Transcript Slide 1

Assessment of Stroke Rehabilitation
in Nebraska Hospitals
Feb 23, 2011
Katherine J. Jones, PT, PhD
Teresa Cochran, PT, DPT, GCS, MA
Lou Jensen, OTD, OT/L
Tammy Roehrs, PT, MA, NCS
Kathleen Volkman, PT, MS, NCS
Amy Goldman PT, DPT
Supported by the Nebraska Department of Health and Human
Services, Cardiovascular Health Program
PHOTO GOES HERE (Need higher resolution
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Funding & Acknowledgements
• Supported by the Nebraska Department of
Health and Human Service, Cardiovascular
Health Program
• Robin High, MA for assistance with statistical
analysis
• Anne Skinner, RHIA for database construction
• Andrea Bowen, BA for data entry and table
formatting
• Clinicians across the state who assisted in
instrument construction
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Objectives
• Explain a framework to assess health care
quality
• Describe the structure and process of stroke
rehabilitation in Nebraska hospitals
• Identify two factors that predict variability in
the prevalence of evidence-based structures &
processes
• Discuss options to improve access to evidencebased stroke rehabilitation for survivors of
stroke in Nebraska
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Purpose of the Study
1. Assess the structure and process of acute
stroke rehabilitation in a representative
sample of Nebraska hospitals
2. Determine the extent to which reported
structures and processes are consistent
with current evidence relative to stroke
rehabilitation
3. Develop an action plan to increase the
prevalence of evidence-based structures
and processes for acute stroke
rehabilitation in Nebraska hospitals
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What is Quality?
•“The degree to which health services for individuals and
populations increase the likelihood of desired health
outcomes and are consistent with current professional
knowledge.”*
•“The greatest good that is possible to achieve in any given
situation.” – Donabedian, 1980
• Avoid “underuse, overuse, misuse…” – National
Roundtable on Healthcare Quality, 1998
*Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new
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health system for the 21st century. Washington,
DC: National Academy Press.
Donabedian’s Framework
to Assess Quality
• Quality is inferred by measuring elements of care
– Structure–conditions under which care is provided (human
resources, equipment, environment)
– Process–what was done (diagnosis, treatment,
rehabilitation, prevention, patient education)
– Outcome–changes in individuals and populations that are
due to health care
Structure
Process
Outcomes
Donabedian, A. (1980). The definition of quality and approaches to its
6 Administration Press.
assessment. Ann Arbor, Michigan: Health
Assessing Outcomes to Infer Quality
• Limitations
• Advantage
– Determined by multiple
– “Ultimate validator” of
factors
quality
– Time to develop (survival)
– Difficult to measure (role
resumption, attitudes)
– Knowledge of relationship
between process and
outcomes ?
– Ability to reveal processes
responsible for outcomes?
Donabedian, A. (1980). The definition of quality and approaches to its
7 Administration Press.
assessment. Ann Arbor, Michigan: Health
Assessing Structure to Infer Quality
• Advantages
– Equivalent to system
design, capacity for
work
– Major determinant
of average quality of
care
– Readily observable,
easily documented,
stable
• Limitation
– Variations must be
large to validly judge
quality
Donabedian, A. (1980). The definition of quality and approaches to its
8 Administration Press.
assessment. Ann Arbor, Michigan: Health
Assessing Process to Infer Quality
• Advantages
– Most closely related
to outcomes
– Small variations in
process can be
related to variations
in outcomes
• Limitations
– Must establish causal
relationship between
process and outcomes
– Understand role of
medical beliefs,
traditions
– Understand
complexity of process
inputs
Donabedian, A. (1980). The definition of quality and approaches to its
9 Administration Press.
assessment. Ann Arbor, Michigan: Health
Patient Clinical Risk Factors
1. Baseline cognitive and functional status before disease or injury
2. Clinical status (severity)
Treatment Characteristics
Outcomes of Care
Structure of Care
Care
1. Patient
a. Disease specific – lab values,
X-ray
b. Holistic – quality of life, ADLs
2. Provider – infection rate
3. Organization – Length of Stay,
Ambulatory Care Sensitive adms.
4. Payer – Cost
Process of
Patient Demographic &
Psychosocial Risk Factors
1. Age
2. Gender
3. Race
4. Marital status
5. Social Support
6. Occupation
7. Education
8. Depression
9. Residence
Kane RL. Understanding Health Care Outcomes Research. Gaithersburg, MD: Aspen Publishers;1997.
