edicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2013;94:38-45

ORIGINAL ARTICLE

Assessing Stroke Patients for Rehabilitation During the AcuteHospitalization: Findings From the Get With TheGuidelineseStroke Program

Janet A. Prvu Bettger, ScD,a,b Lisa Kaltenbach, MS,b Mathew J. Reeves, PhD,c

Eric E. Smith, MD,d Gregg C. Fonarow, MD,e Lee H. Schwamm, MD,f

Eric D. Peterson, MD, MPHb

From aDuke University School of Nursing and bDuke Clinical Research Institute, Duke University, Durham, NC; cDepartment of Epidemiology, MichiganState University, East Lansing, MI; dDepartment of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; eDivisionof Cardiology, University of California, Los Angeles, CA; and fDivision of Neurology, Massachusetts General Hospital, Boston, MA.

Abstract

Objective: To examine the frequency and determinants of an assessment for rehabilitation during the hospitalization for acute stroke.

Design: Prospective cohort of patients admitted with acute stroke in the Get With The GuidelineseStroke (GWTG-Stroke) program from January

8, 2008, to March 31, 2011.

Setting: Acute hospitals (nZ1532) in the United States participating in the GWTG-Stroke program.

Participants: Adults with a stroke diagnosis (NZ616,982) from a GWTG-Strokeeparticipating acute hospital.

Interventions: Not applicable.

Main Outcome Measure: Documentation of an assessment for rehabilitation services during the acute hospitalization.

Results: Overall, almost 90% of stroke patients had documentation of an acute assessment for rehabilitation. In multivariable analysis, patients

significantly more likely to be assessed for rehabilitation were younger, male, black or of other nonwhite races (Asian, American Indian, Alaska

Native, Native Hawaiian, or Pacific Islander) when compared with white, independently ambulating before admission, and admitted from the

community. Patients who received a stroke consult, cared for in a stroke unit, and treated in the northeast region of the United States were also

more likely to be assessed.

Conclusions: There is evidence that rehabilitation was considered for 90% of acute stroke patients in this sample. Future research is needed to examine

what assessments are conducted and by whom, and how these are used to determine the appropriate level of rehabilitation care for their needs.

Archives of Physical Medicine and Rehabilitation 2013;94:38-45

ª 2013 by the American Congress of Rehabilitation Medicine

Supported in part by an Agency for Healthcare Research and Quality Mentored Scholar in

Comparative Effectiveness Research training grant awarded to Duke University (grant no.

K12HS019479). The Get With The GuidelineseStroke (GWTG-Stroke) program is currently sup-

ported in part by a charitable contribution from Janssen Pharmaceutical Companies of Johnson &

Johnson. GWTG-Stroke has been funded in the past through support from Boehringer-Ingelheim,

Merck, Bristol-Myers Squibb/Sanofi Pharmaceutical Partnership, and the AHA Pharmaceutical

Roundtable. These organizations did not and do not participate in the design, analysis, manuscript

preparation, or approval.

The contents of this manuscript are solely the responsibility of the authors and do not necessarily

represent the official views of the funding agencies.

No commercial party having a direct financial interest in the results of the research supporting this

article has or will confer a benefit on the authors or on any organization with which the authors are

associated.

0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Re

http://dx.doi.org/10.1016/j.apmr.2012.06.029

Stroke is the leading cause of long-term disability among adults.1 Inthe United States, 15% to 30% of stroke survivors report significantdisabilities, 20% require institutional care, and 23% to 35% arerehospitalized within 3 months of discharge from acute care.1-3

Central to a stroke patient’s functional recovery, psychologicaladjustment, and prevention of complications is rehabilitation care.A considerable body of evidence indicates better clinical outcomeswhen stroke patients are treated in a setting that provides coordi-nated, multidisciplinary stroke-related evaluation and services thatinclude rehabilitation.4 When initiated early after stroke, rehabili-tation can enhance the recovery process, minimize functionaldisability, and reduce long-term medical expenditures.5-7

habilitation Medicine

Assessed for rehabilitation 39

Evidence for early initiation of rehabilitation therapy for strokepatients is clear and well establishedda national guideline class Irecommendation supported with the highest level of evidence (levelA).8,9 Both the U.S. stroke rehabilitation clinical guidelines9 and thestroke systems of care task force10 acknowledged the need for earlystroke rehabilitation and recommended that all ischemic andhemorrhagic stroke patients receive a standardized screening andassessment during the acute hospitalization to determine the type andduration of rehabilitation needed.9,10 The clinical guidelines furtherrecommend that rehabilitation professionals be consulted, that theyassess needs, and then recommend the most appropriate plan of care,including the setting, to meet those needs. Beginning in 2013, theCenters for Medicaid and Medicare Services (CMS) have proposedto include an “assessed for rehabilitation” hospital reportingmeasure.11 To date, however, there has been no national study of thefrequency and predictors of whether patients with an acute strokereceive this recommended assessment during their hospital stay.

