Poster 85: Payment-Efficiency Analysis of Joint Replacement Rehabilitation in Skilled Nursing and Inpatient Rehabilitation Facilities

Poster 85: Payment-Efficiency Analysis of Joint Replacement Rehabilitation in Skilled Nursing and Inpatient Rehabilitation Facilities

2009 ACRM–ASNR JOINT EDUCATIONAL CONFERENCE ABSTRACTS Measurement, Health Policy, and Other Poster 82 Peer Mentoring Outcomes and Processes in In-Pat...

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Measurement, Health Policy, and Other Poster 82 Peer Mentoring Outcomes and Processes in In-Patient Rehabilitation: A Mixed-Methods Study Integrating Multiple Stakeholder Perspectives. Susan Magasi (Northwestern University, Brookfield, IL), Christina Papadimitriou, Lisa Rosen, Kristine Cichowski. Disclosure: None declared. Objective: To evaluate the outcomes and processes of a coordinated peer mentoring program in inpatient rehabilitation from the perspective of multiple rehabilitation stakeholders. Design: Iterative 3-phase mixed-methods design, including: (1) in-person patient surveys, (2) peer mentor focus groups, and (3) an internet-based survey of rehabilitation providers. Setting: Large free-standing rehabilitation hospital in the Midwestern United States. Participants: Rehabilitation inpatients (n⫽50), trained peer mentors with spinal cord injuries, strokes, traumatic brain injuries and amputations (n⫽19), rehabilitation professionals (n⫽366). Interventions: Not applicable. Main Outcome Measures: (1) 20-item in-person patient satisfaction survey that evaluates peer mentoring outcomes and processes, including: perceived benefits, quality of interactions, overall satisfaction, and resources sharing. (2) 27-item internet-based provider survey of knowledge and use of peer mentoring services including barriers to use. Results: Rehabilitation inpatients (94%) rated peer mentoring as an important component of the rehabilitation process. Inpatients reported receiving informational (90%), emotional (77%) and appraisal support (94%) from their interactions with disabled peer mentors. Informational support was most frequently related to independent living and community participation. Providers rated peer mentoring as an important component of the rehabilitation process (98%) and endorsed its coordination with clinical staff to support integration (60%) and communication (76%). Survey and focus group data point to the importance of systematic coordination of clinical and nonclinical staff for a successful peer mentoring program. They also suggest that important barriers to successful integration of peer mentors include concerns over patients’ readiness for peer interventions, clinician time constraints, and reduced patient stays. Conclusions: This study elucidates the process, outcomes, and integration of a coordinated peer mentoring program in inpatient rehabilitation. The study findings can help inform the development of best practice guidelines for peer mentoring services. Key Words: Program evaluation; Rehabilitation. Poster 83 Locked-In Syndrome in Children: Etiology, Diagnosis and Prognosis. Review of the Literature and Report of Cases. Marie-Aure´lie Bruno (University of Lie`ge, Lie`ge, Belgium), Caroline Schnakers, Franc¸ois Damas, Fre´de´ric Pellas, Steve Majerus, Gustave Moonen, Serge Goldman, Steven Laureys. Disclosure: None declared. Objectives: Some children may awake from their coma being nearly completely paralyzed and only able to communicate via eye movements. This condition is called the Locked-In Syndrome (LIS) (Plum and Posner, 1983) and is a rare neurologic disorder defined by the presence of sustained eye opening, preserved awareness, aphonia or hypophonia, quadriplegia or quadriparesis, and a primary mode of communication that uses vertical or lateral eye movement or blinking. The rarity of LIS in children causes the diagnosis to be oftentimes missed and/or delayed. Additionally, there is not much literature informing pediatric physicians and medical professionals about the management of LIS in children. Data Sources: Medline search September 2008 for papers in English, French, Spanish and German. Retrospective multicentric case-series. Study Selection: We here review previous literature on LIS in children and adolescents and report