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Stroke Rehabilitation Rationale
Stroke rehabilitation is the holistic, comprehensive
approach to addressing the physical, psychological,
social, educational, and vocational needs of individuals
with stroke.1 The structure and process of stroke
rehabilitation determine its outcomes. Access to
coordinated systems of stroke care may be limited in
rural areas.2
1. Keith RA. The comprehensive treatment team in rehabilitation. Arch Phys
Med Rehabil. 1991;72:269-274.
2. Schwamm LH, Pancioli A, Acker JE,3rd, et al. Recommendations for the
establishment of stroke systems of care: Recommendations from the
American Stroke Association's task force on the development of stroke
systems. Stroke. 2005;36:690-703.
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Stroke Rehabilitation Rationale
• Interprofessional team =
Foundation of structure
• Standardized assessments =
Key element of process
– Document baseline, progress,
outcomes
– Identify pt’s at risk
– Determine need for addl
therapies
– Facilitate team communication,
planning
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Consistent with IOM Competencies
Institute of Medicine. Health Professions Education: Bridge to Quality. Washington, DC:
The National Academies Press; 2003; p. 46.
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Stroke Rehabilitation Rationale
• Barriers to use of
Standardized assessments
– Time
– Lack of peer support
– Lack of information systems
– Lack of library of assessments
– Difficulty interpreting
– Perception that they are more
relevant to research than
clinical care
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Limited Access in Rural?
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Short Length of Stay in IRFs
•16.5 day…avg IRF LOS
•58% discharged to home
•20% discharged to SNF
•Rural stroke survivors likely access post-IRF outpatient,
home-health, or skilled nursing care from a CAH
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Methods
• Instrument validated by expert panel
• Design: cross-sectional mail survey Jan–Mar 2010
• Stratified random sample of 53/84 Nebraska hospitals
that provide acute stroke rehabilitation
• Verified target recipient: person most knowledgeable
about stroke rehabilitation in each facility
• 36/53 hospitals returned survey (68% response rate)
• Analysis
• PROC SURVEYMEANS to estimate statewide means,
• Fisher’s Exact Test, ANOVA, and logistic regression to examine
associations between hospital size and team structure with
practices consistent with current evidence for stroke
rehabilitation
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Stroke Rehabilitation in Nebraska Hospitals: Stratified Random Sampling
90
84
NE Hospitals
that provide
services to
patients with
stroke
80
70
60
53
Study
Hospitals
50
40
36
34
30
20
19 19
15
18
12
8
10
Respondent
Hospitals
16
15
5
8
4
0
47-689 beds
25 beds
20 - 24 beds12 - 19 beds
Bed Size Categories
Total
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Methods: Sample Weighting
Hospital Size
> 25 beds 25 beds 20 - 24 beds 12 - 19 beds
Total
Population of NE
Hospitals that provide
services to stroke
survivors
19
34
15
16
84
Study Hospitals
19
18
8
8
53
Number to Achieve 60%
response rate
11
11
5
5
32
Respondent Hospitals
15
12
5
4
36
1.267
2.833
3.000
4.000
Sampling Weight for
Statewide Estimates
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Results
• Structure of stroke rehabilitation care
– Professionals
– Team structure
– Access to specialized services
– Use of standardized assessments
• Team Processes
– Purpose of standardized assessments
– Barriers to standardize assessments
– Quality improvement
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Professionals Providing Stroke Rehabilitation Care in Nebraska Hospitals by Hospital Size
47-689 Beds, n=15 (%)
CAH 14-25 Beds, n=21 (%)
Speech and Language Pathologist
Social Worker (Master’s Prepared)*
Physical Therapist
Occupational Therapist
Nutrition Therapist (Dietitian)
Registered Nurse
Case manager*
Spiritual care (pastoral services)
Internal Medicine Physician*
Radiologist*
Family Practice Physician
Psychologist*
Physician Assistant
Neurologist*
Advanced Practice Registered Nurse
Physical Medicine & Rehab Physician*
Recreational Therapist
Certified Rehabilitation Registered Nurse*
* Statistically significant p< .05
0
10
20
30
40
50
60
70
80
21 100
90
Professionals Providing Stroke Rehabilitation Care in Nebraska Hospitals
Physical Therapist
Registered Nurse
Family Practice Physician
Physician Assistant
Speech and Language Pathologist
Occupational Therapist
Nutrition Therapist (Dietitian)
Spiritual Care (Pastoral Services)
Case Manager
Social Worker (Master’s Prepared)
Radiologist
Internal Medicine Physician
Advanced Practice Registered Nurse
Psychologist
Neurologist
Physical Medicine & Rehab Physician
Recreational Therapist
Certified Rehabilitation Registered Nurse
100
95
92
91
87
82
80
78
68
55
53
44
44
32
23
22
21
12
0
10 20 30 40 50 60 70 80 90 100
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Weighted Proportion of Nebraska Hospitals (n=84)
Team Structure of Stroke Rehabilitation Care in Nebraska Hospitals
CAH 14-25 Beds (n=21)
47-689 Beds (n=15)
Weighted Proportion of Nebraska Hospitals (n=84)
42.9
No formal team
organization
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39.2
57.1
General rehabilitation
team
46.7
53.2
0
Dedicated stroke
rehabilitation team*
33.3
7.5
0
* Statistically significant p = 0.008
5
10 15 20 25 30 35 40 45 50 55 60 65
Proportion
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Use of Standardized Assessments and Access to Specialized Services
in Stroke Rehabilitation by Hospital Size
CAH 14-25 Beds (n=21)
47 - 689 Beds (n=15)
Weighted Proportion of Nebraska Hospitals (n=84)
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Access to Specialized
services*
27.4
17
14.2
Use of Standardized
assessments**
21.5
15.8
*Statistically significant p <.001 0
**Statistically significant p=.024
5
10
15
20
Frequency Count
25
30
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Purpose for Use of Standardized Assessments in Stroke
Rehabilitation by Team Structure
No Team (n=12) %
Team (n=24) %
50%
Measure progress and outcomes*
77%
27%
Evaluate effectiveness of practice*
55%
8%
Improve communication*
52%
Compare patient outcomes across
conditions*
2%
Compare performance across
professionals
2%
Compare performance across
departments
2%
6%
Conduct research
2%
5%
28%
8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
*p<0.05)
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Proportion of Sample Hospitals
Barriers to Use of Standardized Assessments in Stroke
Rehabilitation by Team Structure
No Team (n=12) %
Team (n=24) %
Interested in collaborating to increase use
of assessments*
Assessments more relevant to research
than clinical practice
Information collected does not inform plan
of care*
49%
76%
10%
9%
5%
22%
44%
43%
We do not have a database
33%
28%
Assessments are difficult to interpret
Assessments take too much time to
complete, analyze
16%
Lack familiarity with assessments*
30%
29%
75%
34%
33%
Lack access to library of assessments
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
*p<0.05)
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Proportion of Sample Hospitals
Stroke Rehabilitation Quality Improvement by Team Structure and Hospital Size
No Team
Team
CAH
47-689 Beds
44%
Admission Criteria*
73%
62%
41%
Discharge Criteria*
62%
51%
21%
Outcome Data Collected
18%
17%
% of stroke survivors discharged to
community†
Stroke rehabilitation QI project in past
year†
*p<.05 No team vs. team
† p<.05 47 – 689 Beds vs CAH
9%
1%
52%
47%
27%
59%
31%
48%
12%
0%
0%
71%
43%
16%
Re-hospitalization rate within 30 days of
discharge†
85%
29%
10%
20%
30%
40%
50%
60%
70%
80%
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90%
Strengths and Limitations
• Strengths
– Expert panel ensured face validity of instrument
– Stratified random sample enabled statewide est.
– Adequate response rate (68%)
• Limitations
– Assessed structure and process by self report
– Did not assess outcomes
– Small sample size limits power
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Summary
• Stroke survivors receiving rehabilitation in CAH setting
– Limited access to interprofessional team care
– Limited access to specialized services
– Less likely to receive standardized assessments
• Stroke rehabilitation care in CAHs
– Less likely to collect outcome data or engage in QI
• Barriers to use of standardized assessments do not vary
by hospital size
– Hospitals with formal teams use assessments to guide care
• 60% of hospitals interested in collaboration to improve
use of standardized assessments, access to services
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Conclusion
Due to short lengths of stay in IRFs, the structure
and process of stroke rehabilitation must be
consistent with the IOM competencies across the
continuum of settings.
Future research needed:
(1) Is team structure a determinant of post-IRF
stroke rehabilitation outcomes?
(2) What are the specialized service needs of rural
stroke survivors and their caregivers?
(3) How can technology facilitate use of stroke
rehabilitation standardized assessments?
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