Abstract
Background
Patients with cancer have been noted to have inadequate continuity of care after discharge from hospital. We sought to assess patient‐reported continuity of care and functional safety concerns after acute inpatient rehabilitation.
Methods
This was a prospective study that used cross‐sectional surveys at a National Cancer Institute Comprehensive Cancer Center. All patients who were admitted to acute inpatient rehabilitation from September 5, 2018, to February 7, 2020, met the inclusion criteria, and completed two surveys (assessing continuity of care and functional safety concerns) upon discharge and 1 month after discharge were included in the study.
Results
A total of 198 patients completed the study, and no major concerns were reported by the patients. The greatest concern was a lack of adequate communication management among different providers, reported by only 10 (5.0%) patients. The combined fall and near‐fall rate within 1 month after discharge was (25/198) 13%. Brain metastasis, a comorbidity of depression, and a history of falls were significantly associated with a higher risk of falls or near falls within 1 month after discharge.
Conclusion
Although overall patients with cancer reported adequate continuity of care and feeling safe to function at home after acute inpatient rehabilitation, it is important to be aware that fall or near‐fall events within 1 month after acute inpatient rehabilitation are associated with brain metastasis, comorbidity of depression, and a history of falls. Thus, patients with these risk factors may benefit from including more focused fall prevention education and interventions.
Implications for Practice
Patients with cancer often have extensive problems that require care from multiple health care providers simultaneously, and a high level of coordination is needed for adequate transition of care from the inpatient to the outpatient setting. This transition of care period is prone to inadequate continuity of care and, for older adults, a particular risk for falls. Assessment for risk of fall is also an important factor to consider when evaluating patients to continue oncology treatments. There is a gap in knowledge regarding patient‐reported continuity of care and functional safety concerns after acute inpatient cancer rehabilitation.
Keywords: Cancer, Prospective, Continuity, Falls, Inpatient, Rehabilitation
Short abstract
Safe patient discharge after acute care is increasingly challenging because of a trend toward shorter hospital stays. This article assesses patient‐reported continuity of care and functional safety concerns after acute inpatient rehabilitation in patients with cancer.
Introduction
Safe patient discharge after acute care is becoming increasingly critical because of the trend toward shorter hospital acute care stays [1, 2] and because health care responsibility is being transferred from the inpatient team to the patient and patient's community health care team [1, 3, 4]. Unfortunately, this transition has the potential to disrupt continuity of care from inpatient to outpatient health care [2, 5]. These disruptions include hampered communication, imprecise transfer of information, and unsuccessful coordination of care between clinicians [6, 7]. The problems that may occur during this transition period have been evaluated from the perspectives of patients, relatives, and care providers [6, 8]. Studies support that continuity of care assessments include patient's perspective and measure important aspects of care such as informational, relational, and management continuity [9, 10] to support collaboration of actual receipt of service with respect to coordination of care.
During hospitalization, changes occur to patients’ medical and often functional status, which can continue to affect patients after hospital discharge. Aside from medical adverse events [11], patients may be vulnerable to physical injuries during the transition of care because they may have new or more severe functional impairments compared with their preadmission functional status. After being discharged from the hospital, older patients aged ≥65 years have a reported fall rate of 15% within the first month [12]. Falls are associated with functional decline, institutionalized care [3], and increased morbidity, mortality [13, 14], and health care costs [15].
A systematic review concluded that there is a 16%–17% higher risk of falls in older adults (aged ≥65 years) with cancer than in older adults overall [16]. Another systematic review suggested that falls are common among advanced stage or palliative patients with cancer, older adults (aged ≥60 years) with cancer, and those receiving chemotherapy [17]. There is a particular need to address falls in patients with cancer because falls are more common in older adults and cancer is more common in older adults [14, 18, 19].
Cancer and its treatment can affect bone health and patients’ functional status [20]. Patients with cancer with a history of falls have a higher risk of chemotherapy toxicity and death [16]. In addition, fall assessment may be an important factor to consider when evaluating patients for further oncology treatments [21].
The goal of acute inpatient rehabilitation is to provide simultaneous medical and intensive rehabilitative care for patients, with oversight by physical medicine and rehabilitation physician, to improve patients’ functional status to safely function at home with more independence. In a large comprehensive cancer center, acute inpatient rehabilitation is further specialized with higher acuity medical problems and interventions. Thus, discharge becomes more complex than traditional acute inpatient rehabilitation. The aim of this study was to address a gap in knowledge of assessing patient‐reported concerns on continuity of care and safety with functional status after acute inpatient rehabilitation. We also evaluated the frequency of patient‐reported falls and near falls within 1 month after discharge and their associated risk factors in relation to an acute inpatient rehabilitation cohort's demographic and clinical characteristics. Identifying patients’ risk factors for falls is also important for possible rehabilitation interventions.