5 cases. Data Extraction: The most common etiology is ventral pontine stroke (20 out of 33 published cases including our 5 patients; ie, 61%), most frequently caused by a vertebrobasilar artery thrombosis or occlusion. Concerning the prognosis, 2 of our reported cases died (3 months and 2.5 years after onset; the former after treatment withholding) and 3 survived (one up to 11 years postinsult) remaining with a severely handicapped motricity. The most pediatric LIS patients show some motor recovery (11 out of 31; 35%); in 26% good recovery was reported, 16% remained quadriplegic and anarthric, and 23% died. Data Synthesis: Our review is the first to summarize LIS case-studies in children. Due to the rarity of the condition in children, the diagnosis of LIS may be missed and patients may wrongly be considered as being in a coma, vegetative state, or akinetic mutism. Conclusions: The discussed data stress the need for pediatric physicians to carefully interpret signs and symptoms of LIS. Key Words: Children; Locked-in syndrome; Rehabilitation. Poster 84 The Effects of Revised Exercise Programs for People with Disabilities Who Already Exercise. Nancy Flinn (Courage Center, Minneapolis, MN), Erin Simunds. Disclosure: None declared. Objective: To evaluate the effectiveness of re-evaluation and revision of exercise programs for people with disabilities who have been exercising regularly. Design: Cohort analysis. Setting: Fully accessible fitness program in a community-based rehabilitation center. Participants: Fifty-eight adults with disabilities who had been exercising for an average of 31 months⫾14.0. The participants had a variety of medical diagnoses, including brain injury (12), cerebral palsy (10), neurological diseases (9), stroke (8), spinal cord injury (5) and other (13). 28 women and 30 men enrolled in the project, with an average age 43.7 years ⫾11.8. Interventions: The primary intervention was an individualized exercise program. There were 3 points of evaluation: original intake into program, when the original exercise program was developed; the first reevaluation, during which a revised exercise program addressing strengthening, endurance, and flexibility was presented; the second reevaluation was completed after participants had exercised independently or with assistance for a 6-month period using the revised program. Main Outcome Measures: Endurance, strength, weight and secondary conditions. Results: Participants made significant gains in endurance, but changes in exercise program appeared to have no significant effect on strength or weight loss. Participants reported significant decreases in secondary conditions (P⫽.04), with an average decrease of .73 conditions between their original intake into the exercise program and the second reevaluation. Most commonly decreased conditions included bone and joint pain, leg pain with activity, and breathing problems. Conclusions: Program revision increased the intensity of the exercise program, and resulted in increased endurance, but not in increased strength or weight loss. The 37 months of exercise participation did decrease secondary conditions in the sample. This study demonstrates the value exercise in health promotion for a sample of individuals with a variety of disabilities. Key Words: Disability; Exercise; Rehabilitation. Poster 85 Payment-Efficiency Analysis of Joint Replacement Rehabilitation in Skilled Nursing and Inpatient Rehabilitation Facilities. Wenqiang Tian (National Rehabilitation Hospital, Washington, DC), Gerben DeJong, Koen Putman. Disclosure: None declared. Objective: To assess the payment-efficiency for joint replacement rehabilitation in skilled nursing facilities (SNFs) and inpatient Arch Phys Med Rehabil Vol 90, October 2009



rehabilitation facilities (IRFs). Design: Prospective observational cohort study. Setting: 7 SNFs and 11 IRFs across the nation. Participants: 1,566 participants including 948 knee replacement and 618 hip replacement patients receiving rehabilitation care at either a SNF or IRF. Interventions: None. Main Outcome Measures: Payment-efficiency was measured by 2 means: simple ratio: changes in motor FIM score divided by log-transformed payment, and efficiency score taking both payment and length of stay into account obtained by Stochastic Frontier model. Results: IRF patients incur higher costs than SNF patients while having shorter lengths of stay. This is true for both knee replacement ($9,610⫾$2,394 in 9.0⫾3.7 days vs $5,549⫾$2,870 in 14.2⫾7.2 days) and hip replacement ($10,380⫾$2,614 vs $6,164⫾$3,489 in 10.1⫾4.8 days vs 15.9⫾8.6 days). IRF patients entered with lower motor FIM scores (for knee: 42.4 vs 50.7, P⬍.001; for hip: 39.1 vs. 47.8, P⬍.001) and achieved larger motor FIM gains than SNF patients (for knee: 25.9 vs 21.2, P⬍.001; for hip: 26.5 vs 22.7, P⬍.001). IRFs had higher payment efficiency than SNFs did for knee replacement patients in both measurements. However, no difference in efficiency score was found between SNFs and IRFs for hip replacement patients. Controlling for patient characteristics and severity, multivariate analyses showed that IRFs were more paymentefficient for knee replacement patients, but not for hip replacement patients. Conclusions: Despite receiving a higher payment from Medicare, IRFs are more payment-efficient in providing rehabilitation care to knee replacement patients but not hip replacement patients. Key Words: Joint replacement; Rehabilitation. Poster 86 Ergonometric, Neurophysiologic and Psychological Factors of Rehabilitation at Total Hip Arthroplasty. Sergey Lytaev (Saint Petersburg State Pediatric Medical Academy, Saint Petersburg, Russian Federation), Sergey Maltsev, Andrei Trapeznikov, Ivan Shpita, Dmitry Nazarov. Disclosure: None declared. Objective: The physiologic and psychologic factors for early rehabilitation’s optimization. Design: Controlled clinical study. Setting: Rate of rehabilitation during 2–3 weeks in clinic. Participants: 82 patients (33 men, 49 women), age 36 – 67 years. Interventions: The exercises on the training simulator, registration of the somatosensory evoked potentials (SEPs) and psychologic testing. Main Outcome Measures: The energy productions (E), power of force (W), SEPs mapping, were testing by SCL-90-R, Luscher, Spilberger, Lazarus, and the test of the attitude to illness. Results: E and W were increased (P ⬍.05) at 19 subjects, at 12 subjects – were reduced. SEPs at 17 subjects at a sciatic nerve’s neuropathy were registered. SEP maps where the potential is formed more than in 60% of sites are considered as favorable for rehabilitation. Results of psychologic testing are discussed under: 1. Influence of illness on the person, 2. Variants of the attitude to illness, 3. Adaptive behavior and their correction. Conclusions: Among physiologic factors it is emphasized on various variants of energy power for motor restoration and somatosensory streams’ selectivity. Psychologic support concentrates on dysadaptation and on mechanisms of adaptive behavior. Key Words: Arthroplasty; Hip; Rehabilitation. Poster 87 Functional Outcomes and Return to Primary Service Among Bone Marrow Transplant Rehabilitation Inpatients. Jack Fu (University of Texas M. D., Anderson Cancer Center, Houston, TX), Henrique Parsons, Benedict Konzen. Disclosure: None declared. Objective: To assess bone marrow transplant inpatient rehabilitation risk of return to primary service and poorer functional improveArch Phys Med Rehabil Vol 90, October 2009

