm.

In November 2000, the Health Care Financing Administration (HCFA) published a proposed rule announcing their intention to implement a prospective payment system for rehabilitation inpatient facilities and hospital units. In this system, payments are to be scaled to patient complexity through a classification system referred to as case-mix groups (CMGs) modeled after the Functional Independence Measure-Function Related Groups, which were developed from the FIM instrument. Under the HCFA proposal, CMGs will be derived from the Minimum Data Set for Post-Acute Care (MDS-PAC). This shift to the MDS-PAC, with little scientific evidence to support it, can have a negative impact on how the system expresses patient need, on how patients access services, and on the equity of hospital payments.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

Defining the population, treatments, and outcomes of interest: reconciling the rules of biology with meaningfulness.

Population characteristics, treatment needs, therapeutic interventions, and outcomes are inextricably linked. To appreciate the treatment needs and outcomes of populations served by rehabilitation medicine, it is essential to understand how specific conditions impair mental and physical functioning, given the environments within which people choose to live. States of the mind and body combine with the characteristics of the man-made and natural world and the social infrastructure to yield disabilities and, thus, shape the demand for rehabilitation services. The 1997 draft of ICIDH-2: International Classification of Impairments, Activities, and Participation (ICIDH-2) is described as an approach to population definition and outcome assessment. A new and evolving model referred to as the spheres of human-environmental integration (HEI) is applied to expressing the nonlinear and overlapping relationships among the ICIDH-2 dimensions. HEI is defined as the individual's potential for meaningful physical and mental activity as determined by physical and mental capabilities in relationship to the man-made and natural worlds, social expectations, and available resources. HEI can be expanded by reducing disabilities through medical and rehabilitation interventions and by eliminating environmental barriers. This dual approach implies a need to integrate rehabilitation sciences with the principles of independent living, which view disablement as a function of the environment. The ICIDH-2 dimensions combined with HEI are used to define populations and to study the mechanisms and effects of alternative treatments through various techniques of case-mix measurement, disability staging, and utility assessment.

Activities of Daily Living↗
PubMed2001

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system.

BACKGROUND: Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system. OBJECTIVE: The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences. DESIGN: This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system. SUBJECTS: The study included 55,438 stroke patients. MEASURES: Study measures were LOS, functional status at discharge, and community discharge. RESULTS: The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05). CONCLUSIONS: While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.

Activities of Daily Living↗
PubMed2001

Protection of human subjects with disability: guidelines for research.

Typically, protection of human subjects is a shared responsibility involving the local institutional review board (IRB) and the clinical investigator, guided by federal and state law as well as local organizational policy. The IRB screens protocols to ensure subjects' safety by making sure that risks are acceptable and do not outweigh benefits. However, the recruitment of subjects, as well as obtaining consent, is the principal investigator's responsibility. Through the process of informed consent, the clinical investigator is obliged to ensure that each subject understands all treatments proposed and their potential benefits and risks. Achieving truly informed consent from people with major developmental, physical, sensory, communicative, or cognitive disabilities may be particularly difficult. Spurred on by increasing research of relevance to rehabilitation medicine and the patients served, we review legal, ethical, and moral issues surrounding the processes of obtaining informed consent and offer specific recommendations for protecting people with disabilities.

Adult↗
PubMed2000

A functional diagnostic complexity index for rehabilitation medicine: measuring the influence of many diagnoses on functional independence and resource use.

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.

Activities of Daily Living↗
PubMed2000

Outcome indicators for stroke: application of an algorithm treatment across the continuum of postacute rehabilitation services.