Materials and Methods
Participants
This study screened all patients who were admitted to acute inpatient rehabilitation from September 5, 2018, to February 7, 2020, and included those who completed two surveys upon discharge and 1 month after discharge. The inclusion criteria for participants were as follows: (a) discharged from acute cancer inpatient rehabilitation to a personal residence, (b) provided informed consent, (c) 18 years of age or older, and (d) English speaking. The exclusion criteria were as follows: (a) discharged to another hospital or health facility (e.g., a skilled nursing facility, long term acute care hospital); (b) moderate‐to‐severe cognitive deficits, as determined by speech language pathologists through a variety of formal tests depending on patient's clinical factors (site of lesion, visual impairment, what the patient can tolerate, etc.); (c) rehospitalized at any time during the study period (since completion of the first survey upon discharge from the hospital and until 30 days after discharge); (d) readmitted to acute inpatient rehabilitation and previously completed both surveys; and (e) not reachable via telephone after three attempts to complete the repeated surveys 1 month after discharge.
Design and Measurements
This was a prospective study that used cross‐sectional surveys to collect information upon discharge and 1 month after discharge. There were two separate questionnaires: (a) “Patient Continuity of Care Checklist” and (b) “Perceptions Regarding Functional Safety after Rehabilitation.”
Questionnaires
The “Patient Continuity of Care Checklist” has 41 questions and has been shown to be valid and reliable for measuring patient perceptions of factors that impact continuity of care following discharge from the hospital [22, 23]. It has been used in patients with a wide variety of medical diagnoses, but to our knowledge this is the first time it was used in a cohort of patients with cancer diagnosis. This study used the following two subscales (10 questions): (a) information transfer to patients and (b) management of communication among providers.
Functional safety concerns were captured in the “Perceptions Regarding Functional Safety after Rehabilitation” survey, which was created by study investigators to capture functional status concerns that arise in the immediate post‐rehabilitation hospital discharge period based on feedback from the institution's cancer rehabilitation physicians and physician extenders. This survey was formatted (and thus scored) like the Patient Continuity of Care Checklist with a 5‐point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). It was reviewed by the office of protocol research consent editor to ensure that it was at a 6th–8th grade reading level, but it did not undergo cognitive interviewing or validity and reliability testing.
Select statements from both surveys were administered upon discharge and approximately 1 month after discharge, as appropriate to the time period. Items 1–8 were from “Perceptions Regarding Functional Safety after Rehabilitation” and assessed functional safety concerns at discharge and 1 month after discharge. Items 9–18 were from the “Patient Continuity of Care Checklist”; 9–15 applied to information that was available to patients upon discharge, and items 16–18 applied to information that was available to patients 1 month after discharge. Items 19–20 assessed functional safety concerns after discharge.
As part of functional safety concerns assessments, falls and near falls were assessed in the survey that was administered 1 month after discharge. A fall was defined as an event that resulted in the person unintentionally coming to rest on the ground or at a level lower [24, 25] than sitting level [26]. A near fall was defined as slipping or sliding of the supported leg, resulting in an impact of the leg with an external object or loss of balance that did not result in a fall, either because the person prevented the fall [25] or because another person helped to abort the fall. The statements were as follows: (a) I have had fall(s) (defined as unintentionally coming to rest on level lower than sitting level) over the past 1 month; (b) I have had near fall(s) (a slip, trip with impact on an external object, or loss of balance but was able to prevent the fall) over the past 1 month.
Variables
Demographic and clinical characteristics were collected by research staff and principal investigators through a retrospective review of patients’ electronic health records.
We used Activity Measure for Post‐Acute Care (AM‐PAC) Inpatient “Six Clicks” Short Forms to assess functional status and level of impairment. Physical therapists completed the basic mobility function form and occupational therapists completed the daily activity function form. These are validated forms [27] that were derived from a traditional AM‐PAC, which has excellent reliability and validity in diverse populations [28, 29]. As described by Jette et al., each form has “6 activities, and the therapists scored the patient's level of difficulty or assistance on a scale from 1 (unable to do or total assistance required) to 4 (no difficulty or no assistance required)” [30]. The total of scores provides a raw score from 6 to 24 for each form that is “standardized to a t score for which the mean is 50 and the standard deviation is 10. The range of standardized scores for the basic mobility form is 23.55–61.14, and a score of 42 equates to approximately 50% impairment. The range of standardized scores for the daily activity form is 17.07–57.54, and a score of 37 equates to approximately 50% impairment” [30]. Higher scores indicate higher levels of function [30].
Data Collection
Informed consent was obtained 0–2 days prior to discharge from the acute inpatient rehabilitation service by the research coordinator. Patients were then invited to complete the survey 0–2 days prior to discharge and approximately 1 month plus up to 8 days after discharge. Discharged patients were contacted via telephone by the research coordinator approximately 30–38 days after discharge.
Approval for data collection was obtained by the institutional review board. Study data were collected and managed using Research Electronic Data Capture (hosted at The University of Texas MD Anderson Cancer Center) (Vanderbilt University, Nashville, TN), “a secure, web‐based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources” [31, 32].
Statistical Analysis
Patients’ demographic and baseline clinical characteristics were summarized using descriptive statistics. The AM‐PAC basic mobility and daily activity raw scores were converted to scaled scores and a degree of functional impairment using the method described by Jette et al. [27]. Survey results are presented with completion rates, means, number of patients who disagreed with an item (scores of 1 and 2), and percentages. Additional clinical characteristics used to analyze fall and near‐fall risk factors were summarized using frequency and proportions for categorical variables overall and by fall or near fall after discharge (yes/no) using χ‐squared test or Fisher's exact test. Wilcoxon rank sum test is used to compare continuous variables between two groups. A multicovariable logistic regression model was used to evaluate the associations between post‐discharge falls or near falls and brain metastases, a comorbidity of depression, and a history of falls. A p value < .05 was deemed statistically significant. All statistical analyses were performed using SAS 9.4 software (SAS Institute, Inc., Cary, NC).