In this study, we examined rates of documented assessment forrehabilitationduring the acutehospitalizationand identifiedpatient andhospital characteristics associated with rehabilitation assessment ina national sample of stroke patients. These analyses will help establisha foundation for standardizing the in-hospital evaluation for strokepatients and better direct rehabilitation service use so as to maximizethe likelihood of beneficial patient and health system outcomes.

Methods

This study analyzes a prospective cohort of patients with datadocumented as part of the Get With The GuidelineseStroke(GWTG-Stroke) program. The program, initiated and supportedby the American Heart Association, is an ongoing, voluntary,continuous registry and performance improvement initiative foracute hospitals that collect patient-level data on characteristics,diagnostic testing, treatments, and in-hospital outcomes in patientshospitalized with stroke. Details of the design and conduct of theGWTG-Stroke program have been previously described.12-16 Eachparticipating hospital received either human research approval toenroll cases without individual patient consent under the commonrule, or a waiver of authorization and exemption from subsequentreview by their institutional review board. Outcome Sciences, Inc,serves as the data collection coordination center for the AmericanHeart Association/American Stroke Association Get With TheGuidelines programs. The Duke Clinical Research Institute servesas the data analysis center and has institutional review boardapproval to analyze the aggregate data for research purposes.

Case identification and data abstraction forGWTG-Stroke

Personnel at each GWTG-Stroke participating hospital weretrained to ascertain consecutive patients admitted with acute

List of abbreviations:

CI confidence interval

CMS Centers for Medicaid and Medicare Services

GWTG-Stroke Get With The GuidelineseStroke

ICD-9 International Classification of Diseases,

9th Revision

NIHSSS National Institutes of Health Stroke Scale score

OR odds ratio

PMT Patient Management Tool

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ischemic stroke using International Classification of Diseases, 9thRevision (ICD-9) discharge codes (433.x, 434.x, 436).12,17

Hospitals could choose whether or not to record data fromconsecutive hemorrhagic stroke (ICD-9 430.x, 431.x, 432.x) andtransient ischemic attack admissions with symptoms present onarrival (ICD-9 435.x). The eligibility of each stroke admissionidentified by discharge diagnosis or ICD-9 codes was confirmedby chart review before abstraction.

Patient data were abstracted by trained hospital personnel usingan internet-based PatientManagement Toola (PMT)with predefinedlogic features and user alerts to identify potentially invalid format orvalue entry. Sites received individual data quality reports to promotedata completeness and accuracy. Additional descriptions of the caseascertainment, data collection, and quality auditing methods havebeen previously published.12,17 Hospitals with data in this study hadbeen participating in GWTG-Stroke an average of 3.05 years(median, 2.85y; interquartile range, 1.79e4.33).

Study population

Documentation of an assessment for rehabilitation was optionaluntil 2008 for GWTG-Strokeeparticipating hospitals andmandatory thereafter. Consequently, our study cohort includedpatients admitted to a GWTG-Strokeeparticipating hospitalbetween January 1, 2008, and March 31, 2011. There were962,856 stroke admissions from 1540 participating hospitalsduring the study period. Patients with no stroke-related diagnosis(nZ18,180) and patients admitted with a transient ischemic attack(nZ206,217) were excluded from this study because the assess-ment for rehabilitation recommendation is specific to ischemicand hemorrhagic stroke patients.9 Patients who died in-hospital(nZ65,680), left the acute hospital against medical advice, dis-continued care, or were missing a discharge code or date(nZ13,005) or those transferred in from another acute carefacility or out to another acute or specialty (eg, psychiatric)facility (nZ65,280) were excluded because we were unable toconfirm eligibility for an acute assessment of rehabilitation.