OBJECTIVE: To determine the feasibility and utility of applying a case-mix adjusted algorithm for treatment across the continuum of stroke rehabilitation. DESIGN: Implementation of a clinical algorithm developed through national expert panels to standardize rehabilitation assessment and treatment of veterans with stroke. Stroke patients were stratified into initial severity groups using FIM instrument-Function Related Groups (FIM-FRG) classifications and were followed up from first rehabilitation referral to completion of all active restorative functional goals. FIM-FRG assignments were used to establish case-mix adjusted outcome indicators for the continuum of rehabilitation services. SETTING: Rehabilitation services in medical and surgical units, intermediate care units, inpatient rehabilitation bed units, and outpatient settings in 10 participating Veterans Affairs (VA) medical centers. PATIENTS: Stroke patients (n = 421) who received rehabilitation in the 10 participating VA centers. MAIN OUTCOME MEASURES: Patients' functional gains, length of treatment (LOT), functional status at discharge, LOT efficiency, costs, cost efficiency, and disposition location. RESULTS: Two hundred twenty-three patients began rehabilitation while in acute medical or surgical units, 171 in inpatient rehabilitation units, 24 in intermediate care, and the remainder while in other settings. With cases compiled across all settings, average total rehabilitation costs for patients in the lowest FRG class (most severe disabilities) were more than twice those for patients assigned to the highest FRG class (least severe disabilities). FIM gains were greatest in the subset of younger stroke patients with the most severe disabilities. CONCLUSIONS: Implementing a standard algorithm of rehabilitation care that includes outcome indicators adjusted to patients' disability severity is feasible. The algorithm's utility is evident because it encompasses rehabilitation care provided across the full continuum, promotes access to care by advocating assessment of all stroke patients, encourages early initiation of treatment, and promotes a smooth transition though various levels of care while encouraging cost containment.

Aged↗
PubMed1999

A functional strategy for classifying patients after traumatic spinal cord injury.

OBJECTIVES: To present a function-based strategy for classifying patients by expected functional outcomes measured as patients' performances at discharge on each of the 18 component items of the FIMtrade mark instrument (previously known as the Functional Independence Measure). METHODS: Data included records from 3604 inpatients with traumatic spinal cord injury discharged from 358 rehabilitation units or hospitals in 1995. The function-based strategy assigned patients to four Discharge Motor-FIM-Function Related Groups defined by patients' admission performance on the motor-FIM items. RESULTS: The majority of patients whose motor-FIM scores at admission were above 30 were able to groom, dress the upper body, manage bladder function, use a wheelchair, and transfer from bed to chair, either independently or with supervision, by the time of discharge from inpatient rehabilitation. Most patients whose scores were above 52 attained independence in all but the most difficult FIM tasks, such as bathing, tub transfers, and stair climbing. CONCLUSIONS: This classification scheme can be used to determine the degree to which patients' actual FIM outcomes compare to other individuals who had similar levels of disabilities at the time of admission to rehabilitation. The clinician can apply these 'FIM item attainment benchmarks' retrospectively in quality improvement, in guideline development, and in anticipating the types of post-discharge care required by clinically similar groups.

Adult↗
PubMed1998

Diagnostic coding and medical rehabilitation length of stay: their relationship.

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.

Brain Injuries↗
PubMed1998

Functional task benchmarks for stroke rehabilitation.

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.

Activities of Daily Living↗
PubMed1998

The Capabilities of Upper Extremity instrument: reliability and validity of a measure of functional limitation in tetraplegia.

OBJECTIVE: To evaluate the reliability and validity of the Capabilities of Upper Extremity (CUE) instrument, designed to measure upper extremity functional limitations in individuals with tetraplegia. Functional limitations are actions such as reaching or grasping and are a link between the domains of impairment and disability. DESIGN: Survey of people with chronic spinal cord injury. SETTING: Regional spinal cord injury center. SUBJECTS: One hundred fifty-four individuals (140 male) with tetraplegia at least 1 year after injury and followed by the center. Mean age was 36.7 years (SD=11.1). Sixty-eight percent were motor complete. METHODS: The 32-item CUE was administered by telephone interview twice about 2 weeks apart. The motor portion of the Functional Independence Measure (FIM) was collected during the first interview. Upper extremity motor scores and motor levels were obtained from the most recent assessment in the outpatient chart. The instrument was evaluated for internal consistency, reliability, and validity. Exploratory factor analysis was performed to examine scale structure. RESULTS: Homogeneity of the scale was excellent. Cronbach's alpha was .96, and item-total correlations ranged from .49 to .78. Test-retest reliability was high (ICC=.94). All but three items had desired levels of agreement (K > .60). Analysis of variance indicated that the CUE distinguished between motor levels of tetraplegia more than one level apart. The CUE was correlated highly with both motor scores and FIM. Regression analysis indicated that the CUE was better than upper extremity motor scores for predicting FIM scores. The model containing the CUE explained 73% of the variance in FIM and was not enhanced by the addition of motor scores. Factor analysis suggested four potential subscales: arm function (bilateral), right hand function, left hand function, and reaching down. CONCLUSION: The CUE exhibits good homogeneity, reliability, and validity; further work is needed to determine its sensitivity to change in function.

