Performance measures and clinical outcomes.
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Benchmarking↗
Biomedical subjects
Susan D Horn
Publications and source records attributed to Susan D Horn.
The post-stroke rehabilitation outcomes project revisited.
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Clinical Trials as Topic↗
Measuring medical complexity during inpatient rehabilitation after traumatic brain injury.
OBJECTIVE: To compare the performance of 3 severity of illness (SOI) indices--the Comprehensive Severity Index (CSI), All Patient Refined Diagnosis Related Groups Severity of Illness, case-mix group (CMG)--and 5 well-known neurologic parameters, as measures of medical complexity. DESIGN: Retrospective chart review. SETTING: Inpatient rehabilitation center within a level I trauma center. PARTICIPANTS: Consecutive traumatic brain injury (TBI) admissions (N=212). INTERVENTION: Acute inpatient TBI rehabilitation. CSI and neurologic parameters were scored by chart extraction. SOI was based on diagnosis codes by using 3M PC Grouper software, version 15. MAIN OUTCOME MEASURES: Adjusted R 2 was used to predict rehabilitation charges as a proxy of medical complexity. RESULTS: The highest adjusted R 2 values for single variables predicting charges were: CMG .349, CSI .293, duration of posttraumatic amnesia .260. Adjusted R 2 values for the CMG combined with the CSI, 5 neurologic parameters, and SOI to predict charges were .446, .431, and .365, respectively. CONCLUSIONS: The CMG was the best single predictor of rehabilitation charges for TBI. Predictive ability was better when the CMG was combined with the CSI or a combination of the 5 neurologic parameters. A severity index based on objective clinical findings rather than diagnostic codes may have distinct advantages for rehabilitation outcome studies and reimbursement methodology.
Adolescent↗
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↗
Nutrition support (tube feeding) as a rehabilitation intervention.
UNLABELLED: James R, Gines D, Menlove A, Horn SD, Gassaway J, Smout RJ. Nutrition support (tube feeding) as a rehabilitation intervention. OBJECTIVE: To describe site variation in use of enteral feeding and its association with stroke rehabilitation outcomes, controlling for a variety of confounding variables. DESIGN: Prospective observational cohort study. SETTING: Six inpatient rehabilitation facilities in the United States. PARTICIPANTS: Patients (N=919) from the Post-Stroke Rehabilitation Outcomes Project database with moderate or severe stroke who were discharged to home, community, or skilled nursing facility. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in total, motor, and cognitive FIM instrument scores and change in severity of illness. RESULTS: Monitoring of nutritional status and the frequency of tube-feeding interventions for patients with moderate and severe stroke varied significantly among sites. Patients with tube feeding had higher severity of illness and lower functioning on admission compared with patients who did not receive tube feeding. However, when we controlled for severity of illness, admission FIM score, and other important covariates, we found that patients with severe strokes who were tube fed for more than 25% of their stay had greater increases in total, motor, and cognitive FIM scores and greater improvement in severity of illness by discharge. CONCLUSIONS: Nutrition support (tube feeding) is an effective therapy in rehabilitation service for patients with severe strokes and is associated with greater motor and cognitive improvements, even in patients with the most severe strokes.
Activities of Daily Living↗
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↗
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↗
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↗
Physical therapy during stroke rehabilitation for people with different walking abilities.
UNLABELLED: Latham NK, Jette DU, Slavin M, Richards LG, Procino A, Smout RJ, Horn SD. Physical therapy during stroke rehabilitation for people with different walking abilities. OBJECTIVE: To describe how physical therapy (PT) activities during post-stroke inpatient rehabilitation vary by admission walking ability and over time. DESIGN: Observational cohort study. SETTING: Six inpatient rehabilitation hospitals in the United States. PARTICIPANTS: People receiving post-stroke PT (N=715) who were classified as walking at admission. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Percentage of time spent in 11 activities, percentage of patients who participated in each activity, and the FIM instrument scores. RESULTS: The majority of PT time was spent in gait activities. Even people with the most limited mobility spent 25% to 38% of PT time in gait activities during the first 6-hour treatment block. Treatment progression was evident, and a shift to more advanced activities occurred over time (eg, less bed mobility and more advanced gait). However, even in the final 6-hour block, a small proportion of time was spent on community mobility activities (1.2%-5.2%), and most people received no community mobility training. CONCLUSIONS: PT activities focused on specific functional tasks at the ability level of each individual patient and provided higher-level activities as patients improved their function. However, although there is increasing recognition that the environment influences task performance, little time was spent in community mobility activities before discharge.
