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R C Fiedler

Publications and source records attributed to R C Fiedler.

At least 19 recordsLinked to original sources
PubMed2001

Comparison of logistic regression and neural networks to predict rehospitalization in patients with stroke.

CONTEXT: Rehospitalization following inpatient medical rehabilitation has important health and economic implications for patients who have experienced a stroke. OBJECTIVE: Compare logistic regression and neural networks in predicting rehospitalization at 3-6-month follow-up for patients with stroke discharged from medical rehabilitation. DESIGN: The study was retrospective using information from a national database representative of medical rehabilitation patients across the US. SETTING: Information submitted to the Uniform Data System for Medical Rehabilitation from 1997 and 1998 by 167 hospital and rehabilitation facilities from 40 states was examined. PARTICIPANTS: 9584 patient records were included in the sample. The mean age was 70.74 years (SD = 12.87). The sample included 51.6% females and was 77.6% non-Hispanic White with an average length of stay of 21.47 days (SD = 15.47). MAIN OUTCOME MEASURES: Hospital readmission from 80 to 180 days following discharge. RESULTS: Statistically significant variables (P <.05) in the logistic model included sphincter control, self-care ability, age, marital status, ethnicity and length of stay. Area under the ROC curves were 0.68 and 0.74 for logistic regression and neural network analysis, respectively. The Hosmer-Lemeshow goodness-of-fit chi-square was 11.32 (df = 8, P = 0.22) for neural network analysis and 16.33 (df = 8, P = 0.11) for logistic regression. Calibration curves indicated a slightly better fit for the neural network model. CONCLUSION: There was no statistically significant or practical advantage in predicting hospital readmission using neural network analysis in comparison to logistic regression for persons who experienced a stroke and received medical rehabilitation during the period of the study.

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PubMed2001

Characteristics of persons rehospitalized after stroke rehabilitation.

OBJECTIVE: To develop classification models for risk of hospital readmission 80 to 180 days after discharge based the demographic and functional characteristics of persons discharged from acute inpatient rehabilitation after stroke. DESIGN: Retrospective, using information from US facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDS(MR)). SETTING: Information submitted to the UDS(MR) from 1994 through 1996 by 167 hospital and rehabilitation facilities from 40 states was examined. PARTICIPANTS: A total of 15,992 records of patients (mean age +/- standard deviation, 70.97 +/- 12.19yr) with a diagnosis of stroke were included in the final sample. The sample included 52.7% women and was 80% non-Hispanic white with an average length of stay (LOS) of 25.31 +/- 14.72 days. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six subscales of the FIM instrument (self-care, sphincter control, transfers, locomotion, communication, social cognition), total FIM, and other predictor variables for regression analysis (gender, age, ethnicity, marital status, prehospital living setting, LOS, primary payer source, level of function-related group). RESULTS: A logistic regression model included the following statistically significant variables (p <.05): ethnicity, sphincter control, self-care ability, gender, and LOS. The greatest variability occurred among men. Exactly 18.1% of non-Hispanic white men and 17.9% of African-American men were rehospitalized. In contrast, only 10.1% of Hispanic men and 11.4% of Asian men were rehospitalized. The odds of rehospitalization were lowest for Hispanic men. CONCLUSION: As prospective payment systems are introduced for postacute care, it is important that the relationship among functional abilities, demographic characteristics, and incidence of hospital readmission following medical rehabilitation be examined.

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PubMed2001

Satisfaction with medical rehabilitation in patients with cerebrovascular impairment.

OBJECTIVE: Overall satisfaction has important social and economic implications for patients who have received inpatient medical rehabilitation. We conducted this study to examine the overall satisfaction level at 3- to 6-mo follow-up for inpatients with cerebrovascular impairments discharged from medical rehabilitation. DESIGN: The study was retrospective using information from a national database representative of medical rehabilitation patients across the United States. Information submitted in 1997 and 1998 to the Uniform Data System for Medical Rehabilitation by 177 hospital and rehabilitation facilities from 40 states was examined. The final sample included 8,900 patient records. The main outcome measure was the level of satisfaction with medical rehabilitation at 80-180 days postdischarge follow-up. RESULTS: A logistic regression model including ten independent variables was used to predict satisfied vs. dissatisfied at follow-up. Three statistically significant variables were included in the final model and correctly classified 95.1% of the patients. Higher FIM instrument discharge scores were associated with increased satisfaction. Further analysis of the FIM instrument subscales indicated that higher ratings in transfers, social cognition, and locomotion were significantly associated with increased satisfaction. CONCLUSION: We identified several functional variables associated with increased satisfaction after medical rehabilitation in persons with stroke. The ability to objectively assess patient satisfaction is important as consumer-based outcome measures are integrated in accreditation and healthcare evaluation.