Results
Of 490 admitted patients, 315 met the eligibility criteria; 298 were approached, 261 were enrolled, and 198 completed the study, with surveys completed at discharge and 1 month after discharge (Fig. 1).
Figure 1.
Flow of participants.
Patients’ basic demographic or clinical characteristics did not significantly differ between patients who reported falls or near falls and those who did not (Table 1). Most of the patients were men (57%), White (83%), and married (68%). Their median age was 63 years, and the median length of hospital stay, which included the length of the acute inpatient rehabilitation stay, was 23 days. The most common type of primary neoplasm in the patient population was brain and other nervous system (48%).
Table 1.
Demographic and clinical characteristics of patients who completed both surveys
| Patient characteristics | Total (n = 198; 100%) | No falls/near falls (n = 173) | Falls/near falls (n = 25) | p value |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| Female sex | 85 (43) | 71 (41) | 14 (56) | .158 |
| Race | ||||
| White | 164 (83) | 144 (83) | 20 (80) | .199 |
| Black | 19 (10) | 18 (10) | 1 (4) | |
| Asian | 5 (2) | 4 (2) | 1 (4) | |
| Others | 10 (5) | 7 (4) | 3 (12) | |
| Hispanic ethnicity | 18 (9) | 16 (9) | 2 (8) | .208 |
| Married | 135 (68) | 117 (68) | 18 (72) | .661 |
| Insurance | ||||
| Commercial | 102 (52) | 88 (51) | 14 (56) | .125 |
| Medicare | 91 (46) | 82 (47) | 9 (36) | |
| Others | 5 (2) | 3 (2) | 2 (8) | |
| Primary neoplasm type | ||||
| Brain and other nervous system | 48 (24) | 39 (23) | 9 (36) | .514 |
| Hematologic and lymphatic | 45 (23) | 39 (23) | 6 (24) | |
| Bones and joints | 32 (16) | 31 (18) | 1 (4) | |
| Genitourinary | 26 (13) | 23 (13) | 3 (12) | |
| Digestive | 12 (6) | 10 (6) | 2 (8) | |
| Respiratory | 12 (6) | 10 (6) | 2 (8) | |
| Breast | 8 (4) | 8 (5) | 0 | |
| Other neoplasmsa | 15 (8) | 13 (8) | 2 (8) | |
| Visual dysfunction during rehabilitation | 7 (4) | 7 (4) | 0 | .599 |
| Mildb cognitive dysfunction during rehabilitation | 45 (23) | 39 (23) | 6 (24) | .871 |
| Rehabilitation prescribed upon discharge | ||||
| Outpatient therapy | 146 (74) | 129 (75) | 17 (68) | .486 |
| Home health therapy | 52 (26) | 52 (26) | 44 (25) |
| Median (IQRc) | Median (IQR) | Median (IQR) | ||
|---|---|---|---|---|
| Age, yr | 63 (51–70) | 66 (50–71) | 59 (56–66) | .279 |
| Total hospital length of stay, days | 23 (17–30) | 23 (17–31) | 23 (18–26) | .626 |
| Acute inpatient rehabilitation length, days | 11 (8–14) | 11 (8–14) | 12 (8–15) | .594 |
| Hospital length of stay before transfer to rehabilitation, days | 10 (7–19) | 10 (7–19) | 10 (7–13) | .761 |
| AM‐PACd basic mobility score, admission, median | 40.78 (39.45–43.63) | 40.78 (40.78–43.63) | 40.78 (39.45–43.63) | .614 |
| AM‐PAC daily activity score, admission, median | 37.26 (35.96–40.22) | 37.26 (35.96–40.22) | 37.26 (35.96–40.22) | .999 |
| AM‐PAC basic mobility score, discharge, median | 47.67 (42.13–53.28) | 47.67 (42.13–53.28) | 45.44 (43.63–47.67) | .538 |
| AM‐PAC daily activity score, discharge, median | 40.22 (40.22–44.27) | 40.22 (40.22–44.27) | 40.22 (38.66–42.03) | .170 |
| Laboratory valuese | ||||
| White blood cell count (reference range: 4–11 K/μL) | 5.70 (4.10–7.75) | 5.70 (4.20–7.75) | 5.55 (3.45–7.65) | .297 |
| Hemoglobin (reference range: 12–16 g/dL) | 10.00 (9.10–11.25) | 10.00 (9.10–11.30) | 10.25 (9.35–11.15) | .555 |
| Platelet count (reference range: 140–440 K/μL) | 217.50 (126.25–290.00) | 221.50 (133.00–290.00) | 202.50 (97.00–296.00) | .526 |
| Creatinine (reference range: 0.60–1.00 mg/dL) | 0.75 (0.63–0.95) | 0.76 (0.64–0.95) | 0.71 (0.61–0.89) | .488 |
| Sodium (reference range: 135–147 mEq/L) | 139.00 (136.00–140.00) | 139.00 (136.00–140.00) | 139.00 (137.00–140.00) | .423 |
Other neoplasms included endocrine, eye/orbit, oral cavity and pharynx, skin, and other soft tissue.
