Abstract
Objective
Present yearly aggregated summaries of rehabilitation outcomes at admission, discharge, and follow-up from a national sample of patients receiving inpatient medical rehabilitation for stroke, traumatic brain injury, lower extremity fracture, lower extremity joint replacement, traumatic spinal cord injury, or debility.
Design
Analysis of secondary data from more than 300 inpatient rehabilitation facilities in the United States that contributed inpatient and follow-up data to the Uniform Data System for Medical Rehabilitation during the period January 2002 through December 2010. Aggregate variables reported include demographic information, social situation, and functional status (FIM® instrument ratings at admission, discharge, and follow-up). Follow-up data were obtained 80–180 days post-discharge through telephone interviews by trained clinical staff.
Results
The final sample included 287,104 patients with follow-up information. Median time to follow-up was 95 days. Overall, more than 90% of patients within each impairment group were living in the community at follow-up. Follow-up FIM total ratings were stable to slightly increased over time. Change scores (discharge to follow-up) increased in all six groups. Mean FIM gains from discharge to follow-up, as a percentage of mean gains from admission to discharge, varied by impairment category: 46% for spinal cord injury to 71% for lower extremity fracture. Locomotion yielded the lowest ratings at all three assessments within each of the six impairment groups.
Conclusions
Follow-up data from a national sample of patients discharged from inpatient rehabilitation indicate that gains in mean functional independence scores from both admission to discharge and discharge to follow-up gradually increased from 2002 to 2010. At follow-up, more than 9 out of 10 patients in all 6 groups are living in the community.
Keywords: Benchmark, Evaluation, Quality Improvement
This article complements a series of six impairment-specific reports of multi-year data from the Uniform Data System for Medical Rehabilitation database (UDSMR® database) providing national benchmarking information for follow-up information on key rehabilitation outcomes. The current report includes follow-up data on a subset of patients with stroke, traumatic brain injury, lower extremity fracture, lower extremity joint replacement, traumatic spinal cord injury, or debility who received inpatient rehabilitation services from 2002 through 2010 in facilities that subscribed to the UDSMR. Recent reports published in this journal contain the admission and discharge benchmark information for patients in these rehabilitation impairment categories.1–6 An earlier report containing follow-up information from 1994–1996 was also published in this journal.7
Following a debilitating illness or injury, patients and family members universally desire recovery of functional independence to enable a return to community living. Traditionally, inpatient providers have had no established need and few if any resources to document patient outcomes and experiences following discharge. The Affordable Care Act8 contains several provisions (e.g. readmission reduction, bundled payments, and care coordination) that expand provider accountability beyond the immediate stay. In other words, the financial incentives (penalties) included in these provisions have heightened the interest of upstream providers in the downstream care and longer-term outcomes their patients experience. Implicit in this expanded episode-of-care framework are the needs and impacts of family caregivers and the understanding that longer-term recovery of health status and independence are largely a function of a person’s combined formal and informal care networks.9
Our goal for this report was to display yearly aggregated summaries of select rehabilitation outcomes in a natural, meaningful sequence (admission, discharge, follow-up) for patients within the six largest impairment groups receiving inpatient medical rehabilitation services. We believe this information can serve as a valuable resource for all stakeholders working to improve the long-term outcomes, care transitions, and/or care coordination for persons requiring intensive post-acute rehabilitation services.
METHODS
Data Source
The UDSMR, a not-for-profit organization affiliated with the UB Foundation Activities, Inc. at the State University of New York at Buffalo, maintains the largest non-governmental database for inpatient medical rehabilitation outcomes. The UDSMR® database contains administrative and functional assessment data for patients receiving inpatient rehabilitation services. Approximately 70% of inpatient rehabilitation facilities (free-standing inpatient rehabilitation hospitals or acute hospital-based rehabilitation units) in the United States utilize UDSMR services. Several facilities collect follow-up information from a subset of patients as part of their quality assurance or improvement programs. This report contains yearly aggregated summaries for persons who were discharged from inpatient rehabilitation between January 2002 and December 2010 and were followed up between March 2002 and June 2011.
Inclusion Criteria
To maintain consistency between these cohorts with follow-up and the larger inpatient populations in which they are included, we applied the same five criteria used in the series of prior reports: 1) the patient must have been receiving initial rehabilitation services (i.e., no persons admitted for evaluation or readmissions), 2) the record could not have missing data for discharge setting or functional measures (this excludes patients who died during their rehabilitation stay), 3) the patient had to be less than 105 years at admission, 4) the duration from impairment onset to rehabilitation admission could not exceed 365 days (1 year), and 5) the total length of stay could also not exceed 1 year.
Variable Definitions
Functions Status
Information on functional status is based on ratings from the Functional Independence Measure or FIM® instrument. The FIM instrument includes 18 items covering 6 domains (self-care, sphincter control, transfer, locomotion, communication, and social cognition). Each item is rated on a scale from 1 (complete dependence) to 7 (complete independence); higher ratings representing greater functional independence (summed scores range from 18 to 126). FIM ratings are also presented as Motor and Cognition subscales. The Motor subscale includes 13 items across 4 domains: sphincter control, self-care, transfer, and locomotion. The Cognition subscale includes 5 items across 2 domains: communication and social cognition. Assessments were conducted at admission, discharge, and 80–180 days post discharge. The follow-up ratings were obtained through telephone interviews by clinical staff trained in the administration and interpretation of the FIM. The validity and reliability of the FIM instrument, including self-report by phone interview, have been documented by independent investigators.10;11 Agreement between in-person and phone FIM total ratings is high: intraclass correlation coefficient = 0.97.11
Community Setting
Community setting refers to the person’s primary residence at the time of assessment. Community includes assisted living, board and care, or transitional living settings, whereas the reference (non-community) category includes all institutional settings.
Living Alone
Living alone describes the person’s social situation at his or her residence. The not-alone category includes family, friends, or an attendant.
Vocation
Vocation classifies self-reported work status. The other category includes student, homemaker, or other.
Health Maintenan
Health maintenance designates who is primarily responsible for the person’s ongoing care. Paid help includes a paid attendant or skilled professional.
Therapy
Therapy indicates the type of care, if any, that a person received following inpatient rehabilitation discharge. The outpatient /home category includes either or both types of care. The other category includes long-term care, day-treatment, or other types of inpatient services.
RESULTS
Descriptive Summary of Aggregate Data
The number of facilities collecting follow-up information ranged from 216 to 344 per year over the 9-year study period. This represented 25% to 43% of all facilities submitting data to the UDSMR in a given year. Among facilities that collected follow-up information, the mean facility-specific percentages of patients interviewed at follow-up varied from 36% to 44% per year. Consequently, the percentages of patients followed up from the entire inpatient rehabilitation sample varied from 9% to 19% per year. Duration from discharge to follow-up ranged from 80–180 days (mean = 104 days; standard deviation = 23 days; median = 95 days; interquartile range = 87, 114 days).
Compared to patients with no follow-up information, those providing follow-up data were more likely to be discharged from a rehabilitation unit within an acute-care hospital, younger, white, married, and have no tier comorbidities (comorbid conditions which may increase a patient’s resource utilization and thus, are eligible for additional reimbursement under the CMS prospective payment system).12;13 In addition, mean admission and discharge FIM total ratings were approximately 5 points higher in the follow-up cohort and rehabilitation length of stay was 1 day shorter compared to those not followed up. Table 1 displays aggregate demographic information from the 287,104 patients with follow-up data stratified by rehabilitation impairment category. Patient characteristics and outcomes for the entire inpatient rehabilitation cohorts can be found in the previous impairment-specific reports published in this journal.1–6
Table 1.