Activities of Daily Living↗
PubMed2000

Length of stay and hospital readmission for persons with disabilities.

OBJECTIVES: Length of stay (LOS) and hospital readmission for persons receiving medical rehabilitation were examined. METHODS: A total of 96,473 patient records (1994-1998) were analyzed. Mean age of patients was 68.97 years; 61% were female and 83% were non-Hispanic White. RESULTS: A decrease in LOS of 6.07 days (SD = 3.23) and increase in hospital readmission were found across all impairment groups (P < .001). Readmission increases ranged from 6.7% for amputations to 1.4% for orthopedic conditions. LOS was longer (2.1 days) for readmitted patients (P < .01). Age was not a significant predictor of rehospitalization. CONCLUSIONS: Understanding variables associated with rehospitalization is important as prospective payment systems are introduced for postacute care.

Activities of Daily Living↗
PubMed1999

Relation of disability costs to function: spinal cord injury.

OBJECTIVE: This study evaluated the validity of the Functional Independence Measure (FIM instrument) in predicting (1) the number of minutes of daily assistance provided, (2) the cost of durable goods currently used, and (3) the number of paid helper hours provided daily to persons with spinal cord injury living in the community. DESIGN: A cross-sectional study. SUBJECTS: One hundred nine persons with spinal cord injury who were a median 6 years postdischarge from initial medical rehabilitation. RESULTS: A significant inverse linear relationship was observed between FIM scores and the square root values of the three cost-related measures. The FIM-18 and the FIM motor scores were the best single predictors of the square root of minutes of assistance (paid and/or unpaid) per day, explaining 85% of variance. The FIM motor measure was the best single predictor of square root of cost of durable goods, explaining 29% of variance. The Self-Care, FIM motor, and FIM-18 scores equally predicted square root of hours of paid help per day, explaining 58% of variance. CONCLUSION: The findings indicate FIM-related scores predict the amount of assistance needed and certain costs for persons with spinal cord injury disability.

Activities of Daily Living↗
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↗
PubMed1997

A prediction model for functional recovery in stroke.

BACKGROUND AND PURPOSE: Stroke-related physical disability can diminish quality of daily living, place care burden on families, and increase need for long-term institutionalization. We developed a prognostic index for use in research and with potential for adaptation to clinical practice that establishes the likelihood of an individual achieving a specific stage of functional recovery after stroke rehabilitation. METHODS: We constructed the index using logistic regression based on 3760 patient records from 96 rehabilitation facilities in 31 states. The stage, as measured by the Functional Independence Measure, includes achievement of the following: independence in eating, grooming, and dressing the upper body; continence in bowel and bladder; and transfer between a bed and chair with supervision only. RESULTS: This stage was achieved by 26.1% of patients functioning below it at rehabilitation admission. Disability onset of less than 60 days was associated with more than a 3-fold increase in the likelihood of achieving the stage (adjusted odds ratio, 3.5; 95% confidence interval, 2.0 to 6.0). Each eight-point increase in an eight-item activities of daily living score, measured at admission to rehabilitation, increased the odds 2.5-fold (95% confidence interval, 2.3 to 2.8). For those living alone or employed before the stroke, the odds of achieving the stage increased by factors of 1.3 and 2.2, respectively. The index showed minimal shrinkage on cross validation. The achievement of this profile of function is important because 95.3% of stroke patients who achieved or exceeded it were discharged home, as opposed to only 66.8% of those who did not achieve it. CONCLUSIONS: The index can be used to establish prognoses for individual stroke patients at admission to rehabilitation with regard to achieving this stage. Achievement of the stage is associated with a high likelihood of discharge to home.

Activities of Daily Living↗
PubMed1997

Development of function-related groups version 2.0: a classification system for medical rehabilitation.