Outcome: assessed for rehabilitation

The outcome for this study was documentation in the PMT thatthe hospital personnel identified in the medical record that the“patient was assessed for or received rehabilitation services.” Forthe GWTG-Stroke program, acceptable evidence in the medicalrecord for whether a patient was assessed for or received reha-bilitation included documentation of (1) a consult by rehabilitationservices; (2) an assessment by members of the rehabilitation team;(3) receipt of rehabilitation services during hospitalization; (4)transfer to a rehabilitation facility; (5) referral to rehabilitationservices after discharge; and (6) reasons the patient was ineligibleto receive services (symptoms resolved, patient returned to priorlevel of functioning, poor prognosis, or patient was unable totolerate rehabilitation). Hospital personnel reviewed patients’medical records for any one or combination of these 6 indicationsand documented in the PMT “yes” or “no.”

Patient characteristics

Patient characteristics in this study included both sociodemo-graphics and clinical characteristics. Preexisting clinical charac-teristics included documentation on admission of patients’

40 J.A. Prvu Bettger et al

medical history of 9 conditions and 1 behavior (smoking). Self-reported prestroke ambulatory status (unable to ambulate, withassistance from another individual, or independent with or withouta device) was also recorded. Three in-hospital measures of healthstatus included ambulatory status on admission, presence of strokesymptoms on admission, and initial National Institutes of HealthStroke Scale score (NIHSSS).

Hospital characteristics

Data on structural characteristics of the participating hospitals(number of beds, geographic region, hospital type as academic ornonacademic, and urban or rural designation using the rural-urbancommuting area codes) were obtained from the AmericanHospital Association database by the Duke Clinical ResearchInstitute and included in this study.18 This study also explored 7measures that reflect hospital-based decisions for care orprocesses that are largely outside the patient’s control but mayinfluence the likelihood of whether a patient is assessed forrehabilitation. These included whether the patient had documen-tation of an NIHSSS, had a stroke consult, received care ina stroke care unit, received thrombolytic therapy, had documen-tation that care was restricted to comfort measures only, haddocumentation of length of stay, and was referred for rehabilita-tion after the hospital discharge.

Analyses

Patient and hospital characteristics were compared between strokepatients who did and did not have documentation of an acuteassessment for rehabilitation. The P values are based on Pearsonchi-square tests for all categorical variables and the Wilcoxonsigned-rank test for all continuous/ordinal variables. All tests were2-sided and calculated by comparing only nonmissing values. TheP value <.01 was considered statistically significant because ofthe large size of the sample. Although ambulatory status onadmission, presence of stroke symptoms on admission, anddocumentation of care restricted to comfort measures wereexplored as additional indicators of stroke severity or careprocesses, they were only described in univariate tables because ofthe high proportion of missing data.

Multivariable logistic regression with generalized estimatingequations were performed to identify independent factors associ-ated with an acute assessment for rehabilitation while accountingfor within hospital correlation.19 Variables included age, sex, race,health insurance, patient location when stroke symptoms werediscovered, ambulatory status before admission, 9 preexistingmedical conditions and 1 behavior (smoking), whether the patienthad a stroke consult, received care in a stroke unit, length of stay,number of hospital beds, geographic region, hospital type, andurban designation. The regression model with these factors wasrepeated in the subset of patients with a documented NIHSSS(nZ278,473) to determine the independent relationship betweenstroke severity and the likelihood of a rehabilitation assessment.Missing ambulatory status before admission was imputed to ableto ambulate for patients who were able to ambulate independentlyat discharge. Missing insurance status for patients 65 years andolder was imputed to Medicare and imputed for patients youngerthan 65 years to private/other insurance, the most frequent healthinsurance categories for those age groups. Model discriminationwas assessed by determining the C-index for each model.

Multicollinearity was examined with the variation inflation factor.SAS software version 9.2b was used for all analyses.

Results

Of the 616,982 eligible stroke patients cared for in 1532 GWTG-Stroke participating hospitals, 82.7% were patients with anischemic stroke, 10.9% had an intracerebral hemorrhage, 3.4%had a subarachnoid hemorrhage, and 2.9% had a stroke nototherwise specified. The median age was 72 years (interquartilerange, 60e82y), 52% were women, and 70% were white. Analmost equal number of patients were Medicare beneficiaries(41.5%) or had private, veteran, or other health insuranceproviders (43.6%). Seven percent of this sample was admittedfrom a rehabilitation, subacute, or chronic long-term care facility,and 3.5% were unable to ambulate before their stroke.