Patient characteristics by impairment category aggregated across all 9 years (2002–2010).
| Stroke | TBI | SCI | Fracture | Joint | Debility | |
|---|---|---|---|---|---|---|
| N | 93,925 | 16,585 | 6,663 | 41,942 | 107,320 | 20,669 |
| Facility type | ||||||
| Unit in hospital | 82.6% | 78.6% | 79.6% | 83.2% | 76.2% | 79.3% |
| Freestanding | 17.4% | 21.4% | 20.4% | 16.8% | 23.8% | 20.7% |
| Age group, years | ||||||
| < 45 | 5.4% | 34.9% | 44.6% | 1.1% | 1.6% | 4.6% |
| 45–64 | 28.7% | 21.3% | 30.2% | 9.6% | 23.7% | 19.8% |
| 65–74 | 25.1% | 14.0% | 12.8% | 19.0% | 36.1% | 23.1% |
| 75+ | 40.8% | 29.7% | 12.4% | 70.3% | 38.7% | 52.5% |
| Sex | ||||||
| Female | 50.6% | 34.6% | 29.3% | 72.1% | 68.8% | 55.0% |
| Male | 49.4% | 65.4% | 70.7% | 27.9% | 31.2% | 45.0% |
| Race/ethnicity | ||||||
| White | 75.4% | 80.4% | 69.8% | 90.1% | 85.3% | 83.7% |
| Black | 13.3% | 6.7% | 14.0% | 3.2% | 8.0% | 9.8% |
| Hispanic | 4.9% | 6.5% | 9.8% | 2.5% | 2.5% | 2.5% |
| Other/unspecified | 6.5% | 6.4% | 6.5% | 4.3% | 4.2% | 4.0% |
| Marital status | ||||||
| Married | 55.7% | 44.6% | 43.1% | 43.8% | 55.9% | 49.0% |
| Not married | 44.3% | 55.4% | 56.9% | 56.2% | 44.1% | 51.0% |
| Primary payer | ||||||
| Medicare | 66.7% | 43.2% | 27.8% | 88.1% | 75.3% | 79.8% |
| Medicaid | 6.3% | 10.0% | 16.6% | 1.4% | 2.1% | 3.3% |
| Private | 23.7% | 37.0% | 41.1% | 8.0% | 20.8% | 15.0% |
| Workers Comp | 0.1% | 3.1% | 5.6% | 1.2% | 0.9% | 0.3% |
| Self/None | 1.9% | 4.1% | 5.2% | 0.3% | 0.1% | 0.7% |
| Other | 1.4% | 2.6% | 3.6% | 1.0% | 0.7% | 1.0% |
Living Setting and Situation
Maximizing functional independence to enable community living and enhance participation are fundamental goals of rehabilitation. Thus, living in the community is a key marker for rehabilitation success. Tables 2–7 show that the percentages of patients living in the community at follow-up did not completely return to pre-admission levels in 5 of the 6 impairment categories – the exception being the more functionally independent cohort of joint replacement patients. However, more than 9 out of 10 patients within each impairment category were living in the community approximately 3-months post discharge. The percentage ranged from 92% for patients with stroke to 99% for patients with joint replacement. The patterns were relatively stable in all six groups over time. The most common non-community (institutional) setting at follow-up was skilled nursing (3.1% of the total sample).
Table 2.
Social circumstances and functional status at admission, discharge, and follow-up by year for patients with stroke.
| Total | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | |
|---|---|---|---|---|---|---|---|---|---|---|
| N | 93,925 | 13,736 | 13,468 | 10,347 | 9,545 | 10,253 | 9,312 | 9,345 | 9,341 | 8,578 |
| Living in community | ||||||||||
| Admit | 98.9% | 98.7% | 97.6% | 98.4% | 99.2% | 99.1% | 99.4% | 99.4% | 99.5% | 99.5% |
| Discharge | 80.6% | 80.9% | 81.0% | 81.4% | 81.3% | 80.6% | 80.7% | 79.8% | 79.6% | 80.1% |
| Follow-up | 91.6% | 91.0% | 91.3% | 92.2% | 92.1% | 91.7% | 91.5% | 91.6% | 92.0% | 91.8% |
| Living alone | ||||||||||
| Admit | 24.3% | 25.4% | 23.9% | 24.4% | 24.6% | 24.9% | 24.2% | 23.5% | 24.1% | 23.4% |
| Discharge | 9.4% | 10.6% | 10.9% | 10.5% | 9.6% | 9.4% | 8.9% | 8.0% | 7.9% | 7.4% |
| Follow-up | 16.9% | 17.4% | 17.5% | 17.4% | 17.0% | 17.6% | 15.9% | 15.6% | 16.7% | 16.5% |
| Vocation follow-up | ||||||||||
| Employed | 4.6% | 3.8% | 4.5% | 4.7% | 4.9% | 4.8% | 5.0% | 4.7% | 4.9% | 4.6% |
| Unemployed | 16.0% | 14.5% | 14.6% | 14.7% | 14.8% | 16.1% | 16.4% | 18.8% | 18.2% | 18.1% |
| Retired | 77.7% | 79.9% | 79.1% | 79.0% | 78.4% | 77.3% | 77.0% | 74.9% | 75.7% | 76.0% |
| Other | 1.6% | 1.8% | 1.8% | 1.6% | 1.8% | 1.8% | 1.6% | 1.6% | 1.3% | 1.3% |
| Maintain health follow-up | ||||||||||
| Own care | 79.7% | 78.6% | 78.7% | 78.0% | 78.9% | 77.7% | 78.9% | 82.3% | 83.1% | 82.8% |
| Family/unpaid | 11.0% | 12.0% | 11.4% | 12.4% | 11.5% | 11.9% | 11.2% | 9.4% | 8.9% | 8.9% |
| Paid help | 9.3% | 9.4% | 9.9% | 9.6% | 9.6% | 10.5% | 9.8% | 8.3% | 8.1% | 8.3% |
| Therapy follow-up | ||||||||||
| None | 47.3% | 54.7% | 51.7% | 52.4% | 45.9% | 43.6% | 41.6% | 41.7% | 42.6% | 45.6% |
| Outpatient/home | 44.4% | 37.6% | 40.2% | 39.6% | 45.7% | 47.6% | 49.1% | 49.7% | 49.3% | 46.5% |
| Other | 8.3% | 7.8% | 8.1% | 8.0% | 8.4% | 8.8% | 9.3% | 8.6% | 8.1% | 7.9% |
| Length of stay, days | 16.7 (9.9) | 17.1 (10.1) | 17.1 (10.5) | 16.6 (10.1) | 17.0 (10.3) | 16.4 (9.8) | 16.5 (9.7) | 16.8 (9.7) | 16.2 (9.3) | 16.2 (9.2) |
| FIM motor | ||||||||||
| Admit | 39.2 (14.0) | 40.7 (14.3) | 40.2 (14.2) | 40.4 (14.0) | 39.4 (13.9) | 39.0 (13.9) | 38.5 (13.8) | 37.9 (13.9) | 37.7 (13.9) | 37.5 (13.7) |
| Discharge | 60.7 (16.6) | 61.7 (16.7) | 60.8 (16.6) | 61.4 (16.4) | 61.1 (16.3) | 60.4 (16.7) | 60.2 (16.7) | 60.0 (16.8) | 59.9 (16.6) | 60.1 (16.7) |
| Follow-up | 73.9 (18.1) | 73.2 (18.3) | 73.7 (18.4) | 74.1 (18.1) | 74.1 (17.9) | 73.8 (18.3) | 73.9 (17.9) | 74.2 (17.6) | 74.4 (17.8) | 74.1 (18.0) |
| FIM cognition | ||||||||||
| Admit | 21.6 (7.6) | 22.4 (7.9) | 22.4 (7.8) | 22.2 (7.6) | 21.7 (7.6) | 21.6 (7.6) | 21.2 (7.5) | 20.8 (7.4) | 20.7 (7.5) | 20.6 (7.3) |
| Discharge | 25.7 (6.8) | 26.1 (6.9) | 26.0 (6.9) | 26.0 (6.6) | 25.9 (6.6) | 25.7 (6.7) | 25.4 (6.8) | 25.3 (6.7) | 25.4 (6.7) | 25.5 (6.6) |
| Follow-up | 30.9 (5.4) | 31.0 (5.6) | 31.0 (5.4) | 30.7 (5.5) | 30.7 (5.4) | 30.6 (5.5) | 30.9 (5.2) | 30.9 (5.1) | 31.0 (5.2) | 31.1 (5.1) |
| FIM total | ||||||||||
| Admit | 60.8 (18.9) | 63.0 (19.1) | 62.5 (19.0) | 62.6 (18.7) | 61.1 (18.8) | 60.6 (18.8) | 59.7 (18.7) | 58.7 (18.7) | 58.4 (18.8) | 58.1 (18.4) |
| Discharge | 86.4 (21.0) | 87.9 (21.1) | 86.8 (20.9) | 87.5 (20.6) | 87.0 (20.6) | 86.1 (21.0) | 85.6 (21.2) | 85.3 (21.2) | 85.3 (21.0) | 85.7 (20.9) |
| Follow-up | 104.8 (21.6) | 104.2 (21.9) | 104.7 (21.9) | 104.7 (21.6) | 104.8 (21.5) | 104.4 (21.9) | 104.8 (21.3) | 105.1 (21.1) | 105.4 (21.2) | 105.2 (21.4) |
| FIM total change | ||||||||||
| Admit to discharge | 26.1 (13.7) | 24.8 (13.6) | 24.2 (13.4) | 24.9 (13.5) | 25.8 (13.6) | 25.5 (13.7) | 25.9 (13.5) | 28.0 (13.8) | 28.3 (13.7) | 29.0 (13.9) |
| Discharge to follow-up | 18.3 (17.2) | 16.3 (17.4) | 17.9 (17.1) | 17.3 (16.8) | 17.9 (16.6) | 18.3 (17.0) | 19.2 (17.2) | 19.8 (17.5) | 20.2 (17.2) | 19.5 (17.0) |
Table 7.