OBJECTIVE: To present a new version (2.0) of the Functional Independence Measure-Function Related Group (FIM-FRG) case-mix measure. DATA SOURCE/STUDY SETTING: 85,447 patient discharges from 252 freestanding facilities and hospital units contained in the 1992 Uniform Data System for Medical Rehabilitation. STUDY DESIGN: Patient impairment category, functional status at admission to rehabilitation, and patient age were used to develop groups that were homogeneous with respect to length of stay. Within each impairment category patients were randomly assigned to one data set to create the system (through recursive partitioning) or a second set for validation. Clinical and statistical criteria were used to increase the percentage of patients classified, expand the impairment categories of FIM-FRGs Version 1.1, and evaluate the incremental predictive ability of coexisting medical diagnoses. Predictive stability over time was evaluated using 1990 discharges. PRINCIPAL FINDINGS: In Version 2.0, the percentage of patients classified was increased to 92 percent. Version 2.0 includes two new impairment categories and separate groups for patients admitted to rehabilitation for evaluation only. Coexisting medical diagnoses did not improve LOS prediction. The system explains 31.7 percent of the variance in the logarithm of LOS in the 1992 validation sample, and 31.0 percent in 1990 discharges. CONCLUSIONS: FIM-FRGs Version 2.0 includes more specific impairment categories, classifies a higher percentage of patient discharges, and appears sufficiently stable over time to form the basis of a payment system for inpatient medical rehabilitation.

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PubMed1996

Intermodal agreement of follow-up telephone functional assessment using the Functional Independence Measure in patients with stroke.

OBJECTIVE: To examine the intermodal agreement of Functional Independence Measure (FIM) ratings when obtained by two commonly used approaches: telephone interview and in-person assessment of functional performance. DESIGN: A random sample of 40 persons with hemiparesis was tested by two registered nurses trained in FIM definitions and telephone interview techniques. The two assessments occurred within 5 days of each other. The raters were blind to previous assessments. The administration of assessments was alternated to minimize bias and order effects. SETTING: All subjects were assessed at home, between 3 and 10 months after discharge from rehabilitation. PATIENTS: The criteria for inclusion were: (1) diagnosis of cerebral vascular accident (CVA); (2) completion of a minimum of 2 weeks in an acute rehabilitation program; (3) currently living at home; (4) living within a 30-mile radius of the hospital; and (5) cognitive and verbal skills adequate to complete a telephone interview. From a population of 103 patients, 40 subjects were randomly selected, 18 women and 22 men ranging in age from 37 to 90 years. MAIN OUTCOME MEASURES: The intermodal agreement between FIM ratings obtained by telephone interview and in-person assessment was examined using the intraclass correlation (ICC). FIM item scores were analyzed for agreement using the Kappa coefficient. The stability of the responses was determined by computing the coefficient of variation and plotting the data to visually examine the relationship between the two methods of administration. RESULTS: Data analysis revealed that there was no statistically significant difference (p > .05) between the two methods of administration for total FIM score. The total FIM ICC was .97. ICC values for FIM subscales ranged from .85 to .98, except for social cognition. Kappa scores for noncognitive items ranged from .49 (bowel movement) to .93 (grooming). The coefficient of variation computed to examine cognitive and communication items with reduced variability indicated good stability across all items. CONCLUSION: The results indicated good intermodal agreement for follow-up telephone assessment using the Functional Independence Measure. The findings were limited to persons with effective communication skills.

Activities of Daily Living↗
PubMed1996

The reliability of the functional independence measure: a quantitative review.

OBJECTIVE: The reliability of the Functional Independence Measure (FIMSM) for adults was examined using procedures of meta-analysis. DATA SOURCES: Eleven published studies reporting estimates of reliability for the FIM were located using computer searches of Index Medicus, Psychological Abstracts, the Functional Assessment Information Service, and citation tracking. STUDY SELECTION: Studies were identified and coded based on type of reliability (interrater, test-retest, or equivalence), method of data analysis, size of sample, and training or experience of raters. DATA EXTRACTION: Information from the articles was coded by two independent raters. Interrater reliability for coding all elements included in the analysis ranged from .89 to 1.00. DATA SYNTHESIS: The 11 investigations included a total of 1,568 patients and produced 221 reliability coefficients. The majority of the reliability values (81%) were from interrater reliability studies, and the intraclass correlation coefficient (ICC) was the most commonly used statistical procedure to compute reliability. The reported reliability values were converted to a common correlation metric and aggregated across the 11 studies. The results revealed a median interrater reliability for the total FIM of .95 and median test-retest and equivalence reliability values of .95 and .92, respectively. The median reliability values for the six FIM subscales ranged from .95 for Self-Care to .78 for Social Cognition. For the individual FIM items, median reliability values varied from .90 for Toilet Transfer to .61 for Comprehension. Median and mean reliability coefficients for FIM motor items were generally higher than for items in the cognitive or communication subscales. CONCLUSIONS: Based on the 11 studies examined in this review the FIM demonstrated acceptable reliability across a wide variety of settings, raters, and patients.

Activities of Daily Living↗
PubMed1994

Interrater reliability of the 7-level functional independence measure (FIM)

The Functional Independence Measure (FIM) is an 18-item, 7-level scale developed to uniformly assess severity of patient disability and medical rehabilitation functional outcome. FIM interrater reliability in the clinical setting is reported here. Clinicians from 89 US inpatient comprehensive medical rehabilitation facilities newly subscribing to the uniform Data System for Medical Rehabilitation from January 1988-June 1990 evaluated 1018 patients with the FIM. FIM total, domain and subscale score intraclass correlation coefficients (ICC) were calculated using ANOVA; FIM item score agreement was assessed with unweighted Kappa coefficient. Total FIM ICC was 0.96; motor domain 0.96 and cognitive domain 0.91; subscale score range: 0.89 (social cognition) to 0.94 (self-care). FIM item Kappa range: 0.53 (memory) to 0.66 (stair climbing). A subset of 24 facilities meeting UDSMR data aggregation reliability criteria had Intraclass and Kappa coefficients exceeding those for all facilities. It is concluded that the 7-level FIM is reliable when used by trained/tested inpatient medical rehabilitation clinicians.

Activities of Daily Living↗
PubMed1993

Comparison of cold versus warm cardioplegia. Crystalloid antegrade or retrograde blood?

BACKGROUND: To evaluate the efficacy of warm versus cold and antegrade versus retrograde cardioplegia, 163 patients were randomized in sequence in three groups and underwent isolated coronary artery bypasses (mean, 4 grafts/patients) alternating in sequence. METHODS AND RESULTS: The demographic profiles were identical. Cold crystalloid cardioplegia (group 1) was delivered through the aortic root intermittently. The warm retrograde (group 2) was started antegrade with high potassium solution until the heart stopped. It was continued with retrograde coronary sinus perfusion, 100 mL/min of warm blood. Cold retrograde blood cardioplegia (4:1) (group 3) was started antegrade and continued retrograde through the coronary sinus. The heart temperature was kept at 10 degrees to 15 degrees C. Patients were evaluated intraoperatively and postoperatively for (1) supraventricular tachycardia, (2) ECG changes, (3) lactate dehydrogenase and total CPK and isoenzyme (MB) studies, and (4) hemodynamic studies in the intensive care unit. Warm retrograde and cold retrograde patients had sampling of the ascending aorta (antegrade) and the coronary sinus (retrograde) measuring pH, A-VO2 differences, and CK enzyme leak. RESULTS: The incidence of supraventricular tachycardia was 29% in group 2, 22% in group 1, 18% in group 3; not significant (NS). CPK isoenzyme MB fraction showed identical levels (NS). The warm heart consumed 1.3 to 1.6 mL O2/100 mL flow, while the cold group 3 showed 0.5 to 0.6 mL O2/100 mL flow (P < .001). Cold crystalloid cardioplegia (group 1) was similar to group 3 (0.3 mL O2/100 mL). All three groups were similar hemodynamically (cardiac output, cardiac index, left ventricular stroke work index). Two of 163 patients died in group 2. Four sustained stroke, three in group 2, one with a fatal outcome. CONCLUSIONS: Continuous warm cardioplegia (group 2) did not provide better myocardial protection despite that no CK-MB isoenzyme leak was demonstrated intraoperatively. Intermittent cold crystalloid cardioplegia and cold retrograde provided a clearer operative field and motionless heart. As long as O2 was adequately supplied, under 90 minutes' cross-clamp time, cold crystalloid cardioplegia and cold retrograde blood cardioplegia is safe under hypothermic conditions, whereas warm cardioplegia requires continuous uninterrupted technique with oxygen delivery.