Patients with moderate to severe cognitive deficits were excluded from the survey study as per study protocol.
Results as median (IQR, 25–75).
AM‐PAC measured within 24 hours after admission and 24 hours prior to discharge from acute inpatient rehabilitation.
Laboratory values were obtained 0–3 days before discharge and closest to the discharge day.
Abbreviations: AM‐PAC, Activity Measure for Post‐Acute Care; IQR, interquartile range.
The discharge AM‐PAC basic mobility median score of 47.67 indicated only 36% functional impairment, and the daily activity median score of 40.22 indicated 43% functional impairment [27, 28]. Among the 100% patients who were prescribed to continue rehabilitation in their community upon discharge, 146 (74%) were prescribed outpatient rehabilitation and 52 (26%) were prescribed home health rehabilitation. On the surveys, however, 197 (99%) patients upon discharge and 198 (100%) patients 1 month after discharge reported feeling safe in the home setting. Table 2 displays results from the two surveys, which include the statements that were on the surveys.
Table 2.
Before and after discharge surveys: Perceptions Regarding Safety after Rehabilitation and Continuity of Care Checklist
| Item number and description | Discharge | One month after discharge | ||||||
|---|---|---|---|---|---|---|---|---|
| n | Meana | Strongly disagree/somewhat disagree (n) | Patient(s) who disagree (%)a | n | Mean | Strongly disagree/somewhat disagree (n) | Patient(s) who disagree (%) | |
| 1. I feel safe to be in the home setting after my hospital rehabilitation program. | 197 | 4.88 | 0 | 0.0 | 198 | 4.99 | 0 | 0.0 |
| 2. I feel safe to be in the home setting as I no longer have fear of fall after my hospital rehabilitation program. | 197 | 4.59 | 5 | 2.5 | 198 | 4.94 | 1 | 0.5 |
| 3. I feel that I was recommended all the equipment that I needed to function in the home setting. | 195 | 4.93 | 1 | 0.5 | 194 | 4.96 | 0 | 0.0 |
| 4. I feel that my equipment was delivered on time. | 174 | 4.70 | 2 | 1.0 | 189 | 4.89 | 3 | 1.5 |
| 5. I feel that I use all equipment the way that my rehabilitation team recommended. | 188 | 4.93 | 0 | 0.0 | 189 | 4.92 | 0 | 0.0 |
| 6. I feel safe to perform all hygiene tasks independently or with assistance. | 197 | 4.88 | 0 | 0.0 | 198 | 4.90 | 0 | 0.0 |
| 7. I feel safe to perform all transfer tasks independently or with assistance. | 197 | 4.89 | 0 | 0.0 | 198 | 4.92 | 0 | 0.0 |
| 8. If walking, I feel safe to do so independently or with assistance. | 192 | 4.91 | 0 | 0.0 | 197 | 4.92 | 0 | 0.0 |
| 9. I was provided with clear information on my diagnosis. | 195 | 4.82 | 0 | 0.0 | ||||
| 10. I was provided with clear information on my prognosis. | 188 | 4.71 | 1 | 0.5 | ||||
| 11. I was told about non urgent symptoms that may occur and how I should cope with these. | 62 | 4.68 | 1 | 0.5 | ||||
| 12. I was given information on symptoms that may signal a need to seek urgent medical attention. | 46 | 4.70 | 1 | 0.5 | ||||
| 13. I was given complete information on my medications. | 46 | 4.87 | 0 | 0.0 | ||||
|
14. I was provided with information on recommendations and restrictions in activities, exercises and aids. |
188 | 4.75 | 0 | 0.0 | ||||
| 15. The different providers appeared to communicate well with each other while I was in hospital/convalescent care. | 196 | 4.67 | 10 | 5.0 | ||||
| 16. As far as I am aware, the different health care providers in hospital have communicated well with those in the community about my care. | 197 | 4.81 | 0 | 0.0 | ||||
| 17. As far as I am aware, my family physician or other key provider was contacted and informed about the important aspects of care that I received. | 196 | 4.78 | 0 | 0.0 | ||||
| 18. I was given consistent information by all providers about my care. | 197 | 4.80 | 0 | 0.0 | ||||
| 19. I feel that I was able to obtain all the equipment that my rehabilitation team prescribed without financial difficulties. | 186 | 4.86 | 2 | 1.0 | ||||
| 20. I feel that I did not have any time delays in restarting any recommended therapies (physical, occupational, and/or speech) upon discharge. | 183 | 4.80 | 0 | 0.0 | ||||
Items were rated on a scale from 1 (strongly disagree) to 5 (strongly agree). Higher mean scores reflect more positive perceptions of care. Higher percentages reflect a higher number of patients with negative perceptions of care.
Frequency and proportions were used to describe details of falls and near falls after discharge, as shown in Table 3. A total of 18 (9%) out of 198 patients reported falls with 26 total events and 7 (4%) reported near falls with 10 total events. In comparison, during hospitalization, 10 (5.0%) patients experienced a total of 12 falls; none of these patients experienced a fall within 1 month after discharge. The combined fall and near‐fall events within 1 month after discharge occurred in 25 out of 198 (13%) patients. The patients who reported falls did not report near falls and vice versa in this study. We did not assess if patients who fell during hospitalization received any specific fall prevention education or intervention.
Table 3.
Patient‐reported details of falls and near falls within 1 month after discharge
| Fall and near fall characteristics | Falls, n (%) | Near falls, n (%) |
|---|---|---|
| Total patients | 18 (9)a | 7 (4)a |
| Total number of events | 26 | 10 |
| 1 | 12 (67) | 5 (71) |
| 2 | 4 (22) | 1 (14) |
| 3 | 2 (11) | 1 (14) |
| Event details | ||
| Witnessed | ||
| Yes | 25 (96) | 7 (70) |
| No | 1 (4) | 3 (30) |
| Injury required further medical care | ||
| Yes | 4 (15) | 0 (0) |
| No | 22 (85) | 10 (100) |
| Use of equipment during incident | ||
| Cane | 1 (4) | 1 (9) |
| Walker | 5 (19) | 1 (9) |
| Wheelchair | 0 (0) | 0 (0) |
| Other | 1 (4) | 0 (0) |
Total number of patients who experienced falls and near falls after discharge are 18 and 7 out of 198 patients, respectively. Eighteen patients had a total of 26 number of falls, and 7 patients had a total of 10 near falls.
We analyzed the clinical characteristics (Table 4) of patients who reported falls or near falls 1 month after discharge to identify factors that were prognostic for these events. The results of a multicovariable logistic regression analysis indicated that brain metastasis (hazard ratio [HR], 4.57; 95% confidence interval [CI], 1.36–15.35; p = .01), comorbidity of depression (HR, 3.07; 95% CI, 1.25–7.55; p = .01), and a history of falls (HR, 2.67; 95% CI, 0.90–7.91; p = .08) were significantly or borderline significantly associated with a higher risk of post‐discharge falls or near falls.
Table 4.
Additional clinical characteristics of patients
| Clinical characteristics | Total (n = 198; 100%), n (%) | No falls/near falls (n = 173; 87%), n (%) | Falls/near falls (n = 25; 13%), n (%) | p value |
|---|---|---|---|---|
| Metastasis types | ||||
| Bones | 40 (20) | 37 (21) | 3 (12) | .4364 |
| Lungs | 22 (11) | 17 (10) | 5 (20) | .1658 |
| Brain | 16 (8) | 11 (6) | 5 (20) | .0354 |
| Others | 27 (14) | 24 (14) | 3 (12) | .9999 |
| Comorbidities | ||||
| Anemia | 179 (90) | 156 (90) | 23 (92) | .9999 |
| Cardiovascular disorders | 131 (66) | 117 (68) | 14 (56) | .2506 |
| Depression | 54 (27) | 42 (24) | 12 (48) | .0128 |
| Metastasis | 61 (31) | 54 (31) | 7 (28) | .7449 |
| Anxiety | 41 (21) | 39 (23) | 2 (8) | .1158 |
| Diabetes (uncomplicated) | 30 (15) | 25 (15) | 5 (20) | .5488 |
| Insomnia | 30 (15) | 25 (15) | 5 (20) | .5488 |
| Peripheral neuropathy | 26 (13) | 24 (14) | 2 (8) | .5409 |
| History of falls | 23 (12) | 17 (10) | 6 (24) | .0387 |
| Osteoarthritis | 22 (11) | 20 (12) | 2 (8) | .9999 |
| Poor oral intake | 20 (10) | 17 (10) | 3 (12) | .7234 |
| Foot problems | 15 (8) | 15 (8) | 13 (8) | .9999 |
| Orthostatic hypotension | 15 (8) | 15 (8) | 14 (8) | .6984 |
| Urinary symptoms | 14 (7) | 11 (6) | 3 (12) | .3930 |
| Fever | 11 (6) | 10 (6) | 1 (4) | .9999 |
| Osteoporosis | 10 (5) | 10 (6) | 0 | .6179 |
| Stroke | 10 (5) | 10 (6) | 0 | .6179 |
| Dizziness/lightheadedness | 8 (4) | 7 (4) | 1 (4) | .9999 |
| Diabetes (complicated) | 7 (4) | 6 (4) | 1 (4) | .9999 |
| Weight loss | 6 (3) | 5 (3) | 1 (4) | .5600 |
| Parkinsonism | 3 (2) | 2 (1) | 1 (4) | .3344 |
| Parkinson's disease | 2 (1) | 2 (1) | 0 | .9999 |
Discussion
To our knowledge, this is the first study of patient‐reported concerns on continuity of care and functional safety status after intensive acute inpatient rehabilitation in patients with cancer. This heterogenous mix of patients with various cancer types, with predominantly older patients (median age of 63), overall reported feeling safe to function upon discharge and 1 month after discharge. They also did not report any significant concerns on Continuity of Care Checklist. This outcome was unexpected given the complexities and inadequate continuity of care that were noted during monthly outpatient interdisciplinary cancer rehabilitation at our institution [5]. It is important to note that 100% of patients were prescribed to continue rehabilitation in their community upon discharge and that 92% patients reported no time delays in restarting outpatient or home health rehabilitation. Furthermore, there was an improvement of functional scores from admission to inpatient rehabilitation to discharge from inpatient rehabilitation, specifically, an improvement of basic mobility score from 40.78 at admission to 47.67 at discharge and daily activity score from 37.26 at admission to 40.22 at discharge using the AM‐PAC median scores. The continuity of care with continuation of rehabilitation and improvement of functional scores with acute inpatient rehabilitation could have contributed to patients being confident about their own functional status. It is common for rehabilitation patients to continue to have functional impairments upon discharge from acute inpatient rehabilitation, especially because some impairments are permanent. Usually, these functional impairments are addressed with a combination of continuation of rehabilitation, family and/or caregiver training, and recommendations for adaptive equipment including durable medical equipment to compensate for impairments. The majority of the patients (96%) in this study was discharged with family and/or caregiver support.
