December 2004 Article

[drusso]

In an effort to promote some scholarly discussion online, I've started a new PM&R Journal Club. My goal is to post monthly articles (or recruit other SDN regulars to do so). I hope that this will be of interest to residents and students alike. To get things started, I thought that we'd begin with a recent article about trends in medical rehabilitation pubished in JAMA:

Link to Artilce


Trends in length of stay, living setting, functional outcome, and mortality following medical rehabilitation.

Ottenbacher KJ, Smith PM, Illig SB, Linn RT, Ostir GV, Granger CV.

Division of Rehabilitation Sciences, Sealy Center on Aging, University of Texas Medical Branch, Galveston 77555-1137, USA. [email protected]

CONTEXT: Changes in reimbursement have reduced length of stay (LOS) for patients receiving inpatient medical rehabilitation. The impact of decreased LOS on functional status, living setting, and mortality is not known. OBJECTIVE: To examine changes in LOS, functional status, living setting, and mortality in patients completing inpatient rehabilitation. DESIGN: Retrospective cohort study from 1994 through 2001 using information submitted to the Uniform Data System for Medical Rehabilitation. SETTING AND PARTICIPANTS: Data were analyzed from 744 inpatient medical rehabilitation hospitals and centers located in 48 US states. A total of 148,807 patient records from 5 impairment groups (stroke, brain dysfunction, spinal cord dysfunction, other neurologic conditions, and orthopedic conditions) were examined. Patients' mean age was 67.8 (SD, 15.8) years; the sample was 59% female and 81% non-Hispanic white. MAIN OUTCOME MEASURES: Discharge setting, follow-up living setting, change in functional status, and mortality. RESULTS: Median LOS decreased from 20 to 12 days (P<.001) from 1994 to 2001. The proportional decrease in median LOS was greatest (42%) for patients with orthopedic conditions. Mean days to follow-up remained constant from 89 in 1994 to 90 in 2001. Functional status was clinically stable, while efficiency (functional status change divided by LOS) increased significantly (P<.001). Rates of discharge to home and living at home at follow-up remained stable, ranging from 81% to 93%. However, mortality at 80- to 180-day follow-up increased from less than 1% in 1994 to 4.7% in 2001. CONCLUSIONS: Length of stay for inpatient rehabilitation decreased substantially from 1994 to 2001. Effectiveness as measured by change in functional status did not change clinically, and living setting did not change. Efficiency for functional outcomes improved but mortality at follow-up increased.

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[Finally M3]

You know, I thought that the mortality was due to the more acutely ill patients who were being admitted into inpatient rehab nowadays. However, there wasn't any significant change in number of comorbidites on admission from 1994 to 2001. Also, there was only a slight decrease in the admission FIM scoring from 1994 to 2001.

One question is, while it makes intuitive sense that a lower FIM score would correlate with a 'sicker' patient, is there any hard data to back this up? Is using a FIM score along with number of comorbidities a good was of assessing medical 'stability' of patients upon admission?

Ahh...to be on call!

 

[drusso]

Today, I got a consult to "risk stratify" the fall status of a patient with Parkinson's Disease and A-fib who needed anticoagulation. The primary service was concerned about the risk of serious intracranial bleed following a fall if the patient were on coumadin. I had to really think about it before coming up with a good evidence-based answer. This article helped. Enjoy.



The risk of hemorrhagic complications in hospital in-patients who fall while receiving antithrombotic therapy.

Bond AJ, Molnar FJ, Li M, Mackey M, Man-Son-Hing M.

Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada. [email protected].

BACKGROUND: The use of antithrombotic agents and falls are independently associated with an increased risk of hemorrhagic injury. However, few studies have delineated the risk of fall-related hemorrhagic complications in persons who are taking antithrombotic therapy. The objective of this study was to compare the rates of fall-related hemorrhagic injury in hospital in-patients who are taking and not taking antithrombotic therapy. METHODS: A 4-year retrospective chart review of consecutive patients who fell during admission to a 500-bed tertiary-care teaching hospital was conducted. Major hemorrhagic injuries including subdural hematomas and major bleeding/cuts, patients' use of antithrombotic medication (warfarin, aspirin, clopidogrel and heparin) and their anticoagulation status at the time of their fall were recorded. RESULTS: A total of 2635 falls in 1861 patients were reviewed. Approximately 10% of falls caused major hemorrhagic injury. One fall resulted in a subdural hematoma. Persons taking warfarin were less likely to suffer a fall-related major hemorrhagic injury compared with persons not taking antithrombotic therapy (warfarin, 6%; no therapy, 11%; p = 0.01). Logistic regression showed that fall-related major hemorrhagic injury was associated with female gender (odds ratio 1.6; 95% CI 1.3, 2.1), use of aspirin (odds ratio 1.4; 95% CI 1.1, 1.8) and use of clopidogrel (odds ratio 2.2; 95% CI 1.1, 4.8), but not with the use of warfarin or heparin, or the intensity of anticoagulation. CONCLUSIONS: In this study, compared with persons taking no antithrombotic therapy, those taking warfarin had lower rates of fall-related hemorrhagic injuries. The absolute rate of the development of fall-related intracranial hemorrhagic injury such as subdural hematomas was low, even in persons taking warfarin. These counter-intuitive results may be due to selection bias, and suggest that physicians are very conservative in selecting patients for warfarin therapy, choosing only those who are sufficiently healthy to be at much lower than average risk of suffering fall-related hemorrhagic injuries. This phenomenon may lead to physicians overestimating the potential for fall-related major hemorrhagic injury in persons taking antithrombotic therapy, with the possible denial of warfarin therapy to many of those who would benefit. This perception may contribute to the care gap between the number of patients who would theoretically derive overall benefit from warfarin therapy and those who are actually receiving it.

PMID: 15638939 [PubMed - as supplied by publisher]

 

[DigableCat]

Today, I got a consult to "risk stratify" the fall status of a patient with Parkinson's Disease and A-fib who needed anticoagulation. The primary service was concerned about the risk of serious intracranial bleed following a fall if the patient were on coumadin.

Good article.


But I'm surprised they would ask us??? Sounds like a CYA consult to me...