Social circumstances and functional status at admission, discharge, and follow-up by year for patients with debility.
| Total | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | |
|---|---|---|---|---|---|---|---|---|---|---|
| N | 20,669 | 2,308 | 2,953 | 2,656 | 1,915 | 2,190 | 1,901 | 2,177 | 2,330 | 2,239 |
| Living in community | ||||||||||
| Admit | 98.9% | 98.6% | 98.8% | 99.2% | 98.8% | 98.3% | 98.6% | 98.9% | 99.2% | 99.4% |
| Discharge | 84.4% | 83.6% | 85.0% | 85.1% | 86.5% | 85.3% | 83.6% | 84.5% | 81.9% | 83.7% |
| Follow-up | 93.8% | 93.5% | 93.7% | 93.8% | 93.8% | 93.9% | 93.3% | 94.6% | 93.5% | 93.8% |
| Living alone | ||||||||||
| Admit | 30.7% | 32.9% | 33.7% | 33.6% | 30.3% | 30.2% | 30.0% | 29.9% | 26.7% | 27.4% |
| Discharge | 18.2% | 19.4% | 20.8% | 20.3% | 19.8% | 18.0% | 18.0% | 19.1% | 13.7% | 13.5% |
| Follow-up | 26.6% | 28.9% | 29.7% | 29.4% | 27.4% | 26.8% | 24.3% | 26.2% | 23.1% | 21.6% |
| Vocation follow-up | ||||||||||
| Employed | 3.7% | 3.2% | 3.8% | 3.3% | 3.2% | 3.9% | 3.8% | 3.5% | 4.8% | 3.7% |
| Unemployed | 9.7% | 7.4% | 8.5% | 7.8% | 9.2% | 9.4% | 10.2% | 11.3% | 12.5% | 12.2% |
| Retired | 84.7% | 87.9% | 85.5% | 86.5% | 85.6% | 84.8% | 84.6% | 83.5% | 81.0% | 82.8% |
| Other | 1.8% | 1.5% | 2.3% | 2.4% | 2.1% | 1.9% | 1.4% | 1.7% | 1.7% | 1.3% |
| Maintain health follow-up | ||||||||||
| Own care | 83.1% | 77.6% | 80.9% | 80.0% | 80.5% | 83.1% | 82.2% | 87.5% | 88.4% | 89.0% |
| Family/unpaid | 8.2% | 11.3% | 9.3% | 9.6% | 9.6% | 8.1% | 9.4% | 5.5% | 5.3% | 5.2% |
| Paid help | 8.7% | 11.1% | 9.8% | 10.3% | 9.9% | 8.8% | 8.4% | 7.0% | 6.2% | 5.8% |
| Therapy follow-up | ||||||||||
| None | 61.3% | 68.2% | 67.8% | 63.4% | 59.7% | 56.5% | 55.8% | 55.6% | 59.7% | 60.6% |
| Outpatient/home | 32.4% | 25.5% | 26.4% | 30.4% | 33.1% | 36.1% | 37.3% | 38.1% | 34.6% | 33.7% |
| Other | 6.4% | 6.3% | 5.9% | 6.2% | 7.2% | 7.4% | 6.9% | 6.2% | 5.7% | 5.7% |
| Length of stay, days | 12.0 (6.7) | 11.9 (6.5) | 11.7 (6.9) | 12.0 (7.2) | 11.6 (5.9) | 12.1 (6.3) | 12.0 (7.6) | 12.2 (6.5) | 12.0 (6.4) | 12.0 (6.4) |
| FIM motor | ||||||||||
| Admit | 42.6 (11.6) | 44.3 (12.0) | 44.4 (11.6) | 44.2 (11.3) | 43.3 (11.4) | 42.3 (11.4) | 41.7 (11.3) | 41.1 (11.4) | 40.6 (11.4) | 40.3 (11.3) |
| Discharge | 63.0 (14.1) | 63.6 (14.7) | 63.7 (14.0) | 63.6 (13.7) | 63.5 (13.9) | 62.9 (13.9) | 62.6 (14.1) | 62.2 (14.2) | 62.5 (14.4) | 62.2 (14.0) |
| Follow-up | 75.9 (15.5) | 74.3 (16.6) | 75.4 (16.1) | 76.1 (15.1) | 76.4 (15.1) | 75.7 (15.2) | 76.1 (15.4) | 76.4 (15.1) | 76.5 (15.8) | 76.6 (15.0) |
| FIM cognition | ||||||||||
| Admit | 27.3 (6.2) | 27.7 (6.6) | 28.0 (6.0) | 27.9 (5.9) | 27.6 (5.9) | 27.4 (6.1) | 27.1 (6.0) | 27.0 (5.9) | 26.5 (6.3) | 26.0 (6.3) |
| Discharge | 29.6 (5.2) | 29.4 (5.8) | 29.7 (5.3) | 29.7 (5.1) | 29.7 (5.1) | 29.6 (5.1) | 29.4 (5.4) | 29.6 (5.1) | 29.6 (5.1) | 29.4 (5.1) |
| Follow-up | 32.4 (4.2) | 32.1 (4.7) | 32.2 (4.4) | 32.3 (4.1) | 32.4 (4.2) | 32.3 (4.1) | 32.3 (4.3) | 32.6 (3.8) | 32.6 (4.0) | 32.6 (3.9) |
| FIM total | ||||||||||
| Admit | 69.9 (15.0) | 72.0 (15.7) | 72.4 (14.8) | 72.0 (14.6) | 70.9 (14.7) | 69.7 (14.7) | 68.8 (14.6) | 68.1 (14.7) | 67.2 (14.8) | 66.4 (14.9) |
| Discharge | 92.6 (17.2) | 93.0 (18.5) | 93.4 (17.1) | 93.3 (16.6) | 93.2 (17.0) | 92.5 (16.8) | 92.0 (17.4) | 91.8 (17.2) | 92.0 (17.4) | 91.6 (16.8) |
| Follow-up | 108.3 (18.2) | 106.4 (19.8) | 107.6 (18.9) | 108.4 (17.7) | 108.9 (17.7) | 108.0 (17.8) | 108.4 (18.2) | 108.9 (17.5) | 109.1 (18.5) | 109.1 (17.5) |
| FIM total change | ||||||||||
| Admit to discharge | 23.2 (12.8) | 21.0 (12.5) | 21.0 (12.2) | 21.2 (11.8) | 22.3 (12.3) | 22.8 (12.3) | 23.2 (13.0) | 25.2 (12.7) | 26.4 (13.2) | 26.7 (13.3) |
| Discharge to follow-up | 15.7 (16.9) | 13.4 (18.0) | 14.1 (17.0) | 15.1 (16.2) | 15.7 (16.4) | 15.5 (16.1) | 16.5 (18.0) | 17.1 (16.3) | 17.1 (17) | 17.6 (16.8) |
More dynamic patterns were observed in the percentages of patients living alone both between conditions and across time. Prior to admission approximately 37% of people with lower extremity fractures lived alone compared to only 18% of people with SCI. Pre-admission values for the other four cohorts fell between these two extremes. At follow-up, the percentage living alone was nearly equal to pre-admission values for joint replacement, approximately 14% lower for lower extremity fracture and debility, and approximately 30% lower for SCI, TBI, and stroke. Over time, the percentages of patients living alone gradually decreased at all three assessment periods for lower extremity fracture. Patients living alone also decreased at pre-admission and follow-up for SCI; at discharge for joint replacement and stroke; and at discharge and follow-up for debility.
Pre-admission and follow-up vocational categories by year in the respective impairment categories are displayed in Tables 2–7. Retired was the most frequent category at both assessments in all impairment groups except SCI. For persons with SCI, employment was the most frequent (45%) pre-admission category and unemployed was the most frequent (42%) follow-up category.
Continuing Care
Patients in the debility group were most likely (61%) to report receiving no additional therapy from the time of discharge to follow-up, whereas patients in the SCI group were least likely (40%) to receive no additional rehabilitation services (Tables 2–7). Interestingly, all 6 groups demonstrated substantial decreases in the percentages receiving no therapy and concomitant increases in the percentages receiving outpatient and/or home care over the 9-year study period.
Regarding responsibility for maintaining health at follow-up, 75% (SCI) to 94% (joint replacement) of patients reported being primarily responsible for their own care. The most dramatic change in health maintenance over time occurred in the debility group, where the percentages of patients responsible for their own care increased and the percentages identifying family and paid help decreased in more recent years. The SCI and stroke groups also showed increases in the proportions of persons responsible for their own care and related decreases in the proportions relying on family or unpaid care, but the changes were less stark.
Functional Status
Tables 2–7 also display yearly summaries for admission, discharge, and follow-up functional status. Consistent with the patterns described in the previous reports from the larger inpatient rehabilitation populations, the follow-up samples showed subtle yet consistent declines in admission and discharge FIM total ratings and steady increases in change scores (discharge – admission) over the 9-year study period in all 6 rehabilitation impairment categories. Follow-up FIM total ratings remained stable to slightly increased over time, whereas change scores (follow-up – discharge) demonstrated more marked increases over time in all six cohorts. Mean FIM gains from discharge to follow-up, as a percentage of mean gains from admission to discharge, varied by impairment category: 46% for SCI to 71% for lower extremity fracture.
Mean item scores for the 6 functional domains of the FIM instrument by rehabilitation impairment category are presented in Figures 1–6. Locomotion yielded the lowest mean item ratings at all three assessments within each of the six impairment groups. By follow-up, mean ratings for both cognitive domains were > 6 in all groups and mean ratings for the sphincter, self-care, and transfer domains were = 6 in all groups except SCI.
Figure 1.
Mean item scores at admission, discharge, and follow-up on the 6 functional domains of the FIM instrument for patients with stroke.
Figure 6.
Mean item scores at admission, discharge, and follow-up on the 6 functional domains of the FIM instrument for patients with debility.
DISCUSSION
This report provides aggregated follow-up data from more than 280,000 patients who received care in more than 300 inpatient rehabilitation hospitals and units in the U.S. from 2002 through 2010. The number of patients with follow-up information declined over time in all six impairment categories. The most dramatic decrease was in the joint replacement group, whereas the least change was in the debility group. Of the six impairment groups in this report, joint replacement and debility are the only two that are not qualifying conditions under the Center for Medicare and Medicaid Services’ (CMS) rehabilitation facility eligibility criterion (“60% rule”).13 CMS mandates that 60% of an IRF’s annual patient volume must include patients with 1 of 10 specified conditions to qualify for IRF payments. Enforcement of this rule began in 2004 and the compliance threshold was set at 50% with projected annual increases to 75% in 2007. Ultimately, the threshold was fixed at 60%. Interestingly, since enforcement of the rule began, joint replacement has demonstrated the greatest percentage decrease and debility the greatest percentage increase in annual impairment category distributions.
The magnitudes of functional improvement were greater during the relatively short inpatient rehabilitation stays compared to the longer follow-up periods in all six impairment groups. The patterns displayed in this report demonstrate the degree to which recovery of functional abilities continues over the first three months after discharge from inpatient rehabilitation. It is also important to note that most patients receive additional rehabilitation services following discharge, even among the highest functioning impairment category: joint replacement. DeJong and colleagues14 reported that 93% of knee replacement patients and 87% of hip replacement patients received outpatient rehabilitation, home rehabilitation, or both following discharge from 6 inpatient rehabilitation facilities. Our national data indicate that between 40% and 60% of patients – depending on the impairment group – report receiving some level of post-discharge therapy.
From a patient-centered perspective, it is logical to assume that the most important observation is the ultimate level of functional independence achieved and the ability to live in the community. Using a mean FIM item score = 6 as an indicator for not requiring assistance from another person, Figures 1–6 suggest that on average, patients within all 6 impairment groups were not dependent upon another person for activities related to communication, social cognition, sphincter control, self-care, or transfers at follow-up. In addition, more than 90% of patients in all 6 groups were living in the community at follow-up. Although the percentage living in the community at follow-up did not return to pre-admission levels in any impairment group (joint replacement was close), the fact that 9 out of 10 patients in each group were able to live in the community is encouraging..
Our study has some limitations. The data presented in this report are observational and no inferences can be made regarding reasons for change over time. Also, meaningful comparisons of outcomes data across settings (e.g., facility vs. national data) require case-mix adjustment to account for patient-level factors (i.e., impairment severity and type, patient age) that may influence outcomes.15 We did not have information on patients’ functional status prior to their most recent illnesses or injuries. Another potential limitation is the use of self-reported data. However, self-reported functional status recorded from trained interviewers yields reliable information11 and other questions pertaining to social circumstances are best answered from the patient’s perspective in large, population-based, survey research.
CONCLUSIONS
We showed yearly trends in patient outcomes at distinct time-points in the post-acute recovery period: admission, discharge, and follow-up. Gains in mean functional independence scores from both admission to discharge and discharge to follow-up gradually increased from 2002 to 2010. At follow-up, more than 9 out of 10 patients in all 6 groups were living in the community. This benchmark information for the six largest impairment groups receiving inpatient rehabilitation services may be beneficial for patient and/or family education in terms of a starting point for expected outcomes and timeframes. Moreover, with the continued implementation of the Affordable Care Act8 and the introduction of bundled payments across the continuum of care, the value and need for follow-up data will increase dramatically as providers, researchers, and policymakers strive to document the effectiveness of different post-acute care options. The data reported here can serve as a reference for others interested in evaluating programs serving the immediate, transitional, and/or long-term healthcare needs of patients requiring intensive post-acute rehabilitation services.
Figure 2.
Mean item scores at admission, discharge, and follow-up on the 6 functional domains of the FIM instrument for patients with TBI.
Figure 3.
Mean item scores at admission, discharge, and follow-up on the 6 functional domains of the FIM instrument for patients with SCI.
Figure 4.
Mean item scores at admission, discharge, and follow-up on the 6 functional domains of the FIM instrument for patients with fracture.
Figure 5.
Mean item scores at admission, discharge, and follow-up on the 6 functional domains of the FIM instrument for patients with joint replacement.
Table 3.
