Transferring Inpatient Rehabilitation Facility Cancer Patients Back to Acute Care (TRIPBAC)

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    ,atko, PhD

    Conclusions: Motor Functional Independence Measure score on admission is the best

    A.A. Samuel Oschin Comprehensive CancerInstitute, Cedars-Sinai Medical Center, 8700Beverly Blvd, Suite AC 1109, Los Angeles, CA90048. Address correspondence to: A.A.;e-mail: arash.asher@cshs.orgDisclosures related to this publication: grant(money to institution), Donna & Jesse GarberAward in Cancer ResearchDisclosures outside this publication: grants/grants pending (money to institution), Co-I fora National Cancer Institute RO1 grant studyingcancer-related fatigue

    P.S.R. Department of Rehabilitation, Cedars-Sinai Medical Center, Los Angeles, CA

    Post Acute Care, American Congress ofRehabilitation Medicine; consultancy, UniformData System for Medical Rehabilitation, com-mission on accreditation for rehabilitation fa-cilities; employment, Cedars-Sinai MedicalCenter, University of Southern California(USