Medicare Post-Acute Care: Quality Measurement Final Report. REPORT 2: Selecting the Targeted Conditions

Andrew Kramer, Theresa Eilertsen, Danielle Holthaus, Marie Johnson
University of Colorado Health Sciences Center

Barbara Gage
The Urban Institute

July 22, 1998

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.

Conclusions and opinions in this paper are solely those of the authors and do not necessarily reflect the views of the Urban Institute, University of Colorado or ASPE.

 

I. INTRODUCTION

A. Purpose of the Project

In this project, we will develop a set of quality of care measures for Medicare post-acute care (PAC) services provided by SNFs, HHAs, rehabilitation hospitals or units (referred to as rehabilitation hospitals) and long-term hospitals. To the extent that ambulatory care is provided for these conditions during the post-acute period, services such as outpatient physician care will also be considered part of PAC. The measures will be designed for evaluating the quality of PAC services in both fee-for-service and HMO settings.

The project will focus on four clinical conditions for which PAC is frequently provided. For each of the four targeted conditions, outcome measures reflecting quality of PAC will be identified. For each outcome measure, the necessary data items, the data sources, approaches to applying the measures across episodes of care, and risk factors will be specified. In addition, we will develop methods to stratify patients within a condition for the purpose of comparing similar patients across settings, and also approaches to testing the validity and reliability of the outcome measures that are proposed.

B. Framework for Selecting Tracer Conditions

The possible clinical conditions for further study were narrowed down to eight based on policy considerations (Liu, Gage, and Kramer, 1998). The selection criteria to choose eight conditions included: 1) conditions for which PAC is provided in different PAC settings; 2) high volume conditions for PAC either as a proportion of hospital discharges or in terms of the number of PAC admissions; 3) Medicare utilization criteria such as readmission rates to the hospital, conditions where more than one PAC setting is used in an episode, or where prospective payment systems for PAC providers are likely to have their greatest impact; and 4) DRGs that include a homogeneous group of clinical conditions from the perspective of outcome measurement.

Using Medicare claims analyses of hospitalizations occurring in the thirty days prior to PAC episodes, eight DRGs were chosen meeting these eligibility criteria. These included: (1) hip fracture/replacement, (2) stroke, (3) pneumonia, (4) congestive heart failure, (5) acute myocardial infarction, (6) chronic obstructive pulmonary disease, (7) back and neck procedures, and (8) ventilator-dependent patients. In this report, we discuss the framework for further evaluating these eight conditions, and then review the conditions using this framework. Finally, we recommend four conditions for inclusion in the project based on this framework.

The framework for selecting four conditions from these eight emphasizes representativeness of the conditions as a group as much as the characteristics of the individual conditions. We want the conditions included in the project to represent different types of illnesses (chronic versus acute); different PAC settings; different PAC services; and different domains of outcome measures (e.g., functional status, utilization, quality of life). Recognizing that all eight of these conditions meet the criteria of policy relevance, the criteria applied in this paper relate more to clinical issues.

We evaluated each of the conditions based on the literature and further analysis of Medicare claims data. We were interested in the PAC settings in which patients with each condition are treated and the types of PAC services that patients receive in these settings (e.g., physical therapy, IV care). We also classified the conditions in terms of whether PAC is provided following a single acute event or an exacerbation of an underlying chronic disease. With respect to outcomes, we were interested in the types of outcome measures used for the different conditions (e.g., functional status, mortality, quality of life, symptoms). Finally, we were interested in whether there was evidence that outcomes for the condition differed between in PAC settings, to the extent that such information was available.

The results of our literature review and claims analysis are synthesized in two tables. However, a more extensive presentation of selected literature for each condition is provided in the Appendix. The literature included in this paper is intentionally not exhaustive -- our goal was to describe PAC services and the types of outcomes measured. However, after selecting the four tracer conditions, a more comprehensive literature summary will be provided in a subsequent paper with more detail on specific outcome measures.

 

II. METHODS

A. Literature Search

We conducted a systematic review of published studies describing outcomes in skilled nursing facilities, rehabilitation hospitals, home health agencies and long term hospital settings for each of the eight conditions. Because published literature evaluating outcomes in PAC was extremely limited for six of the eight conditions, we broadened our search to include studies describing outcomes in acute care hospitals and outpatient programs using home health or rehabilitation services that may be in the continuum of PAC. We searched the MEDLINE database for articles published in English between January 1990 and March 1998. We supplemented this literature with papers published in the 1980s when limited assessment studies were available. We used each of the eight conditions as a title word or key word combined with the following title and key words: aftercare, PAC, hospital discharge, skilled nursing facility, rehabilitation hospitals, rehabilitation, home health care, and outcomes. To identify additional articles, we searched the reference lists of the selected articles.

B. Definition of the Criteria

Our criteria for selecting targeted conditions included the following service-related criteria: variation in PAC settings, and variation in type of services provided. PAC settings that we included are rehabilitation hospitals (RH), skilled nursing facilities (SNF), home health agencies (HHA), and long term care hospitals (LTH). Of secondary interest were outpatient-based programs and specialized hospital units (SHU). The latter include extended hospital stays in acute hospitals in a specialized program for which PAC may substitute. Type of services referred to the specific services provided within the PAC setting. From claims and the literature, we were only able to obtain meaningful data corresponding to: physical therapy, occupational therapy, respiratory therapy, speech therapy, skilled nursing, and IV care.

One criterion for selecting targeted conditions pertained to the domains of outcome measures used for assessing quality of care. We collapsed individual measures into domains (general categories of measures) that represented similar constructs. However, this taxonomy of measures is preliminary and will be refined in the subsequent paper and throughout the project. Currently, we have identified the following 11 outcome domains: function, mortality, return to community, psychological, physiologic, symptom resolution, quality of life, patient satisfaction, utilization, weaning from mechanical ventilation, and disease-specific outcomes (endurance, re-infarct rate, and motor assessments).

Another criterion related to the chronicity of the condition. This referred to whether the condition occurs acutely without the prior active diagnosis, or as an acute exacerbation of a chronic disease, or as an acute episode that may become a chronic problem. The final criterion referred to whether there was evidence that differences in PAC settings and services actually impact outcomes for the condition. While information on outcomes of PAC was not available for all conditions, we wanted to include conditions for which available evidence suggests that outcomes are influenced by the PAC services. If PAC services do not alter outcomes significantly for a condition, the condition will not be a useful tracer for comparing treatment options.

C. Analysis of Medicare Claims Data

Service utilization was determined using HCFA’s 1995 5% sample Standard Analytical Files for Inpatient, SNF and HHA Medicare claims. Only the Medicare Part A files were available for this analysis. Patients were selected from these files if all the following conditions were met:

  • age >65,
  • enrolled in Medicare Part A and Part B,
  • not ESRD patient,
  • not HMO enrollee, and
  • received PAC in a RH, SNF, or HHA following an acute episode (data were not available for LTH).

The majority of these patients’ admissions occurred in 1995, though there were some 1994 admissions. The claims records indicate what services were provided during the post-acute stay; we compiled statistics for physical therapy, occupational therapy, speech therapy, respiratory therapy, skilled nursing, and IV care. Because skilled nursing is not a separate cost center for SNFs and RHs, we could not determine the percent of patients in these settings receiving skilled nursing.

It is important to note that the file contains claims for services billed under Medicare Part A only; services provided through Part B are not included. This affects SNFs more than RHs or HHAs because some therapy services are billed under Part B for SNFs. This may somewhat underestimate the percent of patients receiving therapy services in SNFs. We have some concern that the claims data are not 100% accurate, as facilities are ultimately reimbursed based on year-end cost report data rather than interim claims data. Because these claims are not used for payment, all services may be somewhat underreported. However, we believe that any error in reporting services is likely to be approximately equivalent across facility types and across services, and thus should not introduce large biases in any particular direction.

D. Application of Criteria

The evaluation of the conditions involved applying the above criteria, synthesizing the information, and considering different combinations of conditions. To apply our criteria, we rated each condition based on setting, chronicity, services, and outcomes. The purpose was to identify similarities and differences among conditions such that four conditions could be chosen that would represent a broad spectrum of PAC. If two or three conditions were found to have similar profiles, only one of them was included in the final set of four conditions.

For each of the eight conditions, the predominant settings in which PAC occurs was determined, based on Medicare billing data. For most conditions, this was two settings (e.g. PAC for pneumonia is received largely in skilled nursing facilities and home health agencies).

Using Medicare claims data, the eight conditions were ranked based on the percentage of patients with that condition receiving each of the following five services: physical therapy, occupational therapy, speech therapy, respiratory therapy and the use of intravenous medications. We did not rank facilities on provision of any skilled nursing care because we only had HHA data for this service. Because the percentage of patients receiving services were very similar for some conditions, the conditions were ranked in quartiles from highest to lowest percentage of patients receiving each service. When the same percentage of patients received a service for more than two conditions, they were all assigned to the same quartile.

Each condition was labeled as either acute or chronic based on the predominant clinical presentation of such conditions. In the case of ventilator-associated conditions, both acute and chronic conditions are included.

Outcome measurement criteria were applied by identifying the outcome domains with some supporting literature and for which validated measures exist. The predominant outcome domains studied for each condition was determined from the literature review. We also identified conditions where outcomes are known to be sensitive to PAC setting, when such information was available.

For each of the four criteria, conditions with a similar profile were assigned to the same group (A, B, C, etc.). A final overall grouping was then determined based on similarities in the individual criteria groups. We then considered various combinations of the conditions to select the final four conditions.

 

III. RESULTS

A. Service Utilization

The proportion of patients receiving six services in different types of PAC facilities is presented in Table 1. The data presented indicate the percent of patients who received any amount of each service during their PAC stay. The PAC stay was defined by the period after hospital discharge until death, hospitalization or no PAC services for at least 30 days. For example, 83% of hip fracture patients in rehabilitation hospitals (RHs) received physical therapy during their stay, and 46% of pneumonia patients in skilled nursing facilities (SNFs) received physical therapy during their stay. The percentages listed for RH, SNF, and HHA include patients who received PAC only in the specified setting during an episode that involved PAC. Data for patients admitted to more than one type of care (for example, RH followed by SNF, or SNF followed by home health) are combined under >1 PAC.

For some conditions, very few patients (less than 1% of discharges) were admitted to RHs, making utilization statistics unreliable. The RH row is therefore not presented for pneumonia, CHF, AMI, or COPD. In addition, skilled nursing is not discernable for patients in RHs and SNFs, all of whom presumably receive skilled nursing care. Therefore, skilled nursing figures are presented only for patients receiving home health care. However, the percent of patients receiving IV care (a type of skilled care) is listed separately for all provider types. Service intensity figures in parentheses for hip fracture and stroke patients were obtained from previous national research conducted by Kramer, et al., 1997. No other studies for other conditions provided intensity figures.

For all eight conditions, it is apparent that the predominant services provided in PAC facilities are therapies, particularly physical and occupational therapy. That there is relatively little IV care provided for conditions such as pneumonia suggests that most patients with these conditions who are discharged to PAC may have completed the acute phase of their illness. Recognizing that the claims may underestimate the percent of patients receiving IV care as well as other services, the important point is that relatively more therapy services were provided for these patients. Thus, the focus of PAC services even for most patients with medical conditions appears to be functional recovery designed to help patients return home, rather than management of extremely ill, medically complex patients.

Across conditions, there is variation in the amount of each therapy provided. For example, the condition with the most patients receiving physical therapy (hip fracture) is also the condition with the fewest patients receiving respiratory therapy. This variation in service mix will enable us to divide the eight conditions into groups with similar patterns of service utilization.

B. Outcomes

The availability of literature on outcomes for the eight conditions varied substantially by condition. With respect to PAC outcomes, only hip fracture and stroke have been studied in some depth. Congestive heart failure and chronic obstructive pulmonary disease have been studied to a lesser extent after hospitalization; while pneumonia, back and neck procedures, and ventilator care have been studied largely with respect to the acute care outcomes. Acute MI has been studied in outpatient treatment and cardiac rehabilitation occurring in the home, but not generally involving home health nurses. The availability of extant research is summarized in the second column of Table 2a. The specific studies that were most relevant to outcomes of these conditions in PAC settings are summarized in the Appendix by condition.

From the studies reviewed, we identified outcomes and classified them into the domains shown in Table 2a. While this is only a preliminary taxonomy of outcomes that will be refined both in the subsequent paper to the clinical panel and clinical panel reviews, it provides a simple way of classifying the various types of outcome measures that we found in the literature. The relative use of measures from the different domains across conditions is rated from +++, denoting that an outcome measure was used in almost all the studies reviewed, to a blank in the table representing that no outcome measure from that domain was found in the literature for that condition. The types of measures that we included in each domain are listed in Table 2b. However, for comparative purposes at this stage of the study we are focusing on outcome domains and not specific measures.

Function was the most widely studied outcome domain for the eight conditions. However, different outcome measures were used depending upon the condition and study. While our intent is not to review the specific measures in this paper, illustrative measures that we identified from the literature are listed in Table 2b. For example, ambulation and walking distance were emphasized for hip fracture, measures of neurological functioning was emphasized for stroke, the New York Heart Association (NYHA) functional classes were used for congestive heart failure, exercise capacity was used for acute MI and independence from mechanical ventilation was used for ventilator-dependent patients. Activity of daily living (ADL) and instrumental activity of daily living (IADL) measures were used for multiple conditions, with substantial variation in the scales used (e.g., RUGS III, FIM).

Mortality was the next most frequent outcome domain for these post-acute conditions, in part because so many of the outcome studies to date examined the hospital stay where keeping patients alive is often the focus of care.

For some conditions, disease-specific measures of physiology and symptom-specific measures were often found. Various quality of life measures were used in studying outcomes for many conditions, but not in the context of PAC. While re-hospitalization is a PAC issue, many studies examined re-hospitalization for chronic conditions over extended periods of time. In the Other category, we included condition-specific outcome measures that were not applied across conditions.

C. Profiling the Eight Conditions

Table 3 classifies each condition based on the settings in which PAC was frequently received following the acute stay, the chronicity of the disease, major outcome domains which are supported in the published literature, and the percentage of patients receiving selected services.

Using the information from Table 3, we grouped the eight conditions into categories according to their similarities with respect to each of the four criteria. Table 4 depicts these categories. Under the Setting criterion, we assigned hip fracture and stroke to the same category because both are primarily treated in rehabilitation hospitals, skilled nursing facilities and home health agencies, and secondarily in long term hospitals. Back and neck procedures differed only slightly because treatment occurs largely in home health agencies but secondarily in rehabilitation hospitals and skilled nursing facilities. Pneumonia, CHF, acute MI, and COPD were all in the same group for setting. Ventilator was in its own category due to the large proportion of patients on ventilators who are treated in long term care hospitals, making this a unique condition.

All conditions were either acute or chronic, with the exception of ventilator, which can be an acute and/or chronic condition. This does not refer to disease severity, rather the difference between a rapid onset event or illness without prior existence of the specific diagnosis (acute) versus an ongoing disease that becomes worse requiring immediate attention (chronic). We recognize that those diseases that we classified as acute often occur in patients at higher risk due to underlying disease processes (e.g., osteoporosis and balance impairment for hip fracture), but the person does not have the diagnosis of hip fracture until the actual fracture occurs, which is not the case for CHF or COPD. These classifications were carried over directly from Table 3 to Table 4.

The conditions were divided into five groups for outcome domains, with hip fracture and stroke grouped together -- having similar outcome domains except that stroke includes additional outcome domains. CHF, Acute MI, and COPD were grouped together because they all included five similar domains (function, mortality, physiology, quality of life, and utilization) and selected other domains (e.g., return to community, symptom resolution). The remaining three conditions had unique combinations of outcome domains based on the literature, and therefore were assigned individual categories.

For the Services criterion, we matched conditions to one another by the overall patterns of quartile designations across five services. We did not include the skilled nursing service for selecting conditions because data for skilled nursing was only available for home health patients. Hip fracture and back and neck procedures are grouped together because a high proportion of patients with these conditions received physical therapy and occupational therapy, and a low proportion of these patients receive respiratory therapy and IV services. Stroke is also similar, but differs slightly by the high proportion of stroke patients who receive speech therapy as well. Ventilator constitutes its own category due to the high proportion of ventilator patients who receive all five services. Among the remaining four conditions, pneumonia and COPD have similar patterns across services -- low proportions of patients receiving physical therapy and occupational therapy, but a high proportion of patients receiving respiratory therapy -- and are therefore grouped together. Finally, low proportions of CHF and AMI patients receive physical therapy, occupational therapy, and respiratory therapy, creating a separate category.

Overall, Table 4 illustrates several points. First, hip fracture, and stroke patients receive similar types of PAC services, both in rehabilitation hospitals and skilled nursing facilities. Both conditions are acute and studied outcome domains are largely functional, return to community living and mortality, with some additions for stroke (i.e., psychological and quality of life).

Second, pneumonia, CHF, COPD and AMI patients all receive PAC largely in skilled nursing facilities and home health agencies, but vary mostly in chronicity of the conditions, the types of outcome domains studied, and in use of respiratory therapy. COPD and CHF are both chronic conditions and share many outcome domains. Pneumonia and AMI are both acute. COPD and pneumonia use more respiratory therapy.

Third, back and neck patients receive similar services to hip fracture and stroke patients, and many similar outcome domains are studied. While the chronicity of illness is different, setting and services are not.

Finally, ventilator patients are different from all other conditions in setting of care, services received (particularly respiratory therapy), combination of both chronic and acute illnesses, and outcome measures related to ventilator weaning.

 

IV. DISCUSSION/CONCLUSION

While there is no scientific method for selecting tracer conditions, we have tried to follow an unbiased and systematic approach to evaluate the eight conditions. Our overall objective is to identify conditions that represent the range of patients, settings, services, and outcomes that constitute PAC. We used explicit criteria, collecting data pertinent to each criterion.

The final step is to examine the profiles of the different conditions to choose a combination of conditions that exhibits the greatest variation in these criteria. This final step involves making selections based on the profiles in Table 4, that summarizes the results from all the previous tables. While all eight of these conditions would be interesting to study for one reason or another, we are restricted to four due to project limitations. Thus, our proposed four tracer conditions are contained below, including the rationale.

Either hip fracture or stroke should be included in the study because they are the major conditions treated in both rehabilitation hospitals and skilled nursing facilities. However, we see little benefit in including both of these conditions because they are both acute, require similar services, and can be studied with similar outcome measures. If our sole criterion were number of PAC admissions or PAC cost, then both of these conditions would probably be chosen for this project. However, for developing quality measures, we are interested in a range of conditions so that we address different clinical situations, different settings, different services, and different outcomes during the developmental process.

We recommend choosing stroke over hip fracture for two reasons. First, with the frequency of speech therapy as a service and the multiple types of neurologic and mobility impairments that result from stroke, to measure outcomes will require a wider range of measures for stroke than hip fracture. This is supported in part by the additional outcome domains that have been studied for stroke. Second, stroke outcomes have been shown repeatedly to be influenced by PAC setting (Kramer et al., 1997, Kane et al., 1996). For hip fracture patients, evidence is mixed at best that the PAC setting influences outcomes (Koval et al., 1998, Kramer et al., 1997, Kane et al., 1996). If this is the case, then hip fracture will not be a very sensitive tracer for comparing care in HMO and fee-for-service settings or examining the impacts of prospective payment on quality.

The four medical conditions -- pneumonia, CHF, Acute MI, and COPD -- exhibit similarities and differences. While they are all treated frequently in both SNFs and home health agencies, two of them are acute (pneumonia and acute MI) and the other two are chronic. PAC services are similar for the two cardiac conditions (acute MI and CHF), while the pulmonary conditions have more respiratory therapy (pneumonia and COPD). By selecting two of these four conditions, we can choose one that is an acute medical problem (either pneumonia or acute MI) and one chronic medical problem (CHF or COPD). We can also choose one that is a cardiac problem and one that is a pulmonary problem. Thus, to maximize variability we should select either pneumonia and CHF, or acute MI and COPD.

In view of the extremely high PAC utilization and cost of both CHF and pneumonia, we recommend including these two in the study. By choosing COPD instead of pneumonia, we would be selecting a second chronic medical condition -- an acute condition such as pneumonia introduces different outcome measurement issues (e.g., measurement time points). Furthermore, pneumonia has more patients treated in SNFs than COPD (Liu et al., 1998), while both have substantial numbers of home health patients. Because there is significant clinical overlap among these conditions, however, we will not be entirely eliminating any of the four. Pneumonia patients receiving PAC often have underlying COPD, while CHF patients receiving PAC often have underlying coronary artery disease and/or a previous acute MI.

Both back and neck procedures and ventilator-dependent patients have unique profiles. However, patients with back and neck procedures use fairly similar settings and services to hip fracture and stroke patients. While it is a chronic condition, often the treatment for which someone is receiving PAC will be in response to an acute repair of a back or neck injury. While an interesting condition, we do not find it as compelling for studying rehabilitation as either hip fracture or stroke. The latter have so many more PAC cases.

Ventilator care offers the addition of long-term hospitals as a major setting, a unique mix of services with very intense respiratory care, unique outcomes, and patients who may in some cases be acute while in others will go on to become chronically dependent on the ventilator. This type of care can be extremely expensive and the choice among post-acute settings will be driven substantially by new payment policies. Controversy exists regarding the use of long-term hospitals, and subacute care reimbursement for treating very complex patients such as those who are dependent upon ventilators.

Thus, the four conditions we recommend for development of quality measures include stroke, pneumonia, congestive heart failure, and ventilator-dependent patients. As a group, they represent both acute and chronic conditions, cover all PAC settings, and the range of post-acute services in these settings. Most importantly for this project, these conditions will require a range of quality measures to assess quality of care across PAC settings.

 

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Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK, Davila-Roman V. Prevention of readmission in elderly patients with congestive heart failure. JGIM 1993;8:585-590.

Smith EB, Hanigan WC. Surgical results and complications in elderly patients with benign lesions of the spinal canal. JAGS 1992;40(9):867-70.

Stapleton DC, Kaplan SJ, Manard, B. Ventilator dependent unit demonstration: outcome evaluation and assessment of post acute care. 1996. Report prepared for Office of Research and Demonstrations, Health Care Financing Administration.

Steiner T, Mendoza G, DeGeorgia M, Schellinger P, Holle R, Hache W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke 1997;28(4):711-15.

Strijbos JH, Postma DS, van Atena R, Gimeno F, Koeter GH. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. Chest 1996;109(2):366-72.

Stineman MG, Fiedler RC, Granger CV, Maislin G. Functional task benchmarks for stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 1998;79(5):497-504.

Swinburne A, Fedullo AJ, Bixby K, Lee DK, Wahl GW. Respiratory failure in the elderly: analysis of outcome after treatment with mechanical ventilation. Arch Inter Med 1993;153:1657-62.

Trzcieniecka-Green A, Steptoe A. Stress management in cardiac patients: a preliminary study of the predictors of improvement in quality of life. Journal of Psychosomatic Research 1994;38(4):267-80.

Vale F, Reardon JZ, ZuWallack RL. The long-term benefits of outpatient pulmonary rehabilitation on exercise endurance and quality of life. Chest 1993. 103(1):42-5.

Votto J, Bowen J, Scalise P, Wollschlager C, ZuWallack R. Short-stay comprehensive inpatient pulmonary rehabilitation for advanced chronic obstructive pulmonary disease. Archives of Physical Medicine & Rehabilitation 1996;77(11):1115-8.

Wijkstra PJ, van der Mark Th. W, Kraan J, van Atena R, Koeter GH, Postma DS. Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease (COPD). European Respiratory Journal 1996;9(1):104-10.

Wijkstra PJ, Van Atena R, Kraan J, Otten V, Postma DS, Koeter GH, Postma DS. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. European Respiratory Journal 1994;7:269-73.

Williams DN. Reducing costs and hospital stay for pneumonia with intravenous cefotaxime treatment: results with a computerized ambulatory drug delivery system. Amer J Med 1994;97:50-55.

Young, JB, Forster A. The Bradford community stroke trial: results at 6 months. BMJ 1992;304:1085-9.

Zuckerman JD, Sakales SR, Fabian DR, Frankel VH. Hip fractures in geriatric patients: results of an interdisciplinary hospital care program. Clinical Orthopeadics 1992; 274:213.

 

TECHNICAL ADVISORY GROUP RECOMMENDATIONS

At the conclusion of this phase of the study, we distributed this report and the report entitled "Selecting and Evaluating Eight Targeted Conditions" to our Technical Advisory Group (TAG) for review. Feedback from members of the TAG revealed a high level of concern over the inclusion of ventilator-dependent patients as one of our four selected conditions. Although many TAG members agreed that ventilator-dependent patients represent a unique and interesting condition for study, they expressed concerns about whether such a group is representative of post-acute care patients. The low prevalence of ventilator-dependent patients in post-acute care, as well as a lack of homogeneity among these patients, were among the specific concerns expressed. Furthermore, the large majority of ventilator-dependent patients are treated in long-term care hospitals, while relatively few are treated in more traditional types of post-acute settings.

In light of these concerns, we decided to include back and neck medical and surgical conditions instead of ventilator dependency as our fourth condition for study. Back and neck patients are similar to ventilator-dependent patients in that they both have somewhat unique profiles across treatment settings, chronicity, outcome domains, and services required (see Table 4). Back and neck patients are also relatively prevalent in the post-acute care population, are treated in multiple settings, and represent a population that has not been well studied.

TABLE 1: Percentage of Post Acute Patients with Each Condition Receiving Selected Services by Setting
  Setting1 Frequent
Settings2
Specific Services3
PT OT RT ST RN4 IV
Hip
Fracture
RH
LTH
SHU
SNF
HHA
OUTPT
>1 PAC
X
X
X
X
X

X

83% (1.5 h/d)2

(2 h/d)
81% (.6-.8 h/d)
89%

98%

82% (1.25 h/d)

56% (.2-.4 h/d)
7%

79%

16%

10%
0%

12%

8%
12%
0%

8%

81%

77%

1%
1%
0%

1%

Stroke RH
LTH
SHU
SNF
SSNF5
HHA
OUTPT
>1 PAC
X
X
X
X
X
X

X

79% (1.3 h/d)

68% (.3-.5 h/d)
(.9 h/d)
62% (.35 h/v)
(.5 h/v)
97%

78% (1.4 h/d)

58% (.2-.4 h/d)
(.9 h/d)
26% (.65 h/v)
(.5 h/v)
90%

20%

14%

0%

20%

71% (.75 h/d)

49% (.1-.25 h/d)
.9 hr/day
23%

76%

93%

76%

3%

2%

0%

2%

Pneumonia RH
LTH
SHU
SNF
HHA
OUTPT
>1 PAC

X
X

X

46%
21%

83%

31%
3%

57%

27%
0%

40%

17%
1%

18%

99%

98%

3%
0%

4%

CHF RH
LTH
SHU
SNF
HHA
OUTPT
>1 PAC

X
X
X
X

55%
17%

82%

40%
3%

60%

19%
0%

30%

14%
0%

11%

100%

97%

2%
0%

3%

Acute MI RH
LTH
SHU
SNF
HHA
OUTPT
>1 PAC

X
X
X
X

59%
20%

83%

43%
3%

59%

17%
0%

23%

18%
1%

21%

100%

90%

1%
0%

2%

COPD RH
LTH
SHU
SNF
HHA
OUTPT
>1 PAC

X
X
X
X

52%
15%

80%

40%
3%

58%

35%
0%

34%

10%
1%

10%

99%

98%

1%
0%

4%

Back &
Neck
Procedures
RH
LTH
SHU
SNF
HHA
OUTPT
>1 PAC
X

X
X

X

85%

81%
63%

97%

84%

60%
10%

81%

20%

9%
0%

16%

13%

9%
0%

14%

91%

79%

3%

1%
0%

2%

Ventilator RH
LTH
SHU
SNF
HHA
OUTPT
>1 PAC
X
X
X
X
X

X

75%

58%
28%

87%

75%

47%
8%

71%

46%

34%
0%

55%

54%

35%
7%

42%

99%

89%

5%

4%
0%

4%

  1. Settings are rehabilitation hospital (RH), long term hospital (LTH), specialized hospital unit (SHU), skilled nursing facility (SNF), home health agency (HHA), outpatient (OUTPT), and more than one PAC setting (>1 PAC).
  2. Frequent settings include those that admit at least 1% of PAC discharges for that condition. Source Liu et al., (1998). Although long term hospitals account for a relatively small percentage of Medicare PAC admissions, patients admitted with hip fracture, stroke, and ventilators represent the largest percentage of long term hospitals’ admissions. Outpatient and specialized hospital units are marked when the literature frequently references PAC in these settings.
  3. Services include physical therapy (PT), occupational therapy (OT), respiratory therapy (RT), speech therapy (ST), skilled nursing (RN), and IV care (IV). Percentages represent patients receiving each service based on Part A Medicare claims cost center data for the PAC episode. These may underestimate actual percentage receiving each service because facilities are reimbursed on year-end cost report data rather than interim claims. These service percentages were only computed for RHs, SNFs, and HHAs and only when a large enough number of cases were available. Actual hours per day for services provided in parentheses are based on literature. Source for stroke and hip fracture is Kramer et al., 1997.
  4. Skilled nursing care is not a separate cost center for SNFs and rehabilitation facilities, so it could not be assessed at the patient level.
  5. For stroke patients, actual hours of therapy were found to differ between traditional SNFs and those providing a high volume of Medicare PAC: 5000 or more Medicare days or >90% Medicare days. These are separated in the table for stroke only.

 

TABLE 2a: Availability of Outcome Research and Outcome Domains Based on Review of Literature Pertaining to the Eight Conditions
Condition Availability of Extant Research by Setting1 Outcome Domains3
Function Mortality Return
to
Community
Indep.
from
Mech.
Vent
Physiology Symptom
Resolution
Psychological Quality
of
Life
Satisfaction Utilization
Outcomes
Other
Hip
Fracture
--  Acute hospitals: High
--  Rehabilitation hospitals: Moderate
--  SNFs: High
--  Home health: Low
--  Long term hospitals: Low
+++ ++ ++             + +
(Home
assistance)
Stroke --  Acute hospitals: High
--  Rehabilitation hospitals: Moderate
--  SNFs: High
--  Home health: Low
--  Long term hospitals: Low
+++ +++ ++       + +   + +
(Motor
assessments)
Pneumonia --  Acute hospitals: High
--  Home health: Low
+ +++     + +          
CHF --  Acute hospitals: High

--  SNFs: Low
--  Home health: Low
--  Multidisc. In/outpt prog: High

+ ++ +   +     ++   +++ +
(Endurance)
Acute MI --  Acute hospitals: High
--  Outpatient rehab.: High
++ +++     +++ + ++ ++   ++ ++
(Re-infarct,
endurance)
COPD --  Acute hospitals: High
--  Rehabilitation hospitals: Low
--  SNFs: Low
--  Home health: Low
--  Outpatient & in-home rehab.: High
++ + +   +++ + ++ ++ + + +++
(Endurance)
Back &
Neck
Procedures
--  Acute hospitals: High +++       ++ +++   + ++ ++ +
(Medication
intake,
re-operation)
Ventilator --  Hospital units: High
--  Home health: Low
--  Long term hospitals: Low
+++ ++   +++ +   ++     ++ ++
(Home oxygen,
vent. Type, d/c
status, post d/c
caregiver)
  1. Only settings for which outcomes research was available are listed. We found no outcomes studies in unlisted settings.
  2. +++ Outcome domain included in almost all studies; ++ Outcome domain included in several studies; + Outcome domain included in one or two studies; Blank - Outcome domain never included in studies.

 

TABLE 2b: Specific Measures Included in Each Outcome Domain
Function
  • Ambulation
  • Walking distance
  • Neurological function
  • Employment status
  • Sickness Impact Profile
  • Roland Score
  • SF-36 score
  • Barthel index
  • Rankin scores
  • Return to usual activities
  • NYHA functional class
  • Exercise capacity
  • Self-rated functional independence
  • Self-rated activity compared to premorbid
  • Lumbar movement
  • Tendon reflex
  • Limp
  • Straight leg raising
  • Return to work
  • Recovery of function in ADL/IADL
  • RUGS III dependence index
  • Functional Independence Measure (FIM)

Mortality

  • Mortality rate
  • 90 day survival rate without re-hospitalization
  • Length of survival after hospital admission
  • Length of survival after hospital discharge

Return to Community

Independence from mechanical ventilation

  • Length of ventilator episode

Physiology

  • Blood gas
  • Pulmonary function tests
  • Morbid complications
  • X-ray resolution
  • Cardiac function measures
  • In-hospital complications
  • Post-operative complications

Other

  • Endurance
  • Re-infarct rate
  • Motor assessments
  • Re-operation
  • Medication intake
  • Home oxygen
  • Ventilator type
  • Discharge status
  • Post-discharge caregiver
  • Need for home assistance
Symptom Resolution
  • Pain
  • Pain relief
  • Pulmonary distress/dyspnea
  • Sciatia/stenosis Frequency Index
  • Neurological symptoms (pain, sensation, weakness)

Psychological

  • Anxiety
  • Stress
  • Caregiver stress
  • Depression
  • Beck Depression Inventory
  • Mood Adjective Check List
  • Hospital Anxiety and Depression Scale
  • SF-36
  • Social support
  • Caregiver burden

Quality of Life

  • Chronic Heart Failure Questionnaire
  • Minnesota Living with Heart Failure Questionnaire
  • Rosser QOL Index
  • Time trade-off
  • Chronic Respiratory Disease Questionnaire

Satisfaction

  • Patient satisfaction with care
  • Rating of whether surgery was worthwhile

Utilization Outcomes

  • Cumulative hospital days
  • Cost
  • Re-hospitalization
  • Mean length of stay
  • Subsequent hospital days
  • Discharge to nursing home
  • Extended care facility days
  • Home nursing services
  • Length of stay (LOS) in hospital
  • LOS in VDU
  • Expenditure measures
  • Discharge destination

 

TABLE 3: Application of the Four Major Selection Criteria to the Eight Conditions
  Setting Chronic
vs.
Acute
Outcome
Domains
Service Quartiles
PT OT ST RT IV
Hip Fracture R, S, H, L A F/C/M/U Q1 Q1 Q3 Q4 Q4
Stroke R, S, H, L A F/M/C/Ps/QL/U Q2 Q1 Q1 Q3 Q3
Pneumonia S, H A M/Ph/F/S Q3 Q3 Q3 Q2 Q1
CHF S, H C UM/QL/F/C/Ph Q3 Q3 Q3 Q3 Q2
Acute MI S, H A M/Ph/U/F/Ps/QL/S Q3 Q3 Q3 Q3 Q4
COPD S, H C Ph/F/QL/Ps/M/C/S/Sa/U Q3 Q3 Q3 Q2 Q2
Back & Neck Procedures R, S, H C F/S/U/Sa/Ph/QL Q1 Q1 Q3 Q4 Q3
Ventilator S, H, L AC F/W/M/Ps/U/Ph Q2 Q2 Q1 Q1 Q1

 

TABLE 4: Classification of the Eight Conditions Based on the Four Major Selection Criteria
  Setting Chronic vs.
Acute
Outcome
Domains
Services
Hip Fracture A A A A
Stroke A A A A+
Pneumonia B A B B
CHF B C C C
Acute MI B A C C
COPD B C C B
Back & Neck Procedures A+ C D A
Ventilator C AC E D
A+ = Similar to Category A, with one anomaly.

 

APPENDIX

HIP FRACTURE
Source Treatment Settings Services Received Outcome Measures
Kramer et al. Outcomes and costs after hip fracture and stroke. JAMA 1997;277:5:396-404.
  • Inpt. rehab. hosp.
  • Skilled nursing facility (subacute and traditional)
  • Physical therapy
  • Occupational therapy
  • Recreational therapy
  • Social work
  • Physician
  • Return to community at 3 and 6 months
  • Functional recovery in bathing, dressing, toileting, transferring and walking 20 feet
  • Mortality
Kane et al. Do rehabilitative nursing homes improve the outcomes of care. JAGS 1996;44:545-554.
  • Rehab. facilities
  • Rehab. NHS
  • NHS
 
  • ADL/IADL dependency scale at discharge, 6 weeks, 6 months and 12 months
Kennie et al. Effectiveness of geriatric rehabilitative care after fFractures of the proximal femur in elderly Women. BMJ 1988; 297:1083.
  • Acute hospital ward
  • Rehab. ward
  • PT/OT
  • Geriatrician as well in rehab. ward
  • Katz ADL Index
  • Discharge to nursing home
Zuckerman et al. hip fractures in geriatric patients: results of an interdisciplinary hospital care program. Clinical Orthopeadics 1992; 274:213.
  • Interdisciplinary unit
  • Acute orthopedic unit
  • Geriatrician
  • PT 2x/day
  • OT
  • Nutrition
  • Social work
  • Case manager f/u
  • Discharge home
  • Ambulatory status 4 levels
  • Ambulatory distance
Koval KJ, et al. Effect of acute inpatient rehabilitation on outcome after fracture of the femoral neck or intertrochanteric fracture. Journal of Bone and Joint Surgery 1998;80-A(3):357-64.
  • Inpt. rehab. program
  • Physical therapy
  • Occupational therapy
  • Education
  • Hospital discharge status
  • Mortality rate
  • Place of residence
  • Walking ability
  • Need for home assistance
  • Independence in ADL/IADL
Munin, MC et al. Early inpatient rehabilitation after elective hip and knee arthorplasty. JAMA 1998;279(11):847-52
  • Inpt. rehab program
 
  • Length of stay
  • Functional Independence Measure
  • SF-36
  • Cost

 

STROKE
Source Treatment Settings Services Received Outcome Measures
Kramer et al. Outcomes and costs after hip fracture and stroke. JAMA 1997;277:5:396-404.
  • Inpt. rehab. hosp.
  • Skilled nursing facility (subacute and traditional)
  • Physical therapy
  • Occupational therapy
  • Recreational therapy
  • Social work
  • Physician
  • Return to community at 3 and 6 months
  • Functional recovery in bathing, dressing, toileting, transferring and walking 20 feet
  • Mortality
Kane et al. Do rehabilitative nursing homes improve the outcomes of care. JAGS 1996;44:545-554.
  • Rehab. facilities
  • Rehab. NHS
  • NHS
 
  • ADL/IADL dependency scale at discharge, 6 weeks, 6 months and 12 months
Young & Forster. The Bradford community stroke trial: results at 6 months. BMJ 1992;304:1085-9.
  • Home care
  • Day hospital
  • 15 visits total: 6.5 hrs PT, 10.0 hrs OT
  • 31 visits total: 15.0 hrs PT, 15.0 hrs OT
  • Barthel Index
  • Motor Club Assessment
  • Frechay Activities Index
  • Ambulation
  • Nottingham Health Profile -- extended activity
  • Caregiver stress: General Health Questionnaire
  • All at 6 months
Keith et al. Acute and subacute rehabilitation for stroke: a comparison. Arch Phys Med & Rehab 1995;76:495-500.
  • Rehab. facility
  • Subacute SNF
  • 4.2 hrs billed/day: 1.7 PT, 1.6 OT, .95
  • 2.7 hrs billed/day: .9 PT, .9 OT, .95
  • FIM change during stay
  • Community discharge
Retchin et al. Outcomes for stroke patients in Medicare fee for service and managed care. JAMA 1997;278(2):119-24.
  • Acute hospital
 
  • Survival rates
  • Discharge destination
Stineman, MG et al. Functional task benchmarks for stroke rehabilitation. Arch Phys Med & Rehab 1998;79(5):497-504.
  • Rehab. facility
 
  • Functional Independence Measure (FIM)

 

PNEUMONIA
Source Treatment Settings Services Received Outcome Measures
Fine, MJ, et al. Prognosis and outcomes of patients with community-acquired pneumonia. JAMA 1996;274:134-141.
  • Hospital
 
  • Mortality
  • Morbid complications
  • Symptom resolution 6 mon-5yr
  • Return to work/usual activities
  • Functional status
Metlay et al. Measuring symptomatic and functional recovery in patients with community acquired pneumonia. JGIM 1997;12:423-430.
  • Outpatient
 
  • Symptom resolution 7, 30, 90 days after onset
  • MOS SF-36
  • Pneumonia related outpatient visits in first 90 days
Williams et al. Reducing costs and hospital stay for pneumonia with intravenous cefotaxime treatment: results with a computerized ambulatory drug delivery system. Amer J Med 1994;97:50-55.
  • Home care
 
  • Length of hospital stay
  • Cost
  • Adverse events
Meehan TP, et al. Quality of care process, and outcomes in elderly patients with pneumonia. JAMA 1997;278:2080-2084.
  • Hospital
 
  • Mortality associated with care processes: O2 saturation measurement, blood cultures, time to antibiotics
Ortqvist, A, et al. Aetiology, Outcome and prognostic factors in community-acquired pneumonia requiring hospitalization. Eur Resp J 1990;3:1105-1113.
  • Hospital
  • Outpatient follow-up
 
  • Mortality
  • Morbid complications
  • LOS
  • Return to normal activities
  • 8 weeks after onset
  • Radiographic resolution

 

CHF
Source Treatment Settings Services Received Outcome Measures
Rich, MW, et al. Prevention of readmission in elderly patients with congestive heart failure. JGIM 1993;8:585-590.
  • Acute care hospital
  • Home care
  • Outpatient clinic
  • Education
  • Medication review
  • Diet assessment
  • Outpatient follow-up
  • Rehospitalization in 90 days
  • Cumulative hospital days in 90 days
Kornowski, R, et al. Intensive home-care surveillance prevents hospitalization and improves morbidity rates among elderly patients with severe congestive heart failure. Am Heart J 1995;129:762-6.
  • Home care (RN and MD)
  • Weekly visit
  • PE
  • Medication review
  • IV drugs as needed
  • Lab tests
  • PT as needed
  • O2 as needed
  • Hospitalizations/year
  • Hospitalizations (cardiac)
  • Hospital days/year
  • “Global functional status” (1-4 rating scale: 1=confined to bed, 2=assist with daily activities, 3=housebound but no assist, 4=independent with daily activities)
Rich, MW, et al. A multidisciplinary intervention to prevent readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333(18):1213-4.
  • Acute care hospital
  • Home care
  • Outpatient clinic
  • Education
  • Dietary instruction
  • Social service evaluation
  • Medication evaluation
  • Quality of life (Chronic Heart Failure Questionnaire)
  • Cost
  • Rehospitalization in 90 days
  • Cumulative hospital days
Dennis, LI, et al. The relationship between hospital readmissions of Medicare beneficiaries with chronic illness and home care nursing interventions. Home Healthcare Nurse 1996;14:303-8.
  • Home care services
  • Assess symptoms and PE
  • Education
  • Hospital readmissions/# of home care nurse visits
Harjai, KJ, et al. Home inotropic therapy in advanced heart failure. Chest 1997;112:1298-1303.
  • Home care
  • Home IV dobutamine, milrinone, dopamine, or combination
  • Cost
  • Hospital readmission
  • Hospital days
  • NYHA functional class
Kane et al. A study of Post-Acute Care. 1994. Institute for Health Services Research.
  • Home health
  • Skilled nursing facility
 
  • Mortality
  • Function (weighted ADL/IADL score)
  • Rehospitalization
  • Cost
  • Symptoms
  • Caregiver burden
  • Return to community
Hanumanthus, S, et al. Effect of a heart failure program on hospitalization frequency and exercise tolerance. Circulation 1997;96:2842-48.
  • Heart failure clinic
  • Home care (10% of patients)
 
  • Use of CHF medications (ACE inhibitors, loop diuretics, Digoxin)
  • Hospitalization frequency
  • Exercise capacity (treadmill)
  • Quality of life (Minnesota Living with Heart Failure Questionnaire)

 

ACUTE MI
Source Treatment Settings Services Received Outcome Measures
Leitch, JW, et al. Randomized trial of a hospital-based exercise training program after acute myocardial infarction: Cardiac autonomic effects. Journal of the American College of Cardiology 1997;29(6):1263-8.
  • Hospital-based outpatient cardiac rehab vs. Home walking program
  • 6 week exercise program. Both groups told to follow unsupervised home walking program.
  • Outpatient: To hospital 3-4x/wk for exercise lasting 30-60 mins & supervised by clinical nurse specialist and physiotherapist.
  • Home: 5 to 30 mins walking 2x/day unsupervised.
Change in begin to end of rehab:
  • Baroreflex sensitivity
  • Heart rate variability
  • Oxygen consumption
  • Endurance capacity
Dressendorfer, RH, et al. Exercise training frequency in early post-infarction cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation 1995;15(4):269-76.
  • Hospital-based outpatient cardiac rehab
  • 5 week monitored exercise program, beginning 4 weeks after MI. Moderate intensity phase II exercise sessions 1 vs 2 vs 3 x/wk.
Change in begin to end of rehab:
  • Treadmill duration
  • VO2 max
  • HR, BP
  • Perceived exertion
Dubach, P et al. Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction. Circulation 1997. 95(8):2060-7.
  • Residential rehab center (Switzerland)
  • 8 week residential program of patient education, exercise, low-fat meals. Two 1hr walking sessions daily, accompanied by a physician with emergency equipment. Monitored cycling exercise 4x/wk.
Change in begin to end of rehab:
  • HR, BP
  • Oxygen consumption
  • Perceived exertion
  • Exercise duration
  • Ventricular mass, volume
  • Ejection fraction
  • Myocardial wall thickness
Gulanick, M. Is phase 2 cardiac rehabilitation necessary for early recovery of patients with cardiac disease? A randomized, controlled study. Heart & Lung 1991;20(1):9-15.
  • Hospital-based outpatient cardiac rehab (exercise+ teaching , teaching only) vs Home walking program
  • 5 week program, beginning 4 weeks after MI. All patients had already participated in inpatient cardiac rehab.
  • Exercise: 15 supervised exercise sessions 30 mins each.
  • Teaching: 2 30 min sessions + video re exercise techniques.
Change in begin to end of rehab in self-efficacy and performance scales for:
  • Walking
  • Climbing stairs
  • Lifting objects
  • Household chores
  • Social visits
  • Sexual activity
  • Driving/Transportation
DeBusk, RF, et al. Medically directed at home rehabilitation soon after clinically uncomplicated acute myocardial infarction: A new model for patient care. American Journal of Cardiology 1985;55(4):251-7.
       - AND -
Miller, NH, et al. Home versus group exercise training for increasing functional capacity after myocardial infarction. Circulation 1984;70(4):645-9.
  • Outpatient vs Home cardiac rehab
  • Begin 3 weeks after MI. Rehab program lasts 8 weeks or 23 weeks, in home or as outpatient (4 groups total). Home: 30 mins 5 days/wk. Nurse-monitored 1-minute EKG via phone line 2x/wk.
  • Outpatient: Supervised by nurse or nurse and physician. 1hr training 3x/wk.
Change baseline to 8 wks, and 8 wks to 23 wks:
  • Functional capacity (peak treadmill workload, in METs)
  • Re-infarction rate
  • Mortality
Trzcieniecka-Green, A, et al. Stress management in cardiac patients; A preliminary study of the predictors of improvement in quality of life. Journal of Psychosomatic Research 1994;38(4):267-80.
  • Outpatient and Home
  • 12 week stress management program. 12 sessions with clinical research psychologist covering relaxation training, education of effect of stress on health, counseling re uncertainties of recovery. Also home relaxation tape 2x/day.
Change in begin rehab vs end rehab (12 wks) vs 6mo followup:
  • Hospital Anxiety & Depression Scale
  • Psychological General Well-Being Schedule
  • Social Support Questionnaire
  • Functional Status Questionnaire (ADL, social, sexual, satisfaction)
  • Spouse’s rating of pt’s psych state
  • Chest pain
  • 16 Personality Factor Questionnaire
Oldridge, N, et al. Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. American Journal of Cardiology 1991;67(13):1084-9.
  • Outpatient cardiac rehab
  • 8 week cardiac rehab program. Exercise: 1hr 2x/wk supervised by cardiologist and exercise specialist. Psych: 1½ hrs 1x/wk group counseling + ½ hr relaxation training.
Change in baseline to 8 wks, 4 mos, 8 mos, and 12 mos:
  • Quality of Life After AMI Questionnaire (symptoms, restrictions, emotional function, confidence, self-esteem)
  • Time trade-off
  • Quality of Well-Being Questionnaire (symptoms, mobility, physical activity, social activity)
  • Exercise tolerance
  • Anxiety
  • Depression
  • Return to work
Hamalainen, H, et al. Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. European Heart Journal 1995;16(12):1839-44.
  • Outpatient and Home cardiac rehab
  • 3 year rehab program, run by multidisciplinary team of physicians, social worker, psychologist, dietitian, physiotherapist. Exercise, anti-smoking and dietary counseling, psycho-social counseling. Visit to physician 1x/mo for 18mos, 3x/yr after that.
3, 6, 10, 15 year followup of:
  • Total mortality
  • Coronary mortality
  • Cancer mortality

 

COPD
Source Treatment Settings Services Received Outcome Measures
Strijbos, JH, et al. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. Chest 1996;109(2):366-72.
  • Hospital-based outpatient rehab vs Home rehab program
  • 12 week program of patient education, breathing & relaxation exercises, bronchial hygiene, exercise reconditioning. Both groups told to continue exercise at home unsupervised.
  • Outpatient rehab: To hospital 2x/wk for 1hr therapy, 3 hrs total education, 3 physician visits.
  • Home rehab: Exercise led by physiotherapist 24x for 30 mins each. Pts told to exercise 30 mins on their own at home. 3 home health nurse visits, 3 physician visits.
Change in admit to 18mo followup:
  • Lung function
  • Cycle ergometer test
  • 4 minute walking test
  • General well-being
Wijkstra, PJ, et al. Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease (COPD). European Respiratory Journal 1996;9(1):104-10.
       - AND -
Wijkstra, PJ, et al. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. European Respiratory Journal 1994;7:269-73.
  • Home rehab program
  • 12 week home rehab program managed by multidisciplinary team (MDT): pulmonologist, physiotherapist, nurse, general practitioner. Patient performed in-home daily inspiratory muscle training, upper limb training, exercise training, and every other day relaxation exercises, breathing retraining. Visit to physiotherapist 2x/wk. Monthly education visit from nurse; monthly clinical visit to general practitioner.
Change in baseline to 12 weeks :
  • Spirometry
  • Cycle ergometer test
  • 6 minute walking distance
  • Quality of life as measured by Chronic Respiratory Questionnaire(dyspnea, fatigue, emotion, mastery)
Votto, J, et al. Short-stay comprehensive inpatient pulmonary rehabilitation for advanced chronic obstructive pulmonary disease. Archives of Physical Medicine & Rehabilitation 1996;77(11):1115-8.
  • Inpatient rehab hospital
  • 8 to 12 day inpatient rehab program managed by MDT: pulmonary physician, physiatrist, respiratory therapist, physical therapist, occupational therapist, nutritionist, rehab nurse, social worker, and therapeutic recreation specialist, with psych eval and therapy as needed. Instruction in compensatory breathing techniques. PT and OT 2 to 3 hours a day (gait & balance training, exercise, stair climbing). Supervised community outings. Instruction in ADLs wrt energy conservation. Home visit to assess safety. Medication adjustment.
Discharge status (O2 reqs and home vs ECF)

Change in admit to discharge:

  • 12 minute walking distance
  • Pulmonary Functional Status Scale (function, dyspnea, and psychosocial status)
Niederman, MS, et al. Benefits of a multidisciplinary pulmonary rehabilitation program. Chest 1991;99(4):798-804.
  • Outpatient rehab
  • 9 week outpatient rehab program. Sessions 3x/wk for 2½ hours of education and exercise. Education: support group, medications, diet, relaxation, stress management, breathing retraining. Exercise: Treadmill, weights, cycle ergometer, upper body.
Change in baseline to 9 weeks:
  • Maximal exercise performance
  • Exercise endurance
  • Beck Depression Inventory
  • COPD disability scale
Reardon, J, et al. The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea. Chest 1994;195(4):1046-52.
       - AND -
Vale, F, et al. The long-term benefits of outpatient pulmonary rehabilitation on exercise endurance and quality of life. Chest 1993. 103(1):42-5.
  • Outpatient rehab
  • 6 week outpatient rehab program of 12 3-hr sessions of education and exercise. Education: breathing retraining, work simplification, nutrition, medication, relaxation, stress management. Physical conditioning: light weights, treadmill, bicycle, stairs, upper extremity training.
Change in baseline to 6 weeks:
  • Dyspnea
  • Spirometry
  • Exercise endurance
  • Heart rate

Change in baseline vs 6 weeks vs approx 12mo followup:

  • 12 minute walking distance
  • Quality of life as measured by Chronic Respiratory Questionnaire(dyspnea, fatigue, emotion, mastery
Kane et al. A study of post-acute care. 1994. Institute for Health Services Research.
  • Home health
  • Skilled nursing facility
 
  • Mortality
  • Function (weighted ADL/IADL score)
  • Rehospitalization
  • Cost
  • Symptoms (pulmonary distress scale)
  • Caregiver burden
  • Return to community
Ketelaars, CAJ, et al. Long-term outcome of pulmonary rehabilitation in patients with COPD. Chest 1997;112(2):363-9.
  • Inpatient rehab hospital
  • 10 to 12 week inpatient rehab program managed by MDT: chest physician, nurse, physical therapist, occupational therapist, dietitian, social worker, psychologist. Respiratory techniques, PT, exercise conditioning, psychosocial rehab, OT, pt/family education.
Change in admit to discharge, and discharge to 9mo followup:
  • Health-related quality of life, as measured by the St. George’s Respiratory Questionnaire (symptoms, activities, impact), and well-being component of the Medical Psychological Questionnaire for Lung Diseases (psychological)
  • COPD Coping Questionnaire
  • Lung function measures
  • 12 minute walking test

 

BACK & NECK PROCEDURES
Source Treatment Settings Services Received Outcome Measures
Deyo, RA, et al. Lumbar spinal fusion: a cohort of complications, reoperations, and resource use in the medicare population. Spine 1993;18(11):1463-70.
  • Hospital unit
 
  • 6 week postoperative mortality
  • In-hospital complications
  • Blood transfusion
  • Discharged to nursing home
  • Mean length of stay
  • Mean hospital charges
    • 4-yr. follow-up - Reoperation, Rehospitalization
Smith, EB, et al. Surgical results and complications in elderly patients with benign lesions of the spinal canal. JAGS 1992;40(9):867-70.
  • Hospital unit
  "Long-term follow-up" - no time specified:
  • Changes in neurological symptoms (pain, sensation, weakness)
  • Changes in ADL
  • Standardized scale obtained from consecutive outpatient visits, telephone interviews, or written responses
  • Complications associated with spinal surgery
  • Associated illness and postoperative complications
Hood, SA, et al. Lumbar spinal stenosis: surgical intervention for the older person. Israel Journal of Medical Sciences 1983;19:169-72.
  • Hospital unit
  1.5-5 yr. follow-up (at 3 mo. intervals in yr. 1, 6 mo. intervals thereafter):
  • Improved walking distance
  • Partial pain relief
  • Complete pain relief
  • Rating of whether surgery was worthwhile

Other measures (objective):

  • Straight leg raising
  • Limp
  • Tendon reflex
  • Lumbar movement
  • Valleix & Valsava signs
Ciol, MA, et al. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. JAGS 1996;44:285-90.
  • Hospital unit
 
  • Postoperative mortality
  • Postoperative complications
  • Reoperation rate (one cohort at 7 years, another at 3 years)
North, RB, et al. Dorsal root ganglionectomy for failed back surgery syndrome: A 5-year follow-up study. J Neurosurg 1991;74:236-42.
  • Hospital unit
  Follow-up at 6 wks, 6 mos, 2 yrs, 5.5 yr mean
  • Pain relief
  • Satisfaction with treatment
  • "Success" = aggregate of 1 & 2

Secondary Measures

  • Ability to perform everyday activities (ADLs)
  • Medication intake
  • Patients' subjective impressions of changes in neurological function (touch sensation, muscle strength, bladder/bowel control).
North, RB, et al. Failed back surgery syndrom: 5 year follow-up in 102 patients undergoing repeated operation. Neurosurgery 1991;28:685-91.
  • Hospital unit
 
  • Pain relief
  • Satisfaction with treatment outcome
  • "Success" = aggregate of pain relief and satis.

Secondary Measures

  • Ability to perform ADLs
  • Neurological function (strength, sensation, bowel/bladder control)
  • Medication intake
  • Return to work
Deyo, RA, et al. Morbidity and mortality in association with operations on the lumbar spine. Journal of Bone & Joint Surgery 1992;74A(4):536-43.
  • Hospital unit
 
  • In hospital mortality
  • Postoperative complications
  • Rate of discharge to a nursing home
  • Prolonged hospitalization (>10 days)
  • Mean hospital charges
Katz, JN, et al. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Spine 1997;22(10):1123-31.
  • Hospital unit
  Follow-up at 6 months and 24 months:
  • Global sickness impact profile (SIP)
  • Walking capacity
  • Back pain
  • Leg Pain
  • Satisfaction with surgery
  • Rpeat operation within 24 months
  • Resource use - costs, mean length of stay
Atlas, SJ, et al. The Maine lumbar spine study, part II: 1-year outcome of surgical and nonsurgical management of sciatica. Spine 1996;21(5):1777-86.
  • Hospital unit
  1 Year follow-up:
Symptoms:
  • Low back pain
  • Leg pain
  • Change in predominant symptom
  • Sciatica Frequency Index (symptom freq.)

Functional status:

  • Roland score, mean change (3,6,12 mos)
  • SF-36 score, mean change (3,6,12 mos)
  • Disability days in past month, mean change
  • Improved quality of life

Satisfaction:

  • Overall results of treatment
  • Spend rest of life like now, satisfied
  • If surgery, still choose back operation, yes

Employment & WC status:

  • Employed after 1 year
  • Receiving WC after 1 year
Atlas, SJ, et al. The Maine lumbar spine study, Part III: 1-year outcomes of surgical and nonsurgical managment of lumbar spinal stenosis. Spine 1996;21(15):1787-95.
  • Hospital unit
  Same asPart II above, except:
  • Stenosis Frequency Index (rather than sciatica)
  • Does not include employment or WC info

 

VENTILATOR
Source Treatment Settings Services Received Outcome Measures
Elpern, EH, et al. Long-term outcomes for elderly survivors of prolonged ventilator assistance. Chest 1989;96(5):1120-4.
  • Hospital unit
 
  • Postdischarge survival (0-12 mos, 13-24 mos, 25-36 mos, >36 mos)
  • Subsequent hospital days
  • Extended care facility days
  • Home nursing services
  • 3 year follow-up (self-rated functional independence)
McLean, RF, et al. Outcome of respiratory intensive care for the elderly. Critical Care Medicine 1985;13(8):625-9.
  • Hospital unit
  12-24 month follow-up:
  • Living at home
  • Living in nursing home
  • Inpatient in acute care hospital
  • Self-rated activity compared to premorbid state
  • Self-rating of quality of life
Gracey, DR, et al. Outcome of patients cared for in a ventilator-dependent unit in a general hospital. Chest 1995;107(2): 494-9.
  • Hospital unit
  Discharge Location:
  • Home
    - Directly home
    - Physicial medicine and rehabilitation then home
    - Other hospital unit then home
  • Nursing home (off ventilator)
  • Hospital near home then home
  • Hospital near home then nursing home (off ventilator)
  • Liberation from ventilator
  • Post-discharge survival
Gracey, DR, et al. Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clinic Proceedings 1992;67(2):131-6.
  • Hospital unit
 
  • No mechanical ventilation
  • Home mechanical ventilation (nocturnal)
  • Home oxygen
  • Died in hospital
Make, B, et al. Rehabilitation of ventilator-dependent subjects with lung diseases: the concept and the initial experience. Chest 1984;86(3):358-65.
  • Hospital unit
Rehabilitation care
  • Physical therapy
  • Occupational therapy
  • Respiratory therapy
  • Discharge planning, including assistance with arranging home health aids, visiting nurses, etc.
  • Number of hours of free time from mechanical assistance (upon discharge from resp. care ctr.)
  • Independence in ADL (upon discharge)
  • Location after discharge from Respiratory Care Center
  • Mortality
Swinburne, A, et al. Respiratory failure in the elderly: analysis of outcome after treatment with mechanical ventilation. Arch Inter Med 1993;153:1657-62.
  • Hospital unit
 
  • Survival to discharge
  • Survival after discharge
Pehrsson, K, et al. Quality of life of patients treated by home mechanical ventilation due to restrictive ventilatory disorders. Respiratory Medicine 1994;88:21-26.
  • Home mechanical ventilation
 
  • Sickness Impact Profile (SIP) - overall health status
  • Mood Adjective Check List (MACL) - emotional status and mental well-being
  • Hospital Anxiety and Depression Scale - psych. morbidity
  • Study-specific questionnaire - effects of HMV and "on-treatment" problems (problems with vent., sleep problems, social life)
  • Blood gas values
Muir, J, et al. Survival and long-term follow-up of tracheostomized patients with COPD treated by home mechanical ventilation: A multicenter French study. Chest 1994;106(1):201-9.
  • Home mechanical ventilation
 
  • ABG - Arterial Blood Gas
  • PFT - Pulmonary Functional Test
  • Survival - 18 months-2 years, 3 years, 5 years, 7 years, 10 years
Kopacz, MA, et al. Multidisciplinary approach for the patient on a home ventilator. Heart & Lung 1984;13(3):255-62.
  • Home mechanical ventilation
 
  • 1-41 month follow-up
  • Number of repeat hospitalizations
  • Length of stay (of repeat hosp.)
  • Complications
Steiner, T, et al. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke 1997;28(4):711-15.
  • Hospital unit
 
  • Survival at one year
  • Barthel Index (at least 12-month follow-up, up to 3 years)
  • Rankin Scores (at least 12-month follow-up, up to 3 years)

Stapleton, DC, et al. Ventilator dependent unit demonstration: outcome evaluation and assessment of post acute care. 1996. Report prepared for Office of Research and Demonstrations, Health Care Financing Administration.

  • Ventilator dependent unit (VDU)
 
  • Length of stay (LOS) in hospital
  • LOS in VDU
  • Length of ventilator episode
  • Length of survival after hospital admission
  • Length of survival after hospital discharge
  • Discharge status
  • Ventilator type
  • Discharge destination
  • Post-discharge caregiver
  • ADLs
  • RUGS III dependence index
  • Expenditure measures