Activities of Daily Living↗
An exploration of central nervous system medication use and outcomes in stroke rehabilitation.
UNLABELLED: Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An exploration of central nervous system medication use and outcomes in stroke rehabilitation. OBJECTIVE: To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables. DESIGN: Observational cohort study of post-stroke rehabilitation. SETTING: Six inpatient rehabilitation hospitals in the United States. PARTICIPANTS: Patients with moderate or severe strokes (N=919). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition, FIM score change, and rehabilitation length of stay (LOS). RESULTS: Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neuro-stimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counter-intuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation. CONCLUSIONS: There are many opportunities to enhance a stroke survivor's ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups.
Activities of Daily Living↗
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↗
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↗
The National Hospice Outcomes Project: development and implementation of a multi-site hospice outcomes study.
Hospice has become a major component of end-of-life care, but little scientific information is available to guide clinicians in knowing when the use of hospice is appropriate, in knowing how to measure the impact of its care, and in knowing which hospice interventions lead to the best outcomes. The National Hospice Outcomes Project (NHOP) arose from the need to identify patient factors and hospice interventions that are associated with better end-of-life outcomes. Clinical Practice Improvement (CPI) methodology allowed us to generate a large comprehensive database that could identify scientifically hospice interventions associated with better outcomes for specific patient populations. The complex interplay of patients, medical and complementary treatments, and families can be evaluated. This paper describes an overview of the research methods used for the NHOP, describes the project's 13 clinical sites and study population of 1,306 patients, and presents some basic findings from the study.
Adult↗
RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care.
OBJECTIVE: A clear link has been demonstrated between lower nurse staffing levels in hospitals and adverse patient outcomes, but the results of studies of such relationships in long-term care facilities haven't been as clear. This study explored the time nurses spent in direct care and how it affected outcomes in long-stay (two weeks or longer) nursing home residents. METHODS: In a retrospective study of data collected as part of the National Pressure Ulcer Long-Term Study (NPULS), we analyzed data on 1,376 residents of 82 long-term care facilities whose lengths of stay were 14 days or longer, who were at risk of developing pressure ulcers but had none at study entry, and who had a Braden Scale score of 17 or less. Primary data came from residents' medical records during 12-week periods in 1996 and 1997. Dependent variables included development of pressure ulcer or urinary tract infection (UTI), weight loss, deterioration in the ability to perform activities of daily living (ADLs), and hospitalization. Independent variables included resident demographics, severity of illness, nutritional and incontinence interventions, medications, and nurse staffing time. RESULTS: More RN direct care time per resident per day (examined in 10-minute increments up to 30 to 40 minutes per resident per day) was associated with fewer pressure ulcers, hospitalizations, and UTIs; less weight loss, catheterization, and deterioration in the ability to perform ADLs; and greater use of oral standard medical nutritional supplements. More certified nursing assistant and licensed practical nurse time was associated with fewer pressure ulcers but did not improve other outcomes. CONCLUSIONS: The researchers controlled for important variables in long-stay nursing home residents at risk for pressure ulcers and found that more RN direct care time per resident per day was strongly associated with better outcomes. There's an urgent need for further research to confirm these findings and, if confirmed, for improving RN staffing in nursing homes to decrease avoidable adverse outcomes and suffering.
Activities of Daily Living↗
Cost analysis of nursing home registered nurse staffing times.
OBJECTIVES: To examine potential cost savings from decreased adverse resident outcomes versus additional wages of nurses when nursing homes have adequate staffing. DESIGN: A retrospective cost study using differences in adverse outcome rates of pressure ulcers (PUs), urinary tract infections (UTIs), and hospitalizations per resident per day from low staffing and adequate staffing nursing homes. Cost savings from reductions in these events are calculated in dollars and compared with costs of increasing nurse staffing. SETTING: Eighty-two nursing homes throughout the United States. PARTICIPANTS: One thousand three hundred seventy-six frail elderly long-term care residents at risk of PU development. MEASUREMENTS: Event rates are from the National Pressure Ulcer Long-Term Care Study. Hospital costs are estimated from Medicare statistics and from charges in the Healthcare Cost and Utilization Project. UTI costs and PU costs are from cost-identification studies. Time horizon is 1 year; perspectives are societal and institutional. RESULTS: Analyses showed an annual net societal benefit of 3,191 dollars per resident per year in a high-risk, long-stay nursing home unit that employs sufficient nurses to achieve 30 to 40 minutes of registered nurse direct care time per resident per day versus nursing homes that have nursing time of less than 10 minutes. Sensitivity analyses revealed a robust set of estimates, with no single or paired elements reaching the cost/benefit equality threshold. CONCLUSION: Increasing nurse staffing in nursing homes may create significant societal cost savings from reduction in adverse outcomes. Challenges in increasing nurse staffing are discussed.
Aged↗
The National Pressure Ulcer Long-Term Care Study: outcomes of pressure ulcer treatments in long-term care.
OBJECTIVES: To identify resident, wound, and treatment characteristics associated with pressure ulcer (PrU) healing in long-term care residents. DESIGN: Retrospective cohort study with convenience sampling. SETTING: Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States. PARTICIPANTS: Eight hundred eighty-two residents, aged 18 and older, with length of stay of 14 days or longer, who had at least one Stage II to IV PrU. MEASUREMENTS: Data collected for each resident over a 12-week period included resident characteristics, treatment characteristics, and change in PrU area. Data were obtained from medical records, Minimum Data Set, and other records. RESULTS: Two multiple regression models, one for each stage grouping (Stage II, Stage III and IV), were completed. The area of Stage II PrU was reduced more with moist (F=21.91, P<.001) than with dry (F=13.41, P<.001) dressings. PrUs cleaned with saline or soap showed less decrease in area (F=12.34, P<.001) than PrUs cleaned with other cleansers such as antiseptic, antibiotic, or commercial cleansers. Change in area of Stage III and IV PrUs was related to sufficient enteral feeding (F=5.23, P=.02), enteral feeding without higher acuity levels (F=3.94, P=.048), size of PrU (very large (F=120.89, P=.001) and large (F=27.82, P=.001)), and type of dressing (moist (F=14.70, P<.001) and dry (F=5.88, P=.02)). Stage III and IV PrUs increased in area when debrided (F=5.97, P=.02). The overall models were significant (Stage III and IV, F=20.30, coefficient of determination (R2)=0.06, P<.001; Stage II, F=40.28, R2=0.13, P<.001) but explained little of the variation in change in PrU area. CONCLUSION: In this sample of nursing facility residents, use of moist dressings (Stage II, Stage III and IV) and adequate nutritional support (Stage III and IV) are strong predictors of PrU healing.
Adolescent↗
Neurostimulant medication usage during stroke rehabilitation: the Post-Stroke Rehabilitation Outcomes Project (PSROP).
Motor recovery after a stroke depends upon many upon different modalities. Intensive therapy using compensatory and facilitatory techniques is the primary method to improve movement and function in affected extremities. However, medications used to modulate neurotransmitters may be useful in augmenting therapy approaches. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the frequency of prescribing neurostimulant medications; the types of neurostimulant medications used; and how the use of neurostimulant medications affected rehabilitation length of stay, motor recovery, cognitive recovery, and discharge destination. Of the 1,161 patients in the PSROP database, 929 (80.0%) patients did not receive any treatment with methylphenidate, modafinil, levodopa, amantadine, or bromocriptine. Patients who received neurostimulant medications did not have any more significant changes in length of stay, motor recovery, cognitive recovery, or discharge destination than patients who did not receive neurostimulant medications. Much research needs to be completed before clinicians know precisely whether and how rehabilitation therapies and medications interact to assist in functional recovery.
Aged↗
Antihypertensive medication usage during stroke rehabilitation: the Post-Stroke Rehabilitation Outcomes Project (PSROP).
Blood pressure management is an important issue for the primary prevention, acute management, and secondary prevention of a stroke. Rehabilitation professionals need to consider the timing in lowering blood pressures in stroke survivors, the types of medications that should be used in managing hypertension, and the target pressures to achieve. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the types of antihypertensive medications prescribed to stroke survivors, compare prescription patterns with current practice guidelines of the management of hypertension after a stroke, and determine whether systolic and diastolic blood pressures decrease during admissions to inpatient rehabilitation facilities (IRFs). Of the 1,161 patients in the PSROP database, the most commonly prescribed antihypertensive medications were the angiotensin-converting enzyme antagonists and angiotensin II antagonists, followed by beta-blockers, calcium-channel blockers and diuretics, adrenergics (alpha-blockers), and other (minoxidil, hydralazine) medications. Systolic, diastolic, and mean arterial pressures declined in participants during admissions to IRFs. However, blood pressures were significantly higher throughout IRF stays in participants receiving antihypertensive medications when compared to those not receiving antihypertensive medications. Rehabilitation professionals need to be cognizant of the relationship between stroke and hypertension, clinical practice guidelines that provide evidence-based management tools for hypertension, and patient issues that may hinder the effective treatment of hypertension.
Aged↗