ment. Design: Descriptive retrospective review of medical records. Setting: Major national cancer hospital. Participants: 55 patients admitted to inpatient rehabilitation between January 1, 2005 and December 31, 2007 with a diagnosis of bone marrow transplant, regardless of primary cancer. Intervention: Analysis was performed. Main Outcome Measures: Return to primary service and factors including age, gender, race, albumin, marital status, white blood cell count, platelet count, peripheral white cell count, albumin, prealbumin, creatinine, and type of primary cancer. Functional improvement was also analyzed with respect to the above factors. Results: 52% of bone marrow transplant patients transferred back to the primary service. Of those that transferred back, 45% died after being transferred back to the primary service. Only 13% of patients transferred back to the primary service were alive as of March 1, 2009. 50%, 64%, and 50% of leukemic, lymphoma, and multiple myeloma transplant patients were transferred back to the primary service respectively. There was 1 patient with breast cancer and one with germinoma, neither of whom were transferred back. Mean length of stay on rehabilitation was 9.41 days. Mean length of stay in hospital before rehabilitation was 38.38 days. Mean total FIM efficiency was 0.93. Conclusions: Bone marrow transplant patients have a high rate of transfer back to the primary service. A significant amount of these patients transferred back died before leaving the hospital. The study illustrates the medical fragility of this patient population. Close follow-up by the primary team while on inpatient rehabilitation is recommended. Key Words: Bone Marrow Transplant; Cancer; Rehabilitation.

Poster 88 Neurocognitive Training in Normal Older Adults: Effects of Categorization Training. Fofi Constantinidou (University of Cyprus, Nicosia, Cyprus), Abby Migut. Disclosure: None declared. Objective: To test the hypothesis that a systematic cognitive training with the Categorization Program (CP) will improve categorization abilities and neuropsychologic performance in normal older adults. Design: Before-after between group comparison. Setting: Standard Clinical Setting. Participants: Group 1 was the older adult group (n ⫽ 14) and group 2 the younger adults (n ⫽ 15). Average age and years of education was 67.285⫾10.469 and 14.107⫾2.321 for older and 29.69 years⫾10.87 and 14.38 years⫾1.927 for younger adults. Intervention: Subjects received 3– 4 hours of cognitive treatment per week for 10 –12 weeks. Main Outcome Measures: Two categorization tests (CP Test 1 and CP Test 2) and 3 probe tasks (to check generalization of skills) were constructed for the CP along with extensive neuropsychologic battery. Results: There was no difference between groups in the pretest administration on the CP Test 1. MANOVA analyses demonstrated significant improvement in CP Test 1 (P⫽.0001) for both groups. Younger subjects demonstrated greater gains than older subjects (P⫽.002). Both groups scored improved on CP Test 2 at posttest (P⫽.027). Subjects also demonstrated gains in their probe tasks across time (P⫽.049). The performance of older subjects approximated the baseline performance of younger subjects after CP training. Conclusions: Normal aging affects certain aspects of categorization performance. The CP is an effective tool to train categorization skills in normal older adults. Future research should expand the subject population to include a larger number of participants. In addition, the inclusion of patients with mild cognitive impairment (MCI) may be another fruitful line of investigation. Key Words: Aging; Categorization; Cognition; Rehabilitation; Retraining.