The Patient Continuity of Care Questionnaire subscales that we used assessed aspects of informational (transmittal of information) care and communication management among providers [22]. The greatest concern, reported by only 10 (5.0%) patients, was lack of adequate communication among different providers regarding plan of care for the patient during transition of care from inpatient to outpatient health care. This result is similar to those of a study that noted that general medicine ward patients overall had positive perceptions of the hospital discharge process but also perceived concerns about lack of communication among providers upon discharge [8]. Patients with cancer often have extensive medical along with functional and psychosocial problems that require care from multiple health care providers simultaneously. A high level of coordination of care is needed, which can be challenging for busy clinicians. Of note, items 11–13, shown in Table 2, were mostly incomplete because the surveys were completed early in the morning before the patient had received their after‐discharge summary. Future quality improvement effort may include discussing certain information 1 day prior to discharge so that the patients are aware that a discharge summary will be provided, which includes medications, discharge instructions, and future appointments with providers.
Because falls can lead to a fear of falling and decreased physical activity [14, 15], fear of falls was assessed on the survey. Although 23 (12%) patients had a history of fall(s), only 5 (2.5%) reported a fear of falls after completing acute inpatient rehabilitation, and only 1 (0.5%) reported a fear of fall 1 month after discharge. This result may again be possibly due to improvement of functional scores with acute inpatient rehabilitation.
A systematic review found that no risk factor was consistently associated with falls in older patients with cancer in the outpatient setting [16]. This review found one or two studies that identified age > 80 years, White race, female sex, and comorbidities as risk factors [16]. Patients who experienced falls and near falls in our study were younger (median age, 59 years) than were those who did not (median age, 66 years), and there was no statistical significance. Race and sex were not risk factors. The only comorbidity that we found to be significantly (HR, 3.07; 95% CI, 1.25–7.55; p = .01) associated with falls or near falls was depression, which has been reported as a significant fall risk factor in patients with cancer in the outpatient setting [16] as well as in patients with advanced cancer [33]. The same systematic review found that dependence on others for activities of daily living was significantly associated with falls [16]. Using the discharge AM‐PAC daily activity scores, we did not find a statistically significant difference between the patients who did and did not experience a fall or near fall. Because married status has been associated with a lower risk of falls [16], it is possible that dependency with activities of daily living addressed through family training during acute inpatient rehabilitation helped. In our study, the majority of the 135 (68%) patients were married.
Prior falls have been noted to be a risk factor for falls in patients with advanced cancer [33, 34] as well as in older (aged ≥60 years [17] and ≥ 65 years [16]) patients with cancer in the outpatient setting [16, 17]. We also found that a history of fall(s) was significantly (HR, 2.67, 95% CI, 0.90–7.91; p = .08) associated with a higher risk of post‐discharge falls or near falls. Another risk factor for falls or near falls that we found included brain metastasis, which was not found to be a risk factor for falls in the outpatient setting in one study but was found to be associated with falls in the inpatient setting [16] and in patients with advanced cancer [33, 34].
We combined falls and near falls for statistical analysis because near falls in older patients were reported to be an independent predictor of falls [25]. Additional fall risk factors mentioned in the medical literature for the general population include arthritis, stroke, orthostatic hypotension, dizziness, anemia [13], foot problems, weight loss, poor oral intake, osteoporosis [34, 35], Parkinson's disease, diabetes mellitus, and certain cardiovascular disorders [33, 35]. We assessed these comorbidities and found that none were statistically significant (Table 4).
Limitations
Because of concerns about possible incomplete surveys and oncology patients’ time constraints with ongoing treatments, we used only two subscales from the Patient Continuity of Care Checklist. The two subscales assessed informational and management continuity; we did not assess relational continuity of care. These two subscales were, however, two out of the three that were found to have strong intercorrelations in validation study by Hadjistavropoulos et al. [22] and thus the reason why we chose these subscales. Study investigators felt that patients would complete the surveys if the number of questions was limited. Item analysis can also be used to identify discontinuities of care that need improvement [22, 25]. The strength of this patient survey included a longitudinal assessment of patients’ perspectives regarding their physical activity status and the elimination of interrater variance.
