Pamela Roberts PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP

Health services research (HSR) is a field of study that examines how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and health and well-being. HSR approaches can help build the occupational therapy evidence base, particularly in relation to population health. Data from electronic health record (EHR) systems provide a rich resource for applying HSR approaches to examine the value of occupational therapy services. Transparency about data preparation procedures is important for interpreting results. Based on our findings, we describe a six-step cleaning protocol for preparing EHR and billing data from an inpatient rehabilitation facility for research and provide recommendations for the field based on our experience. Using and reporting similar strategies across studies will improve efficiency and transparency, and facilitate comparability of results.

Objective. To examine associations among the time and content of rehabilitation treatment with self-care and mobility functional gain rate for adults with acquired brain injury.

Design. Retrospective cohort study using electronic health record and administrative billing data.

Setting. Inpatient rehabilitation unit at a large, academic medical center.

Participants. Adults with primary diagnosis of stroke, traumatic brain injury, or nontraumatic brain injury admitted to the inpatient rehabilitation unit between 2012 and 2017 (N=799).

Interventions. Not applicable.

Main Outcome Measures. Gain rate in self-care and mobility function, using the Functional Independence Measure. Hierarchical regression models were used to identify the contributions of baseline characteristics, units, and content of occupational therapy, physical therapy, and speech-language pathology treatment to functional gain rates.

Results. Median length of rehabilitation stay was 10 days (interquartile range, 8-13d). Patients received an mean of 10.62 units of therapy (SD, 2.05) daily. For self-care care gain rate, the best-fitting model accounted for 32% of the variance. Occupational therapy activities of daily living units were positively associated with gain rate. For mobility gain rate, the best-fitting model accounted for 37% of the variance. Higher amounts of physical therapy bed mobility training were inversely associated with mobility gain rate.

Conclusions. More activities of daily living in occupational therapy is associated with faster improvement on self-care function for adults with acquired brain injury, whereas more bed mobility in physical therapy was associated with slower improvement. A potential challenge with value-based payments is the alignment between clinically appropriate therapy activities and the metrics by which patient improvement are evaluated. There is a risk that therapists and facilities will prioritize activities that drive improvement on metrics and deemphasize other patient-centered goals.

Keywords. Brain injuries; Electronic health records; Recovery of function; Rehabilitation; Stroke

Background and objectives. Functional outcomes after stroke are strongly related to focal injury measures. However, the role of global brain health is less clear. Here, we examined the impact of brain age, a measure of neurobiological aging derived from whole brain structural neuroimaging, on post-stroke outcomes, with a focus on sensorimotor performance. We hypothesized that more lesion damage would result in older brain age, which would in turn be associated with poorer outcomes. Related, we expected that brain age would mediate the relationship between lesion damage and outcomes. Finally, we hypothesized that structural brain resilience, which we define in the context of stroke as younger brain age given matched lesion damage, would differentiate people with good versus poor outcomes.

Methods. We conducted a cross-sectional observational study using a multi-site dataset of 3D brain structural MRIs and clinical measures from ENIGMA Stroke Recovery. Brain age was calculated from 77 neuroanatomical features using a ridge regression model trained and validated on 4,314 healthy controls. We performed a three-step mediation analysis with robust mixed-effects linear regression models to examine relationships between brain age, lesion damage, and stroke outcomes. We used propensity score matching and logistic regression to examine whether brain resilience predicts good versus poor outcomes in patients with matched lesion damage.

Results. We examined 963 patients across 38 cohorts. Greater lesion damage was associated with older brain age (β=0.21; 95% CI: 0.04, 0.38, P=0.015), which in turn was associated with poorer outcomes, both in the sensorimotor domain (β=-0.28; 95% CI: -0.41, -0.15, P<0.001) and across multiple domains of function (β=-0.14; 95% CI: -0.22, -0.06, P<0.001). Brain age mediated 15% of the impact of lesion damage on sensorimotor performance (95% CI: 3%, 58%, P=0.01). Greater brain resilience explained why people have better outcomes, given matched lesion damage (OR=1.04, 95% CI: 1.01, 1.08, P=0.004).

Conclusions. We provide evidence that younger brain age is associated with superior post-stroke outcomes and modifies the impact of focal damage. The inclusion of imaging-based assessments of brain age and brain resilience may improve the prediction of post-stroke outcomes compared to focal injury measures alone, opening new possibilities for potential therapeutic targets.

The Canadian Occupational Performance Measure is a standardized outcome measure that assists in structuring and focusing the occupational therapy assessment, reassessment, and intervention process. Using a semi-structured interview with patients who have a wide range of diagnoses in various practice settings, the information gathered by the Canadian Occupational Performance Measure reflects the importance of the skill or activity to the client in the areas of self-care, productivity, and leisure. The Canadian Occupational Performance Measure is designed to assist the occupational therapist in establishing occupational performance goals based on client perceptions of need and measures the change in defined problem areas.

Keywords. COPM, client-centered interview, outcome measure, self-care, productivity, leisure

Background. Persistent sensorimotor impairments after stroke can negatively impact quality of life. The hippocampus is vulnerable to poststroke secondary degeneration and is involved in sensorimotor behavior but has not been widely studied within the context of poststroke upper-limb sensorimotor impairment. We investigated associations between non-lesioned hippocampal volume and upper limb sensorimotor impairment in people with chronic stroke, hypothesizing that smaller ipsilesional hippocampal volumes would be associated with greater sensorimotor impairment.

Methods and Results. Cross-sectional T1-weighted magnetic resonance images of the brain were pooled from 357 participants with chronic stroke from 18 research cohorts of the ENIGMA (Enhancing NeuoImaging Genetics through Meta-Analysis) Stroke Recovery Working Group. Sensorimotor impairment was estimated from the FMA-UE (Fugl-Meyer Assessment of Upper Extremity). Robust mixed-effects linear models were used to test associations between poststroke sensorimotor impairment and hippocampal volumes (ipsilesional and contralesional separately; Bonferroni-corrected, P<0.025), controlling for age, sex, lesion volume, and lesioned hemisphere. In exploratory analyses, we tested for a sensorimotor impairment and sex interaction and relationships between lesion volume, sensorimotor damage, and hippocampal volume. Greater sensorimotor impairment was significantly associated with ipsilesional (P=0.005; β=0.16) but not contralesional (P=0.96; β=0.003) hippocampal volume, independent of lesion volume and other covariates (P=0.001; β=0.26). Women showed progressively worsening sensorimotor impairment with smaller ipsilesional (P=0.008; β=−0.26) and contralesional (P=0.006; β=−0.27) hippocampal volumes compared with men. Hippocampal volume was associated with lesion size (P<0.001; β=−0.21) and extent of sensorimotor damage (P=0.003; β=−0.15).

Conclusions. The present study identifies novel associations between chronic poststroke sensorimotor impairment and ipsilesional hippocampal volume that are not caused by lesion size and may be stronger in women.

The goal of the Enhancing Neuroimaging Genetics through Meta‐Analysis (ENIGMA) Stroke Recovery working group is to understand brain and behavior relationships using well‐powered meta‐ and mega‐analytic approaches. ENIGMA Stroke Recovery has data from over 2,100 stroke patients collected across 39 research studies and 10 countries around the world, comprising the largest multisite retrospective stroke data collaboration to date. This article outlines the efforts taken by the ENIGMA Stroke Recovery working group to develop neuroinformatics protocols and methods to manage multisite stroke brain magnetic resonance imaging, behavioral and demographics data. Specifically, the processes for scalable data intake and preprocessing, multisite data harmonization, and large‐scale stroke lesion analysis are described, and challenges unique to this type of big data collaboration in stroke research are discussed. Finally, future directions and limitations, as well as recommendations for improved data harmonization through prospective data collection and data management, are provided.

Up to two-thirds of stroke survivors experience persistent sensorimotor impairments. Recovery relies on the integrity of spared brain areas to compensate for damaged tissue. Deep grey matter structures play a critical role in the control and regulation of sensorimotor circuits. The goal of this work is to identify associations between volumes of spared subcortical nuclei and sensorimotor behaviour at different timepoints after stroke. We pooled high-resolution T1-weighted MRI brain scans and behavioural data in 828 individuals with unilateral stroke from 28 cohorts worldwide. Cross-sectional analyses using linear mixed-effects models related post-stroke sensorimotor behaviour to non-lesioned subcortical volumes (Bonferroni-corrected, P < 0.004). We tested subacute (≤90 days) and chronic (≥180 days) stroke subgroups separately, with exploratory analyses in early stroke (≤21 days) and across all time. Sub-analyses in chronic stroke were also performed based on class of sensorimotor deficits (impairment, activity limitations) and side of lesioned hemisphere. Worse sensorimotor behaviour was associated with a smaller ipsilesional thalamic volume in both early (n = 179; d = 0.68) and subacute (n = 274, d = 0.46) stroke. In chronic stroke (n = 404), worse sensorimotor behaviour was associated with smaller ipsilesional putamen (d = 0.52) and nucleus accumbens (d = 0.39) volumes, and a larger ipsilesional lateral ventricle (d = −0.42). Worse chronic sensorimotor impairment specifically (measured by the Fugl-Meyer Assessment; n = 256) was associated with smaller ipsilesional putamen (d = 0.72) and larger lateral ventricle (d = −0.41) volumes, while several measures of activity limitations (n = 116) showed no significant relationships. In the full cohort across all time (n = 828), sensorimotor behaviour was associated with the volumes of the ipsilesional nucleus accumbens (d = 0.23), putamen (d = 0.33), thalamus (d = 0.33) and lateral ventricle (d = −0.23). We demonstrate significant relationships between post-stroke sensorimotor behaviour and reduced volumes of deep grey matter structures that were spared by stroke, which differ by time and class of sensorimotor measure. These findings provide additional insight into how different cortico-thalamo-striatal circuits support post-stroke sensorimotor outcomes.

Readmissions to health care facilities are undesirable outcomes that indicate the quality of the care transitions. Although there is a growing evidence-base for preventing readmissions, the focus has been on acute care. Postacute care (PAC) patients are often excluded from these studies, and thus there is limited evidence guiding practitioners’ efforts to facilitate an effective community transition after PAC rehabilitation. To provide direction for PAC research and clinical practice, this scoping review summarizes current community transition interventions and identifies practices that facilitate successful community discharge. Thirteen care processes emerged from 35 studies, of which 5 were included in at least 60% of the studies, including coaching on the care transition process, medical self-management, medication self-management, scheduling follow-up medical services, and telephone follow-up. These findings can inform the development, evaluation, and implementation of PAC community transition interventions.

Exploration of the relationship between Allen Cognitive Level Screen scores on discharge from a mental health hospital and readmission rates will be discussed, with emphasis on opportunities for occupational therapy practitioners to positively affect the clinical outcomes for persons at risk for readmission to a mental health setting.

Objective. To determine factors associated with response to inpatient rehabilitation treatment among TBI patients.

Setting. Inpatient rehabilitation service at a Level I trauma center.

Participants. Moderate-severe TBI patients ages = 18 years old admitted between January 1, 2002 and December 31, 2012.

Main Measures. Response to inpatient rehabilitation, measured by the Functional Independence Measure (FIM) score.

Design. Retrospective cohort study.

Results. Of 1,984 patients treated for TBI, 184 (10.8%) underwent inpatient rehabilitation. The largest proportion of patients improved in mobility (98.9%), followed by self-care (93.7%), communication/social cognition (84.0%), and sphincter control (65.7%). Of these, 99 (53.8%) improved by 2 or more levels of functional independence and were considered rehabilitation responders. Responders were younger (53.1 years vs. 63.8, p < 0.01), had longer average rehabilitation stays (15.4 days vs. 12.2, p < 0.01), and were less likely to have an admission SBP <100mmHg (7.1% vs. 17.1%, p < 0.01). On multivariate analysis, normotension at admission (AOR 0.06, p < 0.01) and longer rehabilitation LOS (AOR 1.11, p < 0.01) were associated with a response to inpatient rehabilitation.

Conclusion. Of the TBI patients who qualified for same-center inpatient rehabilitation, approximately half responded to treatment. Longer rehabilitation time and normotension at admission predicted response to rehabilitation. Further efforts are necessary to identify and optimize TBI patients for inpatient rehabilitation.

Objective. The aim of this study was to determine whether functional status, as measured by the AcuteFIM instrument, can be used to predict discharge destination of stroke patients from the acute hospital setting.

Design. A retrospective cohort study was carried out in an urban academic medical center. Data were collected on 481 new-onset stroke patients 18 yrs or older in an acute hospital between January 1 and September 30, 2013. Functional Independence Measure (FIM) instrument data were linked to a subset of 54 patients who received additional services at an inpatient rehabilitation facility. A receiver operator characteristic curve was constructed to validate the predictive ability of the AcuteFIM instrument and to determine the optimal cutoff score associated with discharge to a community setting.

Results. All AcuteFIM items in stroke patients at admission demonstrated strong interitem correlation coefficients (all above 0.6) and high internal consistency (Cronbach α = 0.94). The AcuteFIM total score was positively associated with discharge to the community from the acute hospital (odds ratio, 1.06; 95% confidence interval, 1.05-1.07). Receiver operator characteristic curve analysis generated a c statistic of 0.89 (95% confidence interval, 0.87-0.92), indicating that the AcuteFIM instrument is predictive of patient discharge to the community setting.

Conclusion. This study suggests that the AcuteFIM instrument is a reliable tool that can be used to predict discharge destination from the acute hospital among stroke patients.

Background. Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups.

Objective. To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission.

Design. Multicenter prospective observational cohort, practice-based evidence, study.

Setting. Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States.

Participants. A total of 226 patients with hip fractures treated with hip arthroplasty.

Methods. Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster).

Main Outcome Measure(s). Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity).

Results. The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group.

Conclusions. Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.

Vision impairments are highly prevalent after acquired brain injury (ABI). Conceptual models that focus on constructing intellectual frameworks greatly facilitate comprehension and implementation of practice guidelines in an interprofessional setting. The purpose of this article is to provide a review of the vision literature in ABI, describe a conceptual model for vision rehabilitation, explain its potential clinical inferences, and discuss its translation into rehabilitation across multiple practice settings and disciplines.

Objective. To determine predictive factors for TRansferring Inpatient rehabilitation facility (IRF) cancer Patients Back to Acute Care (TRIPBAC).

Design. A retrospective chart review of patients with cancer admitted to an IRF from 2009 to 2010 because of a functional impairment that developed as a direct consequence of their cancer or its treatment.

Setting. IRF of a community-based, academic, tertiary care facility.

Methods. The characterization of patients with cancer in the IRF was primarily based on analysis of the IRF Patient Assessment Instrument and other internal IRF data logs.

Main Outcome Measurement. Frequency and reasons for TRIPBAC.

Results. The TRIPBAC rate in our IRF was 17.4%. The most common reasons for TRIPBAC were postneurosurgical complications (31%). Factors associated with TRIPBAC were a motor Functional Independence Measure score of 35 points or lower on admission (odds ratio 4.01, 95% confidence interval 1.79-8.98; P = .001) and the presence of a feeding tube or a modified diet (odds ratio 3.18, 95% confidence interval 1.44-7.04; P = .004).

Conclusions. Motor Functional Independence Measure score on admission is the best predictor for TRIPBAC in patients with cancer admitted to our IRF, followed by the presence of a feeding tube or a modified diet.

Objective. To examine the impact of an inpatient rehabilitation program on functional improvement and survival among patients with newly diagnosed glioblastoma multiforme (GBM) who underwent surgical resection of the brain tumor.

Design. A retrospective cohort study of newly diagnosed patients with GBM between 2003 and 2010, with survival data updated through January 23, 2013.

Setting. An urban academic nonprofit medical center that included acute medical and inpatient rehabilitation.

Participants. Data for newly diagnosed patients with GBM were examined; of these patients, 100 underwent inpatient rehabilitation after resection, and 312 did not undergo inpatient rehabilitation.

Main Outcome Measurements. Overall functional improvement and survival time for patients who participated in the inpatient rehabilitation program.

Results. A total of 89 patients (93.7%) who underwent inpatient rehabilitation improved in functional status from admission to discharge, with the highest gain observed in mobility (96.8%), followed by self-care (88.4%), communication/social cognition (75.8%), and sphincter control (50.5%). The median overall survival among inpatient rehabilitation patients was 14.3 versus 17.9 months for patients who did not undergo inpatient rehabilitation (P = .03). However, after we adjusted for age, extent of resection, and Karnofsky Performance Status Scale scores, we found no statistical difference in the survival rate between patients who did and did not undergo inpatient rehabilitation (hazard ratio [HR], 0.84; P = .16). Among the patients who underwent inpatient rehabilitation, older age (HR, 2.24; P = .0006), a low degree of resection (HR, 1.67; P = .02), and lack of a Stupp regimen (HR, 1.71; P = .05) were associated with greater hazard of mortality.

Conclusions. Patients who undergo inpatient rehabilitation demonstrate significant functional improvements, primarily in the mobility domain. Confounder adjusted multivariate analysis showed no survival difference between patients who did and did not undergo inpatient rehabilitation; this finding suggests that a structured inpatient rehabilitation program may level the survival field in lower-functioning patients who otherwise may be faced with a dismal prognosis.

Objective. To identify medical and functional health risk factors for being discharged directly to an acute-care hospital from an inpatient rehabilitation facility among patients who have had a stroke.

Design. Retrospective cohort study.

Setting. Academic medical center.

Participants. A total of 783 patients with a primary diagnosis of stroke seen from 2008 to 2012; 60 were discharged directly to an acute-care hospital and 723 were discharged to other settings, including community and other institutional settings.

Methods or Interventions. Logistic regression analysis.

Main Outcome Measurements. Direct discharge to an acute care hospital compared with other discharge settings from the inpatient rehabilitation unit.

Results. No significant differences in demographic characteristics were found between the 2 groups. The adjusted logistic regression model revealed 2 significant risk factors for being discharged to an acute care hospital: admission motor Functional Independence Measure total score (odds ratio 0.97, 95% confidence interval 0.95-0.99) and enteral feeding at admission (odds ratio 2.87, 95% confidence interval 1.34-6.13). The presence of a Centers for Medicare and Medicaid-tiered comorbidity trended toward significance.

Conclusion. Based on this research, we identified specific medical and functional health risk factors in the stroke population that affect the rate of discharge to an acute-care hospital. With active medical and functional management, early identification of these critical components may lead to the prevention of stroke patients from being discharged to an acute-care hospital from the inpatient rehabilitation setting.

Objectives. To compare and contrast subjective perceptions with objective compliance of the impact of the 2010 Centers for Medicare and Medicaid Service updates of the Medicare Benefit Policy Manual.

Design or Setting. Cross-sectional survey.

Participants and Methods. An electronic survey was sent by the Uniform Data System for Medical Rehabilitation to all enrolled inpatient rehabilitation facility subscribers (n = 817). The survey was sent April 15, 2011, and responses were tabulated if they were received by May 15, 2011.

Main Outcome Measurements. Comparing and contrasting of the subjective perception to objective evaluation and/or compliance with the Medicare Benefit Policy Manual on case mix index, length of stay, admissions by diagnostic category as well as perception of preadmission screening, postadmission evaluation, plan of care, and interdisciplinary conferencing.

Results. Twenty-five percent of the 817 facilities responded, for a total of 209 responses. Complete data were present in 148 of the respondents. For most diagnostic categories, perception of change did not mirror reality of change; neither did the perception between change in case mix index and length of stay. Perception did match reality in stroke and multiple trauma cases; respondents perceived an increase in admissions for the 2 impairments, and there was an overall increase in reality.

Conclusion. Comparison with actual data identified that gaps exist between diagnostic category perceptions and actual diagnostic category admission performance. Regulations such as the 75%-60% rule and audit focus on non-neurologic conditions as well as actual inpatient rehabilitation facility program payment reports may have influenced respondents perceptions to change associated with the Medicare Benefit Policy Manual modifications. This disparity between perception and actual data may have implications for programmatic planning, forecasting, and resource allocation.

In this retrospective, longitudinal cohort study, the Pediatric Evaluation of Disability Inventory was used to predict the effects of cerebral palsy (CP) on self-care, mobility, and social function for 2,768 children, adolescents, and young adults with CP. Multiple linear regression was used to predict functional performance and level of caregiver assistance and found that CP severity, as measured by the Gross Motor Function Classification System and the Manual Ability Classification System, had the strongest effect. More severe levels of gross motor and fine motor dysfunction resulted in lower levels of self-care, mobility, and social function and increased levels of caregiver assistance. This study provides critical evidence regarding the importance of CP severity as a predictor of self-care, mobility, and social function that can be tested in future research to improve therapy treatment planning, caregiver education, and clinical resource utilization.