Of the stroke patients in this GWTG-Stroke sample, 89.5% hadan assessment for rehabilitation documented. Tables 1 and 2present the descriptive statistics for the entire sample and thecomparison of patient and hospital characteristics for those withand without an acute assessment for rehabilitation services. Eachpatient and hospital characteristic was significantly associatedwith the outcome (P<.000). Univariate analyses of patient char-acteristics found that patients with an assessment were younger,and there were a higher proportion who were men, nonwhite, andambulating independently before admission than those without anassessment (see table 1). Stroke symptoms had resolved onadmission for approximately 5% of each group, those with andwithout an assessment. The mean NIHSSS � SD was higher(indicating more impairment) for those without an assessment(13.9�10.5) compared with those with an assessment (6.5�6.8).

A higher proportion of patients with a rehabilitation assess-ment had an NIHSSS documented, a stroke consult, or receivedcare in a stroke unit (see table 2). The mean � SD length of staywas longer for patients with an assessment for rehabilitationcompared with those without (6.2�7.3d vs 5.6�6.9d), but themedian length of stay was 4 days for both groups. Almost 60% ofpatients with a rehabilitation assessment were discharged topostacute care compared with 20% of patients without anassessment. The largest proportion of patients with an assessmentwere discharged directly home without services (40.26%). Thelargest proportion of patients without an assessment were dis-charged to inpatient or home hospice (nZ29,923, 46.2%), but thisnumber of patients was fewer than the proportion of patientswithout an assessment who also had care restricted to comfortmeasures during the acute stay (nZ37,222, 57.5%).

In multivariable analyses, several factors remained indepen-dently associated with the likelihood of rehabilitation assessment(table 3). With every 10-year increase in age, the likelihood of anacute assessment for rehabilitation declined (odds ratio [OR]Z.84; 95% confidence interval [CI], .82e.85). Women were alsoless likely to have an assessment documented (ORZ.89; 95% CI,.87e.90). Patients who were black or African American or ofother races compared with white were more likely to be assessed.Patients with Medicaid or Medicare were more likely to beassessed than those with private or other insurance. Patients whohad a stroke while in a rehabilitation, subacute, or long-term carefacility (patient location before admission) were half as likely tohave an assessment for rehabilitation (ORZ.45; 95% CI,.44e.47). Requiring assistance to ambulate or being unable toambulate before admission also decreased the likelihood of an

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Table 1 Patient characteristics comparing those with and without an assessment for rehabilitation

Variable, Level Overall NZ616,982

Assessed for

Rehabilitation

nZ552,222 (89.5%)

Not Assessed for

Rehabilitation

nZ64,760 (10.5%)

Sociodemographics

Age (y) 70.11�14.91 69.48�14.74 75.48�15.26

Sex (women) 321,556 (52.12) 28,3371 (51.31) 38,185 (58.96)

Race and ethnicity

White 432,110 (70.04) 382,310 (69.23) 49,800 (76.90)

Black or African American 100,947 (16.36) 94,126 (17.04) 6821 (10.53)

Other race: Asian 16,452 (2.67) 15,121 (2.74) 1331 (2.06)

Other race: Native Hawaiian, Pacific Islander, American

Indian, Alaskan Native, or unable to determine

25,145 (4.07) 22,437 (4.06) 2708 (4.18)

Hispanic 40,908 (6.63) 37,062 (6.71) 3846 (5.94)

Health insurance*

Self-pay/no insurance 39,030 (6.33) 36,545 (6.62) 2485 (3.84)

Medicare 256,312 (41.54) 225,729 (40.88) 30,583 (47.23)

Medicaid 52,868 (8.57) 47,813 (8.66) 5055 (7.81)

Private/VA/CHAMPUS/other insurance 268,772 (43.56) 242,135 (43.85) 26,637 (41.13)

Before admission patient in a rehabilitation, subacute,

or long-term care facility

42,991 (7.03) 31,166 (5.69) 11,825 (18.53)

Medical history (obtained on admission)

Ambulatory status before stroke admission*

Unable to ambulate 21,603 (3.50) 15,485 (2.80) 6118 (9.45)

Ambulating with person assist 31,590 (5.12) 25,870 (4.68) 5720 (8.83)

Ambulating independently with or without a device

(no person assist)

482,267 (78.17) 442,067 (80.05) 40,200 (62.08)

Previous stroke/transient ischemic attack 184,067 (32.51) 162,981 (32.14) 21,086 (35.72)

Atrial fibrillation or flutter 99,632 (17.60) 84,089 (16.58) 15,543 (26.33)