This study also has some limitations that are primarily related to the exclusion criteria used to ensure the completion of surveys; thus, selection bias is present. Most items in the surveys were applicable only to patients who were discharged to home setting. Because the patients who were transferred to another health facility were excluded, it is unknown whether they would have reported inadequate continuity of care. Cognitive deficits were reported to be associated with falls in the outpatient setting in one systematic review [16, 19] but not in another systematic review [17, 20] of patients with cancer. In our study, patients with moderate‐to‐severe cognitive deficits would not have been able to complete our surveys. Thus, exclusion of these individuals may lead to an underestimation of fall risk based on the surveyed population. We included patients with mild cognitive deficits but did not find an association with falls or near falls. Patients who were readmitted within 30 days may be frailer and be at greater risk for falls, but they were not able to complete the 1 month after discharge survey. We did not assess medications and cancer symptoms, stage, treatments, or care continuum in relation to fall risk factors because the primary aim of this study was to assess patient‐reported concerns on continuity of care and safety with functional status.
Conclusion
Overall, patients with cancer had positive perceptions regarding their ability to safely function and did not report any significant concerns about continuity of care after being discharged from acute inpatient rehabilitation at a large, academic comprehensive cancer center. Fall or near‐fall events within 1 month after discharge from acute inpatient rehabilitation are more likely in patients with brain metastasis, a comorbidity of depression, and a history of falls. Future studies with a larger sample size focused on assessment of falls after discharge without our study's exclusion criteria are needed for assessment of the full spectrum of fall risk factors after acute inpatient rehabilitation to address modifiable fall risk factors in patients with cancer.
Author Contributions
Conception/design: Jegy M. Tennison, Amy H. Ng, Diane D. Liu, Eduardo Bruera
Provision of study material or patients: Jegy M. Tennison, Amy H. Ng
Collection and/or assembly of data: Jegy M. Tennison, Amy H. Ng
Data analysis and interpretation: Jegy M. Tennison, Amy H. Ng, Diane D. Liu, Nahid J. Rianon, Eduardo Bruera
Manuscript writing: Jegy M. Tennison, Amy H. Ng, Nahid J. Rianon, Diane D. Liu, Eduardo Bruera
Final approval of manuscript: Jegy M. Tennison, Amy H. Ng, Nahid J. Rianon, Diane D. Liu, Eduardo Bruera
Disclosures
The authors indicated no financial relationships.
Acknowledgments
We thank the data management and research teams of the Department of Palliative, Rehabilitation and Integrative Medicine at The University of Texas MD Anderson Cancer Center for their assistance with patient enrollment and data collection. We appreciate the rehabilitation section clinicians for their dedication in facilitating this study. We acknowledge the editing services in the Research Medical Library.
The preliminary findings of this study were presented at the joint American Academy of Physiatrists Annual Meeting and International Society of Physical and Rehabilitation Medicine World Congress in Orlando, Florida, on March 9, 2020.
No part of this article may be reproduced, stored, or transmitted in any form or for any means without the prior permission in writing from the copyright holder. For information on purchasing reprints contact commercialreprints@wiley.com.
Disclosures of potential conflicts of interest may be found at the end of this article.
References
- 1.Cruz LC, Fine JS, Nori S. Barriers to discharge from inpatient rehabilitation: A teamwork approach. Int J Health Care Qual Assur 2017;30:137–147. [DOI] [PubMed] [Google Scholar]
- 2.Shepperd S, McClaran J, Phillips CO et al. Discharge planning from hospital to home. Cochrane Database Syst Rev 2010;(1):CD000313. [DOI] [PubMed] [Google Scholar]
- 3.Hill AM, Etherton‐Beer C, McPhail SM et al. Reducing falls after hospital discharge: A protocol for a randomised controlled trial evaluating an individualised multimodal falls education programme for older adults. BMJ Open 2017;7:e013931. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Graham JE, Prvu Bettger J, Middleton A et al. Effects of acute‐postacute continuity on community discharge and 30‐day rehospitalization following inpatient rehabilitation. Health Serv Res 2017;52:1631–1646. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tennison JM, Ngo‐Huang A, Fu JB et al. Frequency and characteristics of recommendations from interdisciplinary outpatient cancer rehabilitation monthly team meetings. PM R 2019;11:252–257. [DOI] [PubMed] [Google Scholar]
- 6.Hesselink GJ, Schoonhoven L, Plas M et al. Quality and safety of hospital discharge: A study on experiences and perceptions of patients, relatives and care providers. Int J Qual Health Care 2013;25:66–74. [DOI] [PubMed] [Google Scholar]
- 7.Kripalani S, LeFevre F, Phillips CO et al. Deficits in communication and information transfer between hospital‐based and primary care physicians: Implications for patient safety and continuity of care. JAMA 2007;297:831–841. [DOI] [PubMed] [Google Scholar]
- 8.Pinelli V, Stuckey HL, Gonzalo JD. Exploring challenges in the patient's discharge process from the internal medicine service: A qualitative study of patients’ and providers’ perceptions. J Interprof Care 2017;31:566–574. [DOI] [PubMed] [Google Scholar]
- 9.Medina‐Mirapeix F, Oliveira‐Sousa SL, Sobral‐Ferreira M et al. What elements of the informational, management, and relational continuity are associated with patient satisfaction with rehabilitation care and global rating change? Arch Phys Med Rehabil 2013;94:2248–2254. [DOI] [PubMed] [Google Scholar]
- 10.Haggerty JL, Reid RJ, Freeman GK et al. Continuity of care: A multidisciplinary review. BMJ 2003;327:1219–1221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Forster AJ, Murff HJ, Peterson JF et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138:161–167. [DOI] [PubMed] [Google Scholar]
- 12.Mahoney JE, Palta M, Johnson J et al. Temporal association between hospitalization and rate of falls after discharge. Arch Intern Med 2000;160:2788–2795. [DOI] [PubMed] [Google Scholar]
- 13.Kiel D. Falls in older persons: Risk factors and patient evaluation. In: Schmader K, ed. UpToDate. Waltham, MA: Wolters Kluwer. Available at https://www.uptodate.com/contents/falls‐in‐older‐persons‐risk‐factors‐and‐patient‐evaluation?source=search_result&search=falls&selectedTitle=1~150. Accessed December 26, 2020.