Social circumstances and functional status at admission, discharge, and follow-up by year for patients with TBI.
| Total | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | |
|---|---|---|---|---|---|---|---|---|---|---|
| N | 16,585 | 2,091 | 2,106 | 1,731 | 1,769 | 1,930 | 1,821 | 1,856 | 1,774 | 1,507 |
| Living in community | ||||||||||
| Admit | 98.6% | 98.0% | 97.9% | 98.1% | 98.9% | 98.7% | 98.8% | 99.2% | 98.8% | 99.1% |
| Discharge | 83.7% | 85.5% | 84.0% | 83.8% | 84.7% | 83.8% | 83.1% | 81.8% | 82.2% | 84.0% |
| Follow-up | 94.2% | 94.8% | 94.1% | 94.9% | 95.0% | 93.6% | 93.1% | 93.0% | 94.5% | 95.1% |
| Living alone | ||||||||||
| Admit | 21.0% | 19.8% | 18.3% | 22.8% | 20.8% | 21.6% | 19.6% | 23.2% | 21.6% | 21.9% |
| Discharge | 6.2% | 6.0% | 6.2% | 7.6% | 5.3% | 5.9% | 6.6% | 7.5% | 5.0% | 5.8% |
| Follow-up | 14.9% | 13.0% | 12.9% | 16.9% | 14.9% | 15.1% | 15.4% | 16.8% | 14.1% | 16.0% |
| Vocation follow-up | ||||||||||
| Employed | 12.3% | 13.6% | 13.6% | 13.5% | 12.6% | 12.1% | 13.5% | 10.5% | 9.9% | 11.4% |
| Unemployed | 29.3% | 33.1% | 31.7% | 27.5% | 28.5% | 29.0% | 27.6% | 29.9% | 27.3% | 27.7% |
| Retired | 51.8% | 44.3% | 46.5% | 50.8% | 51.3% | 52.8% | 53.4% | 55.2% | 57.9% | 56.1% |
| Other | 6.6% | 8.9% | 8.2% | 8.2% | 7.5% | 6.1% | 5.6% | 4.4% | 4.9% | 4.8% |
| Maintain health follow-up | ||||||||||
| Own care | 86.0% | 86.7% | 86.4% | 84.1% | 85.3% | 84.2% | 84.0% | 87.8% | 86.6% | 89.1% |
| Family/unpaid | 8.0% | 7.2% | 8.1% | 9.5% | 8.7% | 8.7% | 8.8% | 6.4% | 7.8% | 6.1% |
| Paid help | 6.1% | 6.1% | 5.5% | 6.4% | 6.1% | 7.1% | 7.2% | 5.7% | 5.6% | 4.8% |
| Therapy follow-up | ||||||||||
| None | 53.7% | 61.2% | 59.2% | 59.5% | 53.0% | 47.3% | 47.1% | 48.3% | 50.7% | 56.0% |
| Outpatient/home | 40.0% | 33.6% | 35.6% | 34.0% | 40.7% | 45.0% | 45.6% | 44.1% | 43.4% | 38.7% |
| Other | 6.3% | 5.2% | 5.2% | 6.5% | 6.3% | 7.7% | 7.3% | 7.6% | 5.9% | 5.3% |
| Length of stay, days | 16.3 (12.4) | 17.5 (14.1) | 17.9 (15.1) | 16.6 (13.2) | 15.9 (11.5) | 16.3 (12.2) | 15.3 (11.4) | 15.7 (11.2) | 15.7 (10.8) | 15.3 (10.5) |
| FIM motor | ||||||||||
| Admit | 40.5 (15.9) | 42.7 (17.6) | 41.3 (17.0) | 41.6 (15.9) | 40.9 (15.7) | 40.0 (15.7) | 40.1 (15.4) | 39.4 (15.1) | 39.0 (15.0) | 39.4 (14.9) |
| Discharge | 65.9 (16.6) | 69.1 (17.1) | 67.1 (17.5) | 66.8 (16.6) | 65.9 (15.9) | 65.5 (16.3) | 65 (16.4) | 64.2 (16.6) | 64.4 (16.0) | 64.7 (15.8) |
| Follow-up | 80.5 (15.3) | 81.1 (15.4) | 81.3 (15.2) | 81.0 (15.0) | 80.8 (14.7) | 79.8 (15.6) | 79.7 (16.0) | 79.9 (14.8) | 80.4 (15.2) | 80.2 (15.1) |
| FIM cognition | ||||||||||
| Admit | 18.0 (7.9) | 17.8 (8.2) | 17.8 (8.1) | 18.6 (8.1) | 18.8 (7.9) | 18.2 (8.0) | 17.9 (7.7) | 17.7 (7.8) | 17.7 (7.6) | 17.4 (7.6) |
| Discharge | 24.1 (6.7) | 24.1 (7.0) | 24.0 (6.9) | 24.5 (6.7) | 24.6 (6.5) | 24.1 (6.7) | 23.8 (6.6) | 23.7 (6.8) | 23.9 (6.6) | 23.8 (6.6) |
| Follow-up | 31.1 (5.2) | 31.0 (5.5) | 31.2 (5.3) | 31.0 (5.4) | 31.2 (5.1) | 31.0 (5.2) | 31.1 (5.1) | 31.2 (5.1) | 31.4 (4.8) | 31.4 (5.0) |
| FIM total | ||||||||||
| Admit | 58.5 (21.3) | 60.5 (23.3) | 59.1 (22.6) | 60.1 (21.4) | 59.6 (21.1) | 58.2 (21.0) | 58 (20.6) | 57.2 (20.4) | 56.7 (20.2) | 56.7 (19.8) |
| Discharge | 90.0 (20.9) | 93.2 (21.7) | 91.0 (22.1) | 91.3 (21.0) | 90.5 (20.0) | 89.7 (20.5) | 88.8 (20.5) | 87.9 (20.9) | 88.3 (20.3) | 88.5 (20.1) |
| Follow-up | 111.6 (18.7) | 112.1 (19.2) | 112.5 (18.8) | 112.0 (18.7) | 112.0 (18.1) | 110.8 (18.9) | 110.8 (19.4) | 111.1 (18.3) | 111.8 (18.3) | 111.6 (18.6) |
| FIM total change | ||||||||||
| Admit to discharge | 31.9 (18.6) | 32.7 (19.7) | 31.9 (19.5) | 31.2 (19.0) | 30.9 (18.3) | 31.4 (18.4) | 30.7 (17.6) | 32.2 (18.0) | 32.9 (18.0) | 33.2 (17.7) |
| Discharge to follow-up | 21.6 (17.5) | 19.0 (17.5) | 21.4 (17.2) | 20.7 (18.0) | 21.5 (16.8) | 21.1 (17.6) | 22.0 (17.7) | 23.1 (17.8) | 23.5 (17.1) | 23.1 (17.7) |
Table 4.