Coronary artery disease or prior myocardial infarction 151,284 (26.72) 133,825 (26.39) 17,459 (29.57)

Carotid stenosis 23,939 (4.23) 20,659 (4.07) 3280 (5.56)

Diabetes mellitus 185,716 (32.81) 168,890 (33.31) 16,826 (28.50)

Dyslipidemia 240,888 (42.55) 218,021 (43.00) 22,867 (38.73)

Heart failure 46,218 (8.16) 39,113 (7.71) 7105 (12.03)

Hypertension 459,115 (81.10) 412,122 (81.27) 46,993 (79.60)

Peripheral vascular disease 27,175 (4.80) 23,732 (4.68) 3443 (5.83)

Smoker 112,193 (19.82) 104,518 (20.61) 7675 (13.00)

In-hospital measures of health status

Ambulatory status at admission*

Unable to ambulate 123,958 (20.09) 102,479 (18.56) 21,479 (33.17)

Ambulating with person assist 94,591 (15.33) 90,081 (16.31) 4510 (6.96)

Ambulating independently with or without a device (no

person assist)

143,454 (23.25) 132,678 (24.03) 10,776 (16.64)

Stroke symptoms resolved on admission* 32,891 (5.33) 29,685 (5.38) 3206 (4.95)

First total NIHSSS* 7.10�7.42 6.49�6.75 13.86�10.52

NOTE. Values are mean � SD or n (%). All tests treat the column variable as nominal. All variables significant at P<.000. P values were calculated by

comparing only nonmissing row values.

Abbreviations: CHAMPUS, Civilian Health and Medical Program of the Uniformed Services; VA, Veterans Administration.

* A proportion of the data for these variables is not reported because of missing data: health insurance, 13%; ambulatory status before admission,

13%; ambulatory status at admission, 41%; stroke symptoms resolved, 28%; first NIHSSS, 48%.

Assessed for rehabilitation 41

assessment. Being a smoker, having hypertension, dyslipidemia,diabetes, or a prior stroke increased the odds of having anassessment, but a history of atrial fibrillation, carotid stenosis, orheart failure decreased a patient’s odds of having an assessment.Of the hospital characteristics examined, receiving care in a strokeunit increased the odds of an acute assessment (ORZ1.63; 95%CI, 1.55e1.71). Receiving a stroke consult on admission and carein the Northeast also increased the odds of an assessment. Vari-ation inflation factor values for each variable were low, indicating

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the degree of collinearity between variables was low. The C-indexof .6843 suggests that beyond the included factors there remaineda significant amount of unexplained variance in this model.

We also assessed these independent associations in a samplewith NIHSSS (nZ278,473). This model had better discrimination(CZ.7562). A higher NIHSSS (higher stroke severity) decreasedthe likelihood of receiving an acute assessment for rehabilitation(ORZ.91; 95% CI, .91e.91; c2Z386.35). After the NIHSSS wasincluded, prior stroke or transient ischemic attack, history of

Table 2 Hospital characteristics comparing those with and without an assessment for rehabilitation

Variable, Level Overall NZ616,982

Assessed for

Rehabilitation

nZ552,222 (89.5%)

Not Assessed for

Rehabilitation

nZ64,760 (10.5%)

Structural characteristics

Hospital beds* 438.62�337.23 442.51�337.12 404.46�336.32

Geographic region of the country

West 108,497 (17.59) 96,616 (17.50) 11,881 (18.35)

South 229,958 (37.27) 204,529 (37.04) 25,429 (39.27)

Midwest 122,634 (19.88) 109,702 (19.87) 12,932 (19.97)

Northeast 155,893 (25.27) 141,375 (25.60) 14,518 (22.42)

Hospital type*

Nonacademic 234,131 (37.95) 206,870 (37.46) 27,261 (42.10)

Academic 336,929 (54.61) 305,368 (55.30) 31,561 (48.74)

Urban/rural designation by rural urban commuting

area codes

Rural 25,923 (4.20) 22,072 (4.00) 3851 (5.95)

Urban 585,783 (94.94) 525,481 (95.16) 60,302 (93.12)

Care delivery

NIHSSS (total) documented 322,870 (52.33) 296,125 (53.62) 26,745 (41.30)

Patient had a stroke consult* 402,234 (65.19) 363,460 (65.82) 38,774 (59.87)

Received care in a stroke unit* 367,841 (59.62) 337,262 (61.07) 30,579 (47.22)

Received thrombolytic therapy, IA or IV tPA 35,412 (5.74) 32,503 (5.89) 2909 (4.49)

Comfort care measures onlyy 37,621 (6.10) 399 (0.08) 37,222 (57.48)

Referred for rehabilitation at discharge

No rehabilitation (discharge home no services) 244,063 (39.56) 222,319 (40.26) 21,744 (33.58)

Discharged to postacute care 341,195 (55.30) 328,245 (59.44) 12,950 (20.00)

Inpatient rehabilitation unit or facility 143,772 (26.04) 1514 (2.34)

Skilled nursing facility or Medicare equivalent

subacute unit (swing bed)

114,099 (20.66) 9034 (13.95)

Home with home health 63,651 (11.53) 1784 (2.75)

Long-term acute hospital 6723 (1.22) 618 (0.95)

No rehabilitation (poor prognosis) 31,446 (5.10) 1411 (0.26) 30,035 (46.38)

Discharge to hospice 9 (0.01) 29,923 (46.21)

Discharge to long-term care 1402 (0.25) 112 (0.17)

Length of stay (d) 6.10�7.29 6.16�7.34 5.62�6.87

NOTE. Values are mean � SD or n (%). All tests treat the column variable as nominal. All variables are significant at P<.000. P values were calculated by

comparing only nonmissing row values.

Abbreviations: IA, intra-arterial; IV, intravenous; tPA, tissue-type plasminogen activator.

* A proportion of the data for these variables is not reported because of missing data: number of hospital beds, 10%; hospital type, 7%; stroke

consult, 9%; stroke unit care, 9%.y Care restricted to comfort measures only was determined by earliest documentation of comfort measures on day 1, 2, 3, after day 3, or unclear

timing. All other patients (93.9%) were recorded by hospital personnel as comfort measures not documented or unable to determine if comfort measures

were documented, and <1% of patients were missing data.

42 J.A. Prvu Bettger et al

carotid stenosis, and a stroke consult on admission were no longersignificant. The only hospital characteristics that predicted receiptof a rehabilitation assessment in this model were longer length ofstay (ORZ1.03; 95% CI, 1.02e1.04) and receiving care ina stroke unit (ORZ1.38; 95% CI, 1.29e1.48).

Discussion

Poststroke complications and impairment can be minimized whenrehabilitation professionals are consulted and therapeutic inter-vention is initiated early in acute care.9,20,21 Early initiation oftherapy is a class I level A recommendation for stroke care.9 Ourstudy found that most stroke patients in this U.S. sample have

documentation of an acute assessment for rehabilitation. We alsoidentified patient and hospital factors that were associated withreceiving an assessment.

In this study, 90% of stroke patients discharged alive from thehospital had documentation of an assessment for rehabilitation,that rehabilitation was provided, or there was a referral for post-acute rehabilitation. This translates to more than 20,000 U.S.stroke admissions a year not being assessed for rehabilitation. Ofthose without an assessment, 62% were ambulating independentlybefore admission, and only 20% were discharged to a setting orservice that provides postacute care as defined by CMS. More than40% were discharged to hospice. Patients without an acuteassessment were also more likely to be older and exhibiting othercharacteristics of chronic illness such as comorbid heart failure.

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Table 3 Multivariable logistic regression demonstrating characteristics independently associated with the receipt of an assessment for

rehabilitation

Multivariable Model

Variable* OR Lower (95% CI) Upper (95% CI) P c2

Patient characteristics

Age (per 10-y increase) 0.84 0.82 0.85 <.000 284.94

Sex (woman) 0.89 0.87 0.90 <.000 131.93

Race (reference: white) 176.03

Black or African American 1.38 1.37 1.38 <.000

Other (Asian, American Indian, Alaska Native, Native

Hawaiian, or Pacific Islander)

1.05 1.01 1.10 .007

Health insurance (reference: private/VA/other) 34.01

Medicaid 1.08 1.04 1.12 .000

Medicare 1.07 1.05 1.10 <.000

Before admission patient in a rehabilitation, subacute,

or long-term care facility

0.45 0.44 0.47 <.000 460.04

Medical history

Ambulatory status before admission (reference: independent)

With assistance 0.73 0.70 0.76 <.000 143.48

Unable to ambulate 0.44 0.42 0.46 <.000 394.78

Previous stroke/transient ischemic attack 1.03 1.01 1.05 .003 8.15

Atrial fibrillation or flutter 0.81 0.79 0.83 <.000 202.67

Carotid stenosis 0.79 0.73 0.87 <.000 18.78

Diabetes mellitus 1.21 1.19 1.24 <.000 228.62

Dyslipidemia 1.19 1.16 1.21 <.000 193.99

Heart failure 0.85 0.82 0.88 <.000 78.30

Hypertension 1.22 1.19 1.25 <.000 176.30

Smoker 1.18 1.14 1.21 <.000 98.45

Hospital characteristics

Patient had a stroke consult 1.33 1.26 1.41 <.000 83.80

Received care in a stroke unit 1.63 1.55 1.71 <.000 181.08

Length of stay (d) 1.01 1.00 1.01 <.000 17.76

Geographic region (reference: West) 53.41

Northeast 1.33 1.19 1.48 <.000

Academic hospital type (reference: nonacademic) 1.00 0.92 1.08 .967 0.00

Urban designation (reference: rural) 1.11 0.98 1.26 .117 2.24

Abbreviation: VA, Veterans Administration.

* Not significant at P<.01 and not reported above: self-pay/no health insurance (when compared with private/VA/other insurance), history of

coronary artery disease or prior myocardial infarction, history of peripheral vascular disease, number of hospital beds, hospitals with urban designation

(compared with rural), academic hospital type (compared with nonacademic), and hospitals in the Midwest or Southern regions (compared with West).

Assessed for rehabilitation 43

These patients are at high risk for preventable complications andhospital readmissions.22 We also found that those cared for ina designated stroke unit were more likely to have a rehabilitationassessment. This finding is consistent with those of others,4,23 andis indicative of other measures demonstrating that specializationof care results in more complete, high-quality services.

In this sample, it appears hospitals inconsistently applied thecriteria when reviewing medical records for evidence of anassessment. If we were to add the 1514 patients without anassessment but who were transferred or discharged to inpatientrehabilitation (medical record options 4 and 5), the 29,923 patientsdischarged to hospice as evidence of poor prognosis (option 6), orthe 37,222 patients with comfort care measures as evidence ofbeing unable to tolerate rehabilitation (option 6), then almost 95%of patients would have been “assessed for or received rehabilita-tion” using the current definition. However, the current structureof the question and definition merits consideration. First, theinclusion criteria give equal credit for a physician determination

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of prognosis or ability to tolerate rehabilitation with a rehabilita-tion team member’s patient assessment and receipt of therapy. Anassessment of needs, functioning, and disability should becompleted by trained clinicians to be able to determine the type ofrehabilitation services needed and the optimal frequency, intensity,and duration. Research has not confirmed whether this assessmentand determination of service need can be completed by clinicianswithout rehabilitation training. Second, equal credit is given forthe receipt of rehabilitation postdischarge. Giving credit fordischarge to a postacute rehabilitation facility in the absence ofany assessment or therapy in the acute setting might lead to worsepatient outcomes if therapy is delayed until after discharge.Finally, assessing patients’ needs such as safety, equipment,training, functioning, and disability are separate and differentevaluations than determining the need for rehabilitative services.The current structure of the question and criteria for inclusion donot distinguish one component from the other. It is likely thatacross the 1500þ participating hospitals, there is substantial

44 J.A. Prvu Bettger et al

variability in the process and the quality of this assessment ofrehabilitation needs and factors that are considered for recom-mending rehabilitation therapy. Without a standard process,assessment, and algorithm for referral in the acute hospital, thereliability of referral will be low and the likelihood of misuse ofrehabilitation services could be highdvarying potentially fromhospital to hospital and even from patient to patient within thesame institution. Quality metrics that isolate each component inthe process (ie, refer stroke patients to rehabilitation professionalsin acute care; rehabilitation professionals complete assessment offunctioning and disability; stroke team uses assessment to makean evidence-based recommendation for rehabilitation servicesbased on need) may be important for examining both underuse ofeffective care and overuse of ineffective care at a significant costto both patients and the health system.