Activities of Daily Living↗
PubMed1998

Comparing consumer and clinician values for alternative functional states: application of a new feature trade-off consensus building tool.

OBJECTIVE: To present the Features-Resource Trade-Off Game (Features Game) as a new method for comparing preferences for alternative outcomes among different groups of people. DESIGN: The Features Game is illustrated by comparing preferences for recovery among the 18 functional status items making up the Functional Independence Measure. Methods involved trading levels of independence (resources) across the different items (features). SETTING: Ten community-dwelling consumers with physical disabilities and 10 rehabilitation clinicians participated in four separate expert panels-two in Houston and two in Philadelphia. MAIN OUTCOME MEASURES: Five sets of hierarchical stages defined by the four separate panels specifying the profiles of function believed to most foster independent living. RESULTS: Cognitive and communication skills were selected preferentially over the recovery of physical tasks by all panels, but, in comparison to clinicians, consumers were more willing to accept mild deficits in cognitive skills as trade for realizing earlier recovery of physical abilities. CONCLUSION: The overwhelming choice of cognitive and communication abilities over physical abilities suggests a need to enhance therapeutic efforts in those areas. More subtle differences in consumer and clinician preferences emphasize the importance of establishing consumer-oriented goals.

Activities of Daily Living↗
PubMed1997

Discharge motor FIM-function related groups.

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.

Activities of Daily Living↗
PubMed1997

Impairment-specific dimensions within the Functional Independence Measure.

OBJECTIVE: The analyses presented in this article were intended to seek more fine-grained impairment-specific dimensions beyond the motor and cognitive dimensions of the Functional Independence Measure (FIMSM). DESIGN: The study used factor analysis within 20 categories of impairment to test the hypotheses that FIM items can be grouped according to functional areas of the body and that these item groupings differ depending on the patient's impairment. PATIENTS: Data from 93,829 patients discharged in 1992 from 252 free-standing rehabilitation hospitals and units were obtained from the Uniform Data System for Medical Rehabilitation. RESULTS: In 18 of 20 impairment categories, factor analyses of patients admission FIM scores showed impairment-specific FIM dimensions. Four impairments had a 3-dimensional factor structure, and 14 had a 4-dimensional structure. The impairment-specific dimensions were always nested within the motor-FIM subscale. Reliability coefficients for subscales based on these dimensions ranged from .74 to .97. The subscales appear to cluster FIM items by the area of body involved, neurological level, or relative energy consumption. CONCLUSION: The FIM can be viewed as a multilayered multidimensional measure of human function. The impairment-specific dimensions, at an intermediate layer, provide insight about the causal linkage between the impairment and resultant patterns of disability. Impairment-specific subscales are relevant to those clinical or research applications where the type of disability needs to be more closely related to impairment.

Activities of Daily Living↗
PubMed1997

Measuring casemix, severity, and complexity in geriatric patients undergoing rehabilitation.

Geriatric rehabilitation is intended to maintain or restore function, maximize life satisfaction, enhance psychologic well-being, and maintain the social status of older persons. For clinical services to operate efficiently and equitably, payment must be based on rules that are clinically sound and thus reinforce the objectives of the services provided. This article presents a theoretical basis for casemix measurement in medical rehabilitation, contrasts structure of the functional independence measure-function-related groups (FIM-FRGs) intended for casemix measurement to the diagnosis-related groups (DRGs) and resource utilization groups (RUG) III systems designed for acute and long-term care settings, focuses on special issues of relevance to the rehabilitation of older persons, and provides four challenges in an effort to stimulate discussion.

Activities of Daily Living↗