Patients cope at home after shorter rehabilitation stays but are more likely to die
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《英国医生杂志》
The time spent by US patients in rehabilitation facilities after illnesses such as stroke or injury is decreasing, but the shorter stays have not affected their function on discharge, a study has found.
Changes in reimbursement have reduced the length of stay for patients receiving inpatient medical rehabilitation. The news from the study, which examined outcomes that included the patients?functional status, whether they were living at home at follow up, and mortality, was not all good, however. The study found that the death rate among patients undergoing inpatient rehabilitation increased by about 4% between 1994 and 2001 (JAMA 2004; 292:1687-95).
In the study Dr Kenneth Ottenbacher of the University of Texas Medical Branch, Galveston, Texas, and colleagues analysed information from the uniform data system for medical rehabilitation, a national database of patients undergoing inpatient rehabilitation.
In addition to exploring trends in length of stay for patients with one of five major categories of impairment (stroke; brain dysfunction; other neurological conditions; spinal cord dysfunction, including traumatic and non-traumatic injuries; and orthopaedic conditions), the researchers looked at changes in effectiveness and efficiency of rehabilitation, whether patients were discharged to their home, whether they were living at home at three months and at six months follow up, and mortality.
It has long been believed that the decreasing length of stay at inpatient rehabilitation units would reduce patients?functional status and their chances of living in the community.
The study included 744 inpatient medical rehabilitation hospitals and centres located in 48 US states. Records of 148 807 patients were examined. The patients?average age was 67.8 years. About 60% of the patients were women, and 81% were non-Hispanic white.
The researchers found that from 1994 to 2001 the length of stay fell from 20 to 12 days. The proportional decrease in average length of stay was greatest (42%) for patients with orthopaedic conditions. The patients?functional status was clinically stable during the period, while efficiency (change in functional status divided by length of stay) increased significantly.
The percentages of patients discharged to home and of patients living at home at follow up remained stable, ranging from 81% to 93%. However, mortality at follow up (which ranged from 80 days to 180 days after discharge) increased from less than 1% in 1994 to 4.7% in 2001.
"No clinically significant change in daily living skills such as dressing and bathing was seen, despite a significant reduction in LOS ," the authors write. The authors said they could not determine the cause of the increase in mortality.
In an accompanying editorial Dr Peter Esselman of the University of Washington and Harborview Medical Center, Seattle, writes that the most provocative finding, as well as the outcome that is most difficult to explain, is the increase in mortality.
He writes: "That mortality increased in all the impairment groups would indicate that some factor influencing mortality is common to different diagnostic groups. Potential factors related to increased mortality such as more comorbidities, older age, or lower admission functional independence measure score were not significantly different.
"The medical stability of the patients admitted over this time may have changed due to the pressure to decrease the acute care LOS and to move patients to inpatient rehabilitation earlier in their recovery.
"In summary, the reason for increased mortality over time remains obscure but may reflect changes in admission criteria and medical stability of patients admitted to inpatient rehabilitation facilities that were not measured in the study."(New York Scott Gottlieb)
Changes in reimbursement have reduced the length of stay for patients receiving inpatient medical rehabilitation. The news from the study, which examined outcomes that included the patients?functional status, whether they were living at home at follow up, and mortality, was not all good, however. The study found that the death rate among patients undergoing inpatient rehabilitation increased by about 4% between 1994 and 2001 (JAMA 2004; 292:1687-95).
In the study Dr Kenneth Ottenbacher of the University of Texas Medical Branch, Galveston, Texas, and colleagues analysed information from the uniform data system for medical rehabilitation, a national database of patients undergoing inpatient rehabilitation.
In addition to exploring trends in length of stay for patients with one of five major categories of impairment (stroke; brain dysfunction; other neurological conditions; spinal cord dysfunction, including traumatic and non-traumatic injuries; and orthopaedic conditions), the researchers looked at changes in effectiveness and efficiency of rehabilitation, whether patients were discharged to their home, whether they were living at home at three months and at six months follow up, and mortality.
It has long been believed that the decreasing length of stay at inpatient rehabilitation units would reduce patients?functional status and their chances of living in the community.
The study included 744 inpatient medical rehabilitation hospitals and centres located in 48 US states. Records of 148 807 patients were examined. The patients?average age was 67.8 years. About 60% of the patients were women, and 81% were non-Hispanic white.
The researchers found that from 1994 to 2001 the length of stay fell from 20 to 12 days. The proportional decrease in average length of stay was greatest (42%) for patients with orthopaedic conditions. The patients?functional status was clinically stable during the period, while efficiency (change in functional status divided by length of stay) increased significantly.
The percentages of patients discharged to home and of patients living at home at follow up remained stable, ranging from 81% to 93%. However, mortality at follow up (which ranged from 80 days to 180 days after discharge) increased from less than 1% in 1994 to 4.7% in 2001.
"No clinically significant change in daily living skills such as dressing and bathing was seen, despite a significant reduction in LOS ," the authors write. The authors said they could not determine the cause of the increase in mortality.
In an accompanying editorial Dr Peter Esselman of the University of Washington and Harborview Medical Center, Seattle, writes that the most provocative finding, as well as the outcome that is most difficult to explain, is the increase in mortality.
He writes: "That mortality increased in all the impairment groups would indicate that some factor influencing mortality is common to different diagnostic groups. Potential factors related to increased mortality such as more comorbidities, older age, or lower admission functional independence measure score were not significantly different.
"The medical stability of the patients admitted over this time may have changed due to the pressure to decrease the acute care LOS and to move patients to inpatient rehabilitation earlier in their recovery.
"In summary, the reason for increased mortality over time remains obscure but may reflect changes in admission criteria and medical stability of patients admitted to inpatient rehabilitation facilities that were not measured in the study."(New York Scott Gottlieb)