Several definitions for an “assessed for rehabilitation” acutestroke care quality measure currently exist in the United States.Since 2004, states funded to implement the Paul CoverdellNational Acute Stroke Registry have measured whether patients atparticipating hospitals were assessed for or received rehabilita-tion, and of those included, hospitals reported 94% adherence in2008.24 An assessed for rehabilitation measure was added to theAmerican Heart Association GWTG-Stroke hospital-based dataregistry and quality improvement program in 2008, and perfor-mance on this quality measure was also 94% in 2008.1 The JointCommission (Joint Commission on Accreditation of HealthcareOrganizations) has included the assessed for rehabilitationmeasure for acute hospital stroke center certification since 2006,and the National Quality Forum endorsed the measure in 2008 aspart of a measure set for acute stroke care.25 Performance forJoint Commission stroke-certified hospitals is not publicly re-ported, and a specific benchmark has not been established by theNational Quality Forum for the “assessed for rehabilitation”quality measure. The 3 programs, Coverdell, GWTG-Stroke, andJoint Commission, use different definitions for evidence of anassessment, the denominator exclusion criteria differ, and noneassess patients’ functioning separate from assessing and deter-mining the need for rehabilitative services. An important oppor-tunity exists for all acute stroke quality initiatives to achieveconsensus on defining an evidence-based quality measure that willbest support patient-centered outcomes and appropriate use ofrehabilitation services both in the hospital and after discharge.Unfortunately, at this time, it is not clear what performance wouldbe if all programs endorsed the same inclusion and exclusioncriteria. Nor is it clear what performance would be if the onlymedical record indication for an assessment for rehabilitationwould be functional status assessments by members of the reha-bilitation team. A more stringent and specific measure wouldeither reveal much lower compliance rates or a more accurateaccount of who was assessed.

Study limitations

This study has several limitations. Given the inherent limitationsof the assessment for rehabilitation question’s structure, we areunable to discern who was appropriately assessed, received therecommended type and intensity of therapy during acute care, andwas appropriately referred for rehabilitation care at discharge.Participation in GWTG-Stroke is voluntary, and hospitals thatparticipate are more likely to have a strong interest in stroke andquality improvement; therefore, participating hospitals may not be

representative of the overall U.S. hospital population. However,patient admissions in GWTG-Stroke appear to be representative ofthe overall U.S. stroke population in terms of age, demographics,and medical comorbidities.13 No external audit of case ascer-tainment is in place, and variation in patient selection at the localhospital level could have occurred.

Although the commitment to quality may be high in GWTG-Strokeeparticipating hospitals, we did find that the assessment ofstroke severity as documented by the NIHSSS (also a class I levelA recommendation) was frequently missing. Restricting oursample to patients with stroke severity documented would haveintroduced significant selection bias. Similarly, this study used anassess for rehabilitation analysis construct where patients withacute care restricted to comfort measures only were still consid-ered eligible for a rehabilitation assessment. Although clinicalguidelines state that patients with severe stroke, who are maxi-mally dependent for basic activities of daily living and have poorprognosis for functional recovery, are not candidates for rehabil-itation therapies,9 the level of evidence for completing anassessment for rehabilitation, or tailoring an assessment for thesepatients has not been examined. It is likely that care partners couldbenefit from education and training from rehabilitation profes-sionals in several areas, from swallowing techniques to passiverange of motion to assisted self-care tasks. As such, patients withcomfort care measures were considered eligible for an assessmentand not excluded.

Conclusions

Most patients in this sample had documentation of an assessmentfor rehabilitation as it is currently defined. Patients without anacute assessment for rehabilitation were more likely to be unableto ambulate or ambulating with assistance before admission;admitted from a chronic care, inpatient rehabilitation, or skillednursing facility; did not receive a stroke consult or care in a strokeunit; and were treated at a Western region hospital (compared withthe Northeast). This study will ideally facilitate hospital qualityimprovement efforts that actively engage members of the reha-bilitation team to address barriers to completing an acute assess-ment for rehabilitation for all patients. This study also serves asthe foundation for a discussion on how to better define whatconstitutes an acute assessment for rehabilitation, a discussion thatmay be crucial before the start of CMS-required hospital reportingof acute stroke care. Mixed-method study designs are needed toexplore the unexplained variance related to acute assessment andprovision of rehabilitation, and the decision process that occurs.Future research is needed to examine what assessments are con-ducted and by whom, and how these are used to determine theappropriate level of rehabilitation care for patients’ needs.

Suppliers

a. Quintiles Outcome, 201 Broadway, 5th Fl, Cambridge,MA 02139.

b. SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513.

Keywords

Quality of health care; Rehabilitation; Stroke

www.archives-pmr.org

Assessed for rehabilitation 45

Corresponding author

Janet A. Prvu Bettger, ScD, Duke University School of Nursing,311 Trent Dr, DUMC 3322, Durham, NC 27710. E-mail address:janet.bettger@duke.edu.

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