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  • Time to Standardize Acute Care Rehab for Patients Poststroke, Say Researchers

    Not all rehabilitation is equal for acute care hospital patients with ischemic stroke, say researchers in an article published in the May issue of PTJ (Physical Therapy). Authors found “significant variation” in the use of hospital-based rehabilitation services that “suggest a timely opportunity to standardize rehabilitation service delivery in acute settings for patients with ischemic stroke.”

    While current guidelines recommend early mobilization during hospitalization for ischemic stroke, authors write, they do not “provide clear recommendations on the optimal dosage of therapy.” This, combined with no incentive for hospitals to report on functional status to the US Centers for Medicare and Medicaid Services (CMS), led researchers to examine Medicare claims data from 104,295 patients in 2010 to identify what factors were associated with the type and amount of rehabilitation services patients received while in acute care settings.

    Overall, authors found that only 85.2% received any rehabilitation services: 61.5% received both physical and occupational therapy; 22% received only physical therapy; and 1.7% received only occupational therapy.

    Patients were more likely to receive any type of rehabilitation services if they were older than 70 years of age, had longer lengths of stay, or had received tissue plasminogen activator (tPA).

    However, patients were 16% less likely to receive rehabilitation services if they were dual-eligible for both Medicare and Medicaid, and 11% less likely if they had a recent prior history of hospitalization. Men also were less likely to receive therapy, and patients with more severe stroke—who required an ICU stay or feeding tube—were significantly less likely to receive rehabilitation services.

    There also was variation in the number of minutes of therapy patients received. While patients received an average of 123 minutes of therapy over 4.8 days, authors write, “dual-eligible patients received 5 minutes less therapy compared with non–dual-eligible patients, and patients receiving tPA received 16 more minutes of therapy.” Patients with a feeding tube received 5 more minutes of therapy than those without, on average. [Editor's note: APTA's PTNow online resource offers a clinical summary on stroke as well as guidelines on interventions to address neuroplasticity.]

    In addition, certain hospital characteristics played a role: Rural hospitals, hospitals with a higher volume of patients with stroke, and hospitals with an inpatient rehabilitation unit were linked to a higher likelihood of receiving rehabilitation services. Patients who received rehabilitation services in a limited teaching hospital or nonteaching hospital received an average 19 and 20 more minutes of therapy, respectively.

    Authors found substantial variability in use of rehabilitation services across acute care hospitals, even after accounting for length of stay and other patient and hospital-level factors. Approximately 38% of hospitals provided significantly less (76.3 minutes during the whole length of stay) than the national average of rehabilitation services minutes (123 minutes), whereas 22.4% provided significantly more (180.7 minutes) than the national average. Authors suggest a number of factors contributing to this variation, including a “lack of clear guidance on rehabilitation timing and dosage in the acute care setting” and a hospital reimbursement structure that encourages cost savings by decreasing length of stay and rehabilitation services.

    However, hospitals with inpatient rehabilitation units were more likely to deliver rehabilitation services to these patients, possibly because they are specialized in providing comprehensive care, and therapists “can be proponents of providing upstream rehabilitation interventions to improve downstream outcomes.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • This has more to do with staffing in acute care. My hospital routinely assigns 30+ patients to each PT per day and it is up to us to prioritize pending discharges and the rest of the patients get triaged. How about some acute care patient to PT rarios like we have for RN's? We can't measure outcomes if we don't have the staff.

      Posted by Kristen Krueger on 5/4/2019 2:45 AM

    • In response to Kristen Krueger’s comment, do a PT at your facility really have a caseload of 30+ patients PER DAY??? That’s awfully a lot of patients! Unless she does 8 minutes of eval-Tx per pt and do charting the rest of the day. In our hospital we have the Stroke accreditation and we must evaluate all pts with CVA even if the pt is walking-talking in the hallways. Those walking talking pts would be considered the 15% not receiving treatments.

      Posted by Alex Dewey on 5/4/2019 9:42 AM

    • I really appreciate it that you mentioned how patients with male patients who have been brought to the ICU and are on dual Medicare and Medicaid eligibility are the most unlikely patients to get long and more efficient stroke rehabilitation therapy services. This is precisely why it would be more advantageous for my dad to seek stroke therapy in rural hospitals with a lot of stroke patients because these are where he'd likely end up with the right and proper services for his condition. Since it would be terrible for his newly opened art gallery dealership not to have him doing the work personally, it would surely be more beneficial if he gets only the best stroke therapy so he could bounce back faster and get back to driving his car soon.

      Posted by Angel Bogart on 5/9/2019 3:55 AM

    • We find that there is a decrease in going to a nursing center after a total joint replacement whether or not they are in a bundled care system. They are only going to those facilities if they live alone, have a lot of stairs or have mental impairments that make it difficult to go straight home and are over 65.

      Posted by Kathryn Hammer on 5/11/2019 11:24 AM

    • I think it would have been very interesting to see how patients at varying levels of acute rehab intensity recovered. Perhaps they can use IRF FIM scores, SNF MDS scores, or have a sample complete the Stroke Impact Scale post rehab; in order to better assess the impact of early rehab intensity on recovery outcomes.

      Posted by Ron Vollen on 5/13/2019 8:32 AM

    • Seems there is a lot more to consider for example tolerance to therapy, severity of CVA, level of alertness, cooperation, support system, and other related services involved, before you can make any generalizations.

      Posted by Sandra Scanlan on 6/1/2019 5:26 PM

    • We are a comprehensive Stroke Center, have been through cert with Joint Commission and DNV. There is evidence that too aggressive rehab too early with a stroke (AVERT trials) can result in worse functional outcomes, at time of dc and in further down the road. I have seen it in my 24 yrs of clinical practice. And an MD can document that the patient is back at baseline and does not need a PT or OT eval to dc from the facility. The GWTG state only that they have been assessed for the need for rehab.

      Posted by Lara A Firrone on 6/12/2019 9:05 PM

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