Social circumstances and functional status at admission, discharge, and follow-up by year for patients with SCI.
| Total | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | |
|---|---|---|---|---|---|---|---|---|---|---|
| N | 6,663 | 1,009 | 926 | 719 | 677 | 726 | 687 | 712 | 637 | 570 |
| Living in community | ||||||||||
| Admit | 98.6% | 98.5% | 97.5% | 98.5% | 99.0% | 98.9% | 99.1% | 98.9% | 98.4% | 98.8% |
| Discharge | 82.5% | 83.2% | 82.8% | 82.6% | 82.6% | 82.9% | 84.4% | 79.8% | 82.1% | 81.4% |
| Follow-up | 92.5% | 93.6% | 94.0% | 91.9% | 91.7% | 92.4% | 92.7% | 91.0% | 91.7% | 91.9% |
| Living alone | ||||||||||
| Admit | 17.6% | 19.8% | 18.6% | 19.1% | 18.3% | 16.3% | 14.9% | 16.4% | 17.3% | 16.3% |
| Discharge | 7.2% | 7.9% | 9.4% | 8.2% | 7.1% | 5.4% | 7.1% | 5.3% | 6.1% | 7.4% |
| Follow-up | 12.1% | 13.9% | 13.3% | 12.0% | 13.2% | 10.6% | 11.2% | 10.9% | 11.5% | 10.5% |
| Vocation follow-up | ||||||||||
| Employed | 8.0% | 7.2% | 10.6% | 8.6% | 6.5% | 7.0% | 9.4% | 7.8% | 8.8% | 5.2% |
| Unemployed | 42.0% | 41.9% | 41.1% | 39.6% | 45.7% | 44.8% | 43.6% | 44.6% | 37.5% | 38.9% |
| Retired | 45.1% | 45.2% | 43.1% | 46.0% | 42.3% | 43.1% | 43.9% | 43.9% | 48.5% | 51.9% |
| Other | 4.9% | 5.7% | 5.2% | 5.7% | 5.5% | 5.1% | 3.1% | 3.8% | 5.2% | 4.1% |
| Maintain health follow-up | ||||||||||
| Own care | 75.4% | 72.9% | 75.7% | 76.1% | 74.9% | 72.8% | 78.9% | 72.8% | 78.3% | 78.3% |
| Family/unpaid | 14.8% | 17.6% | 14.1% | 12.7% | 15.7% | 16.6% | 13.1% | 17.4% | 12.1% | 12.0% |
| Paid help | 9.8% | 9.5% | 10.3% | 11.3% | 9.4% | 10.5% | 8.0% | 9.8% | 9.6% | 9.7% |
| Therapy follow-up | ||||||||||
| None | 40.0% | 46.9% | 45.5% | 45.7% | 37.1% | 35.8% | 31.4% | 35.0% | 38.4% | 38.9% |
| Outpatient/home | 53.1% | 47.9% | 49.0% | 47.2% | 55.6% | 56.7% | 62.1% | 56.5% | 53.1% | 53.9% |
| Other | 6.9% | 5.2% | 5.5% | 7.1% | 7.3% | 7.5% | 6.4% | 8.6% | 8.5% | 7.2% |
| Length of stay, days | 26.0 (21.0) | 27.8 (22.3) | 26.7 (22.8) | 27.3 (23.0) | 25.6 (19.2) | 25.7 (22.4) | 25.0 (18.2) | 25.8 (19.1) | 24.1 (20.2) | 23.9 (19.0) |
| FIM motor | ||||||||||
| Admit | 30.3 (14.0) | 31.1 (14.6) | 31.7 (15.0) | 31.4 (13.9) | 30.1 (13.6) | 29.9 (14.1) | 29.5 (13.3) | 28.4 (13.5) | 29.8 (13.2) | 29.5 (13.1) |
| Discharge | 55.0 (20.0) | 55.8 (20.3) | 56.4 (20.3) | 56.2 (20.0) | 54.8 (19.8) | 54.5 (20.1) | 55.0 (19.1) | 51.9 (20.5) | 55.0 (19.3) | 54.8 (19.7) |
| Follow-up | 66.6 (23.2) | 66.0 (23.7) | 67.4 (23.2) | 67.2 (23.5) | 66.7 (22.7) | 65.7 (23.9) | 66.6 (21.7) | 64.4 (24.0) | 67.6 (22.8) | 67.6 (23.0) |
| FIM cognition | ||||||||||
| Admit | 29.9 (5.6) | 30.6 (5.6) | 30.5 (5.6) | 30.3 (5.5) | 29.6 (5.6) | 30.3 (5.0) | 30.1 (5.4) | 29.4 (5.8) | 29.1 (5.9) | 28.7 (5.8) |
| Discharge | 32.3 (4.1) | 32.5 (4.2) | 32.5 (3.9) | 32.2 (4.5) | 32.1 (4.0) | 32.3 (3.9) | 32.3 (4.0) | 32.2 (4.0) | 32.0 (4.1) | 32.2 (3.8) |
| Follow-up | 33.6 (3.0) | 33.8 (3.1) | 33.8 (2.8) | 33.4 (3.7) | 33.6 (2.9) | 33.6 (2.9) | 33.7 (2.5) | 33.3 (3.1) | 33.5 (2.9) | 33.7 (2.7) |
| FIM total | ||||||||||
| Admit | 60.2 (16.1) | 61.7 (16.7) | 62.2 (17.0) | 61.7 (15.8) | 59.7 (15.6) | 60.1 (16.0) | 59.5 (15.1) | 57.8 (16.1) | 58.8 (15.4) | 58.2 (15.9) |
| Discharge | 87.3 (21.4) | 88.3 (21.7) | 89.0 (21.5) | 88.4 (21.7) | 87 (21.0) | 86.8 (21.6) | 87.3 (20.6) | 84.1 (22.0) | 87.1 (20.8) | 87.0 (21.1) |
| Follow-up | 100.2 (24.3) | 99.8 (24.7) | 101.2 (24.2) | 100.7 (24.9) | 100.3 (23.4) | 99.3 (25.0) | 100.3 (22.7) | 97.7 (25.2) | 101.1 (24.1) | 101.3 (23.9) |
| FIM total change | ||||||||||
| Admit to discharge | 27.8 (15.5) | 26.6 (15.2) | 26.8 (15.7) | 26.8 (15.3) | 27.3 (15.5) | 26.7 (14.9) | 27.8 (14.8) | 28.7 (15.6) | 30.4 (15.7) | 31.0 (15.9) |
| Discharge to follow-up | 12.8 (16.5) | 11.5 (16.0) | 12.2 (16.7) | 12.3 (17.2) | 13.4 (16.8) | 12.5 (16.8) | 13.0 (15.8) | 13.6 (16.3) | 14.1 (16.5) | 14.3 (16.9) |
Table 5.
Social circumstances and functional status at admission, discharge, and follow-up by year for patients with fracture.