- 14.Guerard EJ, Deal AM, Williams GR et al. Falls in older adults with cancer: Evaluation by oncology providers. J Oncol Pract 2015;11:470–474. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Davis JC, Robertson MC, Ashe MC et al. International comparison of cost of falls in older adults living in the community: A systematic review. Osteoporos Int 2010;21:1295–1306. [DOI] [PubMed] [Google Scholar]
- 16.Wildes TM, Dua P, Fowler SA et al. Systematic review of falls in older adults with cancer. J Geriatr Oncol 2015;6:70–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Sattar S, Alibhai SMH, Spoelstra SL et al. Falls in older adults with cancer: A systematic review of prevalence, injurious falls, and impact on cancer treatment. Support Care Cancer 2016;24:4459–4469. [DOI] [PubMed] [Google Scholar]
- 18.Bird ML, Cheney MJ, Williams AD. Accidental fall rates in community‐dwelling adults compared to cancer survivors during and post‐treatment: A systematic review with meta‐analysis. Oncol Nurs Forum 2016;43:E64–72. [DOI] [PubMed] [Google Scholar]
- 19.Vande Walle N, Kenis C, Heeren P et al. Fall predictors in older cancer patients: A multicenter prospective study. BMC Geriatr 2014;14:135. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Williams GR, Deal AM, Nyrop KA et al. Geriatric assessment as an aide to understanding falls in older adults with cancer. Support Care Cancer 2015;23:2273–2280. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Hurria A, Togawa K, Mohile SG et al. Predicting chemotherapy toxicity in older adults with cancer: A prospective multicenter study. J Clin Oncol 2011;29:3457–3465. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hadjistavropoulos H, Biem H, Sharpe D et al. Patient perceptions of hospital discharge: Reliability and validity of a Patient Continuity of Care Questionnaire. Int J Qual Health Care 2008;20:314–323. [DOI] [PubMed] [Google Scholar]
- 23.Chen HM, Chen CM. A Chinese version of the Patient Continuity of Care Questionnaire: Reliability and validity assessment. J Clin Nurs 2017;26:1338–1350. [DOI] [PubMed] [Google Scholar]
- 24.World Health Organization. Falls . 2018. World Health Organization Web site. Available at http://www.who.int/mediacentre/factsheets/fs344/en/. Accessed December 26, 2020.
- 25.Nagai K, Yamada M, Komatsu M et al. Near falls predict substantial falls in older adults: A prospective cohort study. Geriatr Gerontol Int 2017;17:1477–1480. [DOI] [PubMed] [Google Scholar]
- 26.Lim JY, Jung SH, Kim WS et al. Incidence and risk factors of poststroke falls after discharge from inpatient rehabilitation. PM R 2012;4:945–953. [DOI] [PubMed] [Google Scholar]
- 27.Jette DU, Stilphen M, Ranganathan VK et al. Validity of the AM‐PAC ‘6‐Clicks’ inpatient daily activity and basic mobility short forms. Phys Ther 2014;94:379–391. [DOI] [PubMed] [Google Scholar]
- 28.Haley SM, Coster WJ, Andres PL et al. Activity outcome measurement for postacute care. Med Care 2004;42:I49–I61. [DOI] [PubMed] [Google Scholar]
- 29.Coster WJ, Haley SM, Andres PL et al. Refining the conceptual basis for rehabilitation outcome measurement: Personal care and instrumental activities domain. Med Care 2004;42(suppl 1):I62–I72. [DOI] [PubMed] [Google Scholar]
- 30.Jette DU, Stilphen M, Ranganathan VK et al. Interrater reliability of AM‐PAC “6‐Clicks” basic mobility and daily activity short forms. Phys Ther 2015;95:758–766. [DOI] [PubMed] [Google Scholar]
- 31.Harris PA, Taylor R, Thielke R et al. Research electronic data capture (REDCap)—A metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Harris PA, Taylor R, Minor BL et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform 2019;95:103208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Stone CA, Lawlor PG, Savva GM et al. Prospective study of falls and risk factors for falls in adults with advanced cancer. J Clin Oncol 2012;30:2128–2133. [DOI] [PubMed] [Google Scholar]
- 34.Said CM, Batchelor F, Shaw K et al. Preparing patients at high risk of falls for discharge home after rehabilitation: Do we meet the guidelines? Geriatr Gerontol Int 2016;16:570–576. [DOI] [PubMed] [Google Scholar]
- 35.Means KM, Mohney LE. Fall prevention in the elderly. PM & R knowledge now. July 18, 2017. Available at https://now.aapmr.org/fall-prevention-in-the-elderly/. Accessed December 26, 2020. [Google Scholar]