Blood↗
PubMed1993

Functional assessment scales: a study of persons after stroke.

The purpose of this study was to investigate disability in persons after stroke by using combinations of functional assessment item, subscale, domain, and full-scale scores, to predict (1) the burden of care measured in minutes of assistance provided per day by another person in the home, and (2) the subject's level of satisfaction with life in general. The Functional Independence Measure (FIM) and the Sickness Impact Profile (SIP) each contributed to prediction of the subject's physical care needs. A change in total FIM score of one point (range, 61 to 126) was equivalent to an average of 2.19 minutes of help from another person per day and a change in one point in the SIP physical dysfunction (SIPPHYS) score (range, 4.0% to 57.4%) was equivalent to an average of 3.32 minutes. Along with the Brief Symptom Inventory and a measure of visual ability, the FIM contributed to predicting the patient's general satisfaction as well. The burden of care and subjective satisfaction with life in general are important standards by which functional assessment instruments may be compared to reflect, in pragmatic terms, the impact of disability on the lives of individuals and on the human and economic resources of the community.

Activities of Daily Living↗
PubMed1992

Discharge outcome after stroke rehabilitation.

BACKGROUND AND PURPOSE: The purpose of this study was to examine the relations between host characteristics (age and side of body affected) and program variables (lengths of stay in acute care and rehabilitation, levels of functional ability at admission and discharge, and rates of community discharge). METHODS: A sample of 7,905 patients was drawn from medical rehabilitation facilities enrolled in the Uniform Data System for Medical Rehabilitation who were admitted and discharged for the first time between January 1988 and June 1989. Data were analyzed using either chi 2 tests or z normal tests of proportions, and analyses of variance (ANOVA) and/or t tests. Significance was set at p less than 0.05, and statistically significant F ratios were examined using Student-Newman-Keuls tests. RESULTS: The average age of patients was 70.7 years (24% less than 65 years, 53% 65-79 years, and 23% greater than 79 years). Lengths of stay in acute care and rehabilitation, admission and discharge functional independence ratings, and rates of community discharge were generally inversely related to patient age. Patients with bilateral paresis had lower rates of community discharge than those with unilateral paresis, although this distinction was not evident in the older group. CONCLUSIONS: Results showed that older age and bilateral paresis are negatively associated with levels of independence at admission and discharge and with rates of community discharge.

Activities of Daily Living↗
PubMed1991

Use of duplex imaging to assess suitability of the internal mammary artery for coronary artery surgery.

The internal mammary artery is the preferred conduit for coronary artery surgery. To determine the role, if any, of preoperative duplex imaging in assessing the suitability of this vessel, preoperative noninvasive measurements of internal mammary artery diameter and blood flow were performed in 243 patients. The left internal mammary artery was insonated through the third intercostal space by use of duplex scanner (5.0 MHz probe) before coronary artery surgery. Internal mammary artery diameter (millimeters), peak systolic velocity (centimeters/second), and mean velocity (centimeters/second) were measured, and internal mammary artery flow was calculated from velocity and cross-sectional area. In 45 of these patients the internal mammary artery diameter also was measured during surgery with a sterile caliper, and blood was collected for 30 seconds from the transected internal mammary artery to measure flow. These findings were compared to the preoperative values. In 243 patients the mean internal mammary artery diameter was 2.34 +/- 0.03 mm, and mean peak systolic blood flow was 226.7 +/- 6.3 ml/min. In the 45 patients in whom intraoperative measurements were obtained, preoperative mean internal mammary artery diameter was 2.39 +/- 0.05 mm and was not significantly different from the intraoperative mean internal mammary artery diameter of 2.36 +/- 0.04 mm. Preoperative peak systolic flow was 231.3 +/- 8.1 ml/min, and mean flow was 110.3 +/- 7.1 ml/min; intraoperative flow measured 136 +/- 3.6 ml/min. Noninvasive determinations correlated with operative findings for internal mammary artery diameter (r = 0.87) (p less than 0.05), peak systolic blood flow (r = 0.70) (p less than 0.05), and mean blood flow (r = 0.60) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