| Total | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | |
|---|---|---|---|---|---|---|---|---|---|---|
| N | 41,942 | 5,512 | 6,346 | 4,994 | 4,815 | 5,102 | 4,328 | 4,117 | 3,679 | 3,049 |
| Living in community | ||||||||||
| Admit | 99.2% | 98.8% | 99.2% | 99.2% | 99.0% | 99.4% | 99.2% | 99.6% | 99.5% | 99.4% |
| Discharge | 81.8% | 81.6% | 82.8% | 83.2% | 82.2% | 80.8% | 80.3% | 81.1% | 80.5% | 83.4% |
| Follow-up | 95.2% | 94.6% | 96.1% | 96.0% | 95.3% | 94.8% | 95.2% | 95.4% | 94.2% | 94.9% |
| Living alone | ||||||||||
| Admit | 36.9% | 39.5% | 37.6% | 37.3% | 38.5% | 37.2% | 35.9% | 34.6% | 35.1% | 33.4% |
| Discharge | 17.8% | 20.6% | 18.3% | 18.6% | 19.0% | 17.6% | 15.9% | 16.3% | 16.3% | 15.0% |
| Follow-up | 31.6% | 33.9% | 32.3% | 31.7% | 33.1% | 31.9% | 31.0% | 29.2% | 29.6% | 29.2% |
| Vocation follow-up | ||||||||||
| Employed | 3.0% | 2.3% | 2.6% | 3.2% | 2.9% | 3.2% | 3.6% | 3.1% | 3.6% | 3.2% |
| Unemployed | 4.9% | 4.6% | 4.9% | 5.0% | 5.4% | 5.1% | 4.5% | 4.8% | 4.9% | 4.4% |
| Retired | 90.4% | 91.1% | 90.8% | 90.0% | 90.0% | 89.7% | 90.6% | 90.2% | 90.1% | 90.8% |
| Other | 1.7% | 2.0% | 1.8% | 1.9% | 1.8% | 2.0% | 1.2% | 1.9% | 1.5% | 1.5% |
| Maintain health follow-up | ||||||||||
| Own care | 85.0% | 85.3% | 87.0% | 86.4% | 83.3% | 84.1% | 82.2% | 84.3% | 85.4% | 86.7% |
| Family/unpaid | 7.3% | 7.3% | 6.3% | 6.8% | 8.1% | 8.0% | 8.2% | 7.5% | 6.7% | 7.1% |
| Paid help | 7.7% | 7.4% | 6.7% | 6.8% | 8.7% | 7.9% | 9.7% | 8.2% | 7.9% | 6.2% |
| Therapy follow-up | ||||||||||
| None | 58.7% | 67.3% | 65.9% | 63.9% | 56.7% | 55.3% | 52.0% | 51.6% | 52.8% | 53.8% |
| Outpatient/home | 36.4% | 27.7% | 30.2% | 31.5% | 37.9% | 39.0% | 42.9% | 43.5% | 41.8% | 41.8% |
| Other | 4.9% | 5.0% | 3.8% | 4.6% | 5.4% | 5.8% | 5.1% | 4.9% | 5.4% | 4.4% |
| Length of stay, days | 12.1 (5.2) | 12.0 (5.6) | 11.6 (5.3) | 11.8 (5.2) | 12.2 (5.3) | 11.9 (4.9) | 12.2 (5.2) | 12.4 (5.2) | 12.5 (5.0) | 12.4 (4.7) |
| FIM motor | ||||||||||
| Admit | 40.2 (9.8) | 41.8 (10.0) | 42.1 (9.6) | 41.6 (9.5) | 40.2 (9.7) | 39.5 (9.7) | 39.0 (9.5) | 38.9 (9.8) | 38.0 (9.9) | 38.3 (9.6) |
| Discharge | 62.6 (12.5) | 63.5 (12.8) | 63.0 (12.2) | 63.0 (12.0) | 62.6 (12.4) | 62.0 (12.5) | 61.8 (12.4) | 62.1 (12.7) | 61.9 (13.1) | 62.5 (12.3) |
| Follow-up | 77.6 (13.0) | 77.0 (13.4) | 78.0 (12.7) | 77.8 (12.9) | 77.7 (12.6) | 77.2 (13.5) | 77.6 (12.8) | 77.4 (13.1) | 77.4 (13.5) | 77.8 (12.5) |
| FIM cognition | ||||||||||
| Admit | 27.5 (6.3) | 28.8 (6.2) | 28.7 (5.9) | 28.2 (6.1) | 27.4 (6.4) | 27.3 (6.4) | 26.8 (6.2) | 26.5 (6.2) | 26.0 (6.5) | 26.1 (6.3) |
| Discharge | 29.8 (5.2) | 30.3 (5.4) | 30.3 (5.0) | 30.1 (5.1) | 29.7 (5.2) | 29.7 (5.2) | 29.3 (5.2) | 29.4 (5.1) | 29.2 (5.4) | 29.5 (5.1) |
| Follow-up | 32.5 (4.1) | 32.8 (4.2) | 32.9 (3.8) | 32.6 (4.1) | 32.3 (4.3) | 32.3 (4.3) | 32.3 (4.1) | 32.3 (4.1) | 32.4 (4.1) | 32.6 (4.0) |
| FIM total | ||||||||||
| Admit | 67.7 (14.1) | 70.6 (14.0) | 70.8 (13.4) | 69.8 (13.6) | 67.6 (14.0) | 66.8 (14.1) | 65.8 (13.8) | 65.4 (14.1) | 64.0 (14.3) | 64.3 (13.9) |
| Discharge | 92.3 (16.0) | 93.8 (16.5) | 93.3 (15.6) | 93.1 (15.4) | 92.3 (15.9) | 91.7 (16.1) | 91.2 (15.9) | 91.5 (16.2) | 91.0 (16.9) | 92.0 (15.8) |
| Follow-up | 110.1 (15.9) | 109.8 (16.3) | 110.9 (15.2) | 110.4 (15.8) | 110.0 (15.7) | 109.5 (16.5) | 109.9 (15.6) | 109.7 (16.0) | 109.7 (16.3) | 110.4 (15.2) |
| FIM total change | ||||||||||
| Admit to discharge | 25.1 (11.5) | 23.3 (11.4) | 22.5 (10.9) | 23.4 (10.8) | 24.7 (11.2) | 24.9 (11.4) | 25.4 (11.4) | 27.6 (11.8) | 28.6 (11.7) | 29.3 (11.6) |
| Discharge to follow-up | 17.7 (14.2) | 16.0 (14.4) | 17.6 (14.0) | 17.2 (14.2) | 17.7 (13.6) | 17.8 (14.3) | 18.8 (14.1) | 18.3 (14.6) | 18.7 (14.7) | 18.4 (13.8) |
Table 6.
Social circumstances and functional status at admission, discharge, and follow-up by year for patients with joint replacement.
| Total | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | |
|---|---|---|---|---|---|---|---|---|---|---|
| N | 107,320 | 20,850 | 23,751 | 17,022 | 12,416 | 10,459 | 7,619 | 6,123 | 4,930 | 4,150 |
| Living in community | ||||||||||
| Admit | 99.7% | 99.7% | 99.7% | 99.6% | 99.6% | 99.7% | 99.7% | 99.6% | 99.7% | 99.7% |
| Discharge | 95.2% | 95.5% | 95.6% | 95.8% | 94.7% | 94.8% | 94.7% | 94.4% | 94.7% | 94.8% |
| Follow-up | 99.1% | 99.1% | 99.3% | 99.2% | 99.1% | 99.2% | 99.0% | 99.1% | 99.0% | 98.7% |
| Living alone | ||||||||||
| Admit | 31.3% | 31.0% | 30.6% | 32.4% | 31.6% | 32.3% | 31.4% | 31.3% | 30.4% | 29.8% |
| Discharge | 20.1% | 20.8% | 20.1% | 21.5% | 20.2% | 19.9% | 19.7% | 18.9% | 17.2% | 17.5% |
| Follow-up | 30.3% | 30.4% | 30.2% | 31.2% | 30.5% | 30.5% | 29.8% | 29.5% | 29.2% | 28.9% |
| Vocation follow-up | ||||||||||
| Employed | 10.5% | 9.3% | 10.2% | 9.8% | 10.0% | 10.7% | 12.0% | 12.6% | 13.1% | 13.0% |
| Unemployed | 7.3% | 6.9% | 7.0% | 7.1% | 7.2% | 7.4% | 7.0% | 8.6% | 8.6% | 9.3% |
| Retired | 80.0% | 81.4% | 80.4% | 81.1% | 80.8% | 79.8% | 78.9% | 76.6% | 76.2% | 75.9% |
| Other | 2.2% | 2.4% | 2.4% | 2.0% | 2.0% | 2.2% | 2.1% | 2.2% | 2.1% | 1.8% |
| Maintain health follow-up | ||||||||||
| Own care | 94.2% | 94.9% | 95.5% | 94.4% | 93.7% | 93.4% | 90.7% | 93.9% | 93.7% | 92.3% |
| Family/unpaid | 3.1% | 3.4% | 2.3% | 3.2% | 3.2% | 3.3% | 4.0% | 3.3% | 3.0% | 3.9% |
| Paid help | 2.7% | 1.7% | 2.2% | 2.3% | 3.1% | 3.3% | 5.3% | 2.8% | 3.3% | 3.8% |
| Therapy follow-up | ||||||||||
| None | 59.4% | 67.7% | 65.6% | 63.9% | 56.5% | 51.0% | 47.3% | 49.6% | 45.0% | 47.6% |
| Outpatient/home | 39.3% | 31.1% | 33.6% | 35.0% | 41.8% | 47.3% | 51.1% | 49.1% | 53.2% | 50.4% |
| Other | 1.3% | 1.2% | 0.8% | 1.1% | 1.7% | 1.7% | 1.6% | 1.3% | 1.8% | 2.1% |
| Length of stay, days | 8.0 (3.7) | 7.9 (3.8) | 7.7 (3.6) | 7.9 (3.6) | 8.1 (3.8) | 8.2 (3.7) | 8.3 (3.7) | 8.3 (3.9) | 8.8 (3.9) | 8.8 (3.8) |
| FIM motor | ||||||||||
| Admit | 48.2 (8.8) | 49.5 (9.1) | 49.1 (8.7) | 49.0 (8.1) | 47.7 (8.3) | 47.0 (8.4) | 46.8 (8.6) | 46.6 (8.9) | 45.3 (9.1) | 45.1 (9.1) |
