Abstract
This cohort study examines whether use of a mobility assessment tool in hospitalized patients with impaired mobility is associated with discharge to a postacute facility.
Patient mobility is an indicator of health and a predictor associated with clinical outcomes. However, mobility status is not routinely measured in hospitalized patients.1 Consequently, physicians do not recognize when patients experience low baseline mobility and declines in mobility status during hospitalization.2
Hospitalized patients with impaired mobility often require discharge to a postacute facility. Because physicians do not recognize impaired mobility until after resolution of acute medical or surgical issues, engagement with physical therapists, case managers, and social workers needed for placement is often delayed.3
Routinely measuring mobility status of inpatients may help facilitate postdischarge planning.4 Hence, we sought to evaluate whether a simple validated mobility assessment tool, completed by nurses as part of routine clinical care, is associated with discharge to a postacute facility.
Methods
We conducted a retrospective cohort study on data from 2876 consecutive patients admitted from January 1, 2015, to January 1, 2016, on 2 inpatient units (medical and neurological and/or neurosurgical) at The Johns Hopkins Hospital. Data were obtained from the electronic medical record and the hospital’s administrative database used for statewide reporting. The Johns Hopkins Institutional Review Board approved this study with a waiver of consent based on retrospective analysis of deidentified data. Data were analyzed from January 1, 2018, to May 1, 2018.
For all patients, mobility status (primary exposure) was measured by nurses as part of routine clinical care on the day of hospital admission and 3 times weekly, using the Activity Measure for Post-Acute Care Inpatient Mobility Short Form (AM-PAC IMSF). This reliable and valid tool consists of 6 items indicating the level of assistance required to perform mobility tasks, with standardized scores ranging from a low of 23.55 to a high of 61.14.5
Mobility status at hospital admission was evaluated in 2 ways: by tertile and by a 10-point (1-SD) difference in the AM-PAC IMSF score. Admission mobility status is reported according to tertile of the AM-PAC IMSF standardized scale score (low: 23.55-39.45; middle: 40.78-45.44; high: 47.67-61.14 [lower scores are associated with higher odds for facility placement]). Change in mobility status during hospitalization was calculated as the difference between discharge and admission scores, with patients dichotomized as declined vs no change or improved, with associated statistical analyses accounting for admission mobility status along with other covariates (detailed in the methods for the multivariable regression analysis).
The primary outcome was discharge to a health care facility (including inpatient rehabilitation or skilled nursing).
Multivariable logistic regression analysis was used to separately evaluate the associations of admission patient mobility status and change in mobility status with the health care facility disposition, adjusting for age, sex, race/ethnicity, payer, primary diagnoses, and Agency for Healthcare Research and Quality Elixhauser comorbidity index. Data analyses were performed using statistical software (SAS, version 9.4; SAS Institute Inc), and statistical significance was defined as 2-sided P < .05.
Results
Mobility scores were completed at admission and discharge for more than 95% of patients. Among 2876 patients, 716 (25%) were discharged to a facility (Table).
Table. Patient Characteristics by Outcomesa.
| Covariates | All Patients (N = 2876) | Discharge to Facility,b No. (%) | |
|---|---|---|---|
| (Yes) (n = 716) | (No) (n = 2160) | ||
| Age, mean (SD), y | 54 (17) | 61 (16) | 52 (16) |
| Male sex | 1305 (45) | 343 (48) | 962 (45) |
| Race | |||
| Black | 639 (22) | 219 (31) | 420 (19) |
| White | 1849 (64) | 393 (55) | 1456 (67) |
| Other | 388 (14) | 104 (15) | 284 (13) |
| Payer | |||
| Private | 1336 (47) | 212 (30) | 1124 (52) |
| Medicaid | 350 (12) | 100 (14) | 250 (12) |
| Medicare | 887 (31) | 347 (49) | 540 (25) |
| Other | 303 (11) | 57 (8) | 246 (11) |
| Diagnostic category for hospitalization | |||
| Craniofacial surgery | 1044 (36) | 187 (26) | 857 (40) |
| Spinal surgery | 797 (28) | 186 (26) | 611 (28) |
| Medical | 688 (24) | 178 (25) | 510 (24) |
| Stroke or traumatic brain injury | 224 (8) | 130 (18) | 94 (4) |
| Other neurological diagnosis | 123 (4) | 35 (5) | 88 (4) |
| Elixhauser comorbidity index, mean (SD) | 2.2 (1.1) | 2.7 (1.6) | 2.0 (0.9) |
| Length of stay, mean (SD), d | 6.0 (7.1) | 12.0 (10.7) | 4.0 (3.7) |
Proportions may not add to 100% because of rounding.
Refers to discharge to a rehabilitation hospital, skilled nursing facility, long-term care facility, or other care facility.
Patient mobility score at hospital admission was independently associated with facility placement, with adjusted odds ratios (aOR) for facility placement of 3.1 (95% CI, 2.8-3.6; P < .001) for a 10-point negative difference in AM-PAC IMSF, and 9.8 (95% CI, 7.3-13.2; P < .001) for comparison of lowest vs highest tertile of mobility score and 2.5 (95% CI, 1.8-3.4; P < .001) for comparison of middle tertiles vs highest tertile of mobility score.
For patients whose mobility score declined (vs no change or improved), after adjustment for mobility score at admission and all covariates, the aOR for facility placement was 3.6 (95% CI, 2.7-4.9; P < .001).
Discussion
A validated measure of patient mobility, routinely collected by nurses as part of clinical care, appears to be associated with discharge placement. Recognition of low mobility scores at admission or declining mobility status during hospitalization should prompt early engagement of physical therapists, case managers, and social workers to address issues of patient mobility and facility placement. Additionally, recognition of high mobility scores may allow physicians to choose wisely and decrease low-value physical therapy consults to reallocate this scarce resource to patients who may achieve greater benefit.1,6
References
- 1.Greysen SR, Patel MS. Annals for Hospitalists Inpatient Notes: bedrest is toxic-why mobility matters in the hospital. Ann Intern Med. 2018;169(2):HO2-HO3. doi: 10.7326/M18-1427 [DOI] [PubMed] [Google Scholar]
- 2.Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57(9):1660-1665. doi: 10.1111/j.1532-5415.2009.02393.x [DOI] [PubMed] [Google Scholar]
- 3.Wong EL, Yam CH, Cheung AW, et al. Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals. BMC Health Serv Res. 2011;11(1):242. doi: 10.1186/1472-6963-11-242 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-620. doi: 10.1001/jama.281.7.613 [DOI] [PubMed] [Google Scholar]
- 5.Hoyer EH, Young DL, Klein LM, et al. Toward a common language for measuring patient mobility in the hospital: reliability and construct validity of interprofessional mobility measures. Phys Ther. 2018;98(2):133-142. doi: 10.1093/ptj/pzx110 [DOI] [PubMed] [Google Scholar]
- 6.Probasco JC, Lavezza A, Cassell A, et al. Choosing wisely together: physical and occupational therapy consultation for acute neurology inpatients. Neurohospitalist. 2018;8(2):53-59. doi: 10.1177/1941874417729981 [DOI] [PMC free article] [PubMed] [Google Scholar]