| Discharge | 70.9 (8.8) | 71.9 (8.9) | 70.8 (8.9) | 71.0 (8.5) | 70.8 (8.6) | 70.6 (8.6) | 70.4 (9.0) | 70.5 (8.8) | 70.4 (9.0) | 70.7 (9.2) |
| Follow-up | 85.1 (6.7) | 85.0 (6.8) | 85.5 (6.2) | 85.2 (6.5) | 85.2 (6.7) | 84.9 (6.8) | 84.8 (7.1) | 84.7 (7.2) | 84.8 (7.0) | 84.8 (7.4) |
| FIM cognition | ||||||||||
| Admit | 31.3 (4.2) | 32.0 (4.0) | 31.8 (4.0) | 31.5 (4.1) | 31.1 (4.3) | 30.9 (4.2) | 30.7 (4.4) | 30.5 (4.6) | 29.9 (4.7) | 29.6 (4.7) |
| Discharge | 32.8 (3.1) | 33.1 (3.0) | 32.9 (3.0) | 32.8 (3.0) | 32.7 (3.1) | 32.6 (3.1) | 32.5 (3.2) | 32.6 (3.1) | 32.3 (3.4) | 32.4 (3.2) |
| Follow-up | 34.2 (1.9) | 34.4 (1.8) | 34.3 (1.7) | 34.1 (1.8) | 34.1 (2.0) | 34.0 (1.9) | 34.0 (2.1) | 34.1 (2.0) | 34.0 (2.1) | 34.0 (2.1) |
| FIM total | ||||||||||
| Admit | 79.4 (11.1) | 81.4 (11.2) | 80.9 (10.6) | 80.4 (10.2) | 78.9 (10.6) | 77.9 (10.7) | 77.5 (11.2) | 77.1 (11.5) | 75.2 (11.8) | 74.7 (12.0) |
| Discharge | 103.7 (10.5) | 105 (10.6) | 103.7 (10.5) | 103.7 (10.0) | 103.4 (10.3) | 103.1 (10.3) | 102.9 (10.8) | 103.1 (10.4) | 102.7 (10.9) | 103.1 (11.2) |
| Follow-up | 119.3 (7.7) | 119.4 (7.7) | 119.8 (7.1) | 119.4 (7.5) | 119.3 (7.8) | 119.0 (7.8) | 118.8 (8.2) | 118.8 (8.3) | 118.8 (8.2) | 118.8 (8.6) |
| FIM total change | ||||||||||
| Admit to discharge | 24.4 (10.0) | 23.5 (9.8) | 22.7 (9.8) | 23.3 (9.5) | 24.6 (9.5) | 25.2 (9.6) | 25.4 (10.0) | 27.4 (10.6) | 28.8 (10.9) | 29.6 (10.8) |
| Discharge to follow-up | 15.6 (10.0) | 14.4 (10.2) | 16.1 (10.2) | 15.6 (9.9) | 15.9 (9.8) | 15.8 (9.7) | 15.9 (10.0) | 15.6 (9.7) | 16.1 (9.9) | 15.7 (10.5) |
Footnotes
Disclosures:
This work was supported by grants from the Department of Education, National Institute on Disability and Rehabilitation Research (H133G080163 [Ottenbacher] and H133N060014 [Deutsch]), and the National Institutes of Health, National Center for Medical Rehabilitation Research (R24 HD065702 [Ottenbacher, Graham, Karmarkar]). The FIM® instrument is a registered trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
References
- 1.Granger CV, Markello SJ, Graham JE, Deutsch A, Ottenbacher KJ. The uniform data system for medical rehabilitation: report of patients with stroke discharged from comprehensive medical programs in 2000–2007. Am J Phys Med Rehabil. 2009;88:961–972. doi: 10.1097/PHM.0b013e3181c1ec38. [DOI] [PubMed] [Google Scholar]
- 2.Granger CV, Markello SJ, Graham JE, Deutsch A, Reistetter TA, Ottenbacher KJ. The Uniform Data System for Medical Rehabilitation: Report of Patients with Traumatic Brain Injury Discharged from Rehabilitation Programs in 2000–2007. Am J Phys Med Rehabil. 2010;89:265–278. doi: 10.1097/PHM.0b013e3181d3eb20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Granger CV, Markello SJ, Graham JE, Deutsch A, Reistetter TA, Ottenbacher KJ. The Uniform Data System for Medical Rehabilitation report of patients with lower extremity joint replacement discharged from rehabilitation programs in 2000 – 2007. Am J Phys Med Rehabil. 2010 doi: 10.1097/PHM.0b013e3181f1c83a. In press. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Granger CV, Reistetter TA, Graham JE, et al. The Uniform Data System for Medical Rehabilitation: report of patients with hip fracture discharged from comprehensive medical programs in 2000–2007. Am J Phys Med Rehabil. 2011;90:177–189. doi: 10.1097/PHM.0b013e31820b18d7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Granger CV, Karmarkar AM, Graham JE, et al. The uniform data system for medical rehabilitation: report of patients with traumatic spinal cord injury discharged from rehabilitation programs in 2002–2010. Am J Phys Med Rehabil. 2012;91:289–299. doi: 10.1097/PHM.0b013e31824ad2fd. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Galloway RV, Granger CV, Karmarkar AM, et al. The Uniform Data System for Medical Rehabilitation: Report of Patients with Debility Discharged from Inpatient Rehabilitation Programs in 2000–2010 [Article] Am J Phys Med Rehabil. 2013;92:14–27. doi: 10.1097/PHM.0b013e31827441bc. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Fiedler RC, Granger CV, Russell CF. UDS(MR): follow-up data on patients discharged in 1994–1996. Am J Phys Med Rehabil. 2000;79:184–192. doi: 10.1097/00002060-200003000-00012. [DOI] [PubMed] [Google Scholar]
- 8.111th Congress. Patient Protection and Affordable Care Act (Public Law 111–148). 1-5-2010.
- 9.Walker AJ, Pratt CC, Eddy L. Informal Caregiving to Aging Family Members: A Critical Review. Family Relations. 1995;44:402–411. [Google Scholar]
- 10.Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the Functional Independence Measure: a quantitative review. Arch Phys Med Rehabil. 1996;77:1226–1232. doi: 10.1016/s0003-9993(96)90184-7. [DOI] [PubMed] [Google Scholar]
- 11.Smith PM, Illig SB, Fiedler RC, Hamilton BB, Ottenbacher KJ. Intermodal agreement of follow-up telephone functional assessment using the Functional Independence Measure in patients with stroke. Arch Phys Med Rehabil. 1996;77:431–435. doi: 10.1016/s0003-9993(96)90029-5. [DOI] [PubMed] [Google Scholar]
- 12.Carter GM, Buchanan JL, Buntin MB, Hayden O, Paddock S, Relles DA, et al. Executive Summary of Analyses for the Initial Implementation of the Inpatient Rehabilitation Facility Prospective Payment System. Santa Monica, CA: Rand Corporation; 2002. [Google Scholar]
- 13.US Department of Health and Human Services. Federal Register. 151. Vol. 74. Washington, DC: Aug 7, 2009. [Google Scholar]
- 14.DeJong G, Tian W, Smout RJ, et al. Use of rehabilitation and other health care services by patients with joint replacement after discharge from skilled nursing and inpatient rehabilitation facilities. Arch Phys Med Rehabil. 2009;90:1297–1305. doi: 10.1016/j.apmr.2008.12.029. [DOI] [PubMed] [Google Scholar]
- 15.Stineman MG, Maislin G, Fiedler RC, Granger CV. A prediction model for functional recovery in stroke. Stroke. 1997;28:550–556. doi: 10.1161/01.str.28.3.550. [DOI] [PubMed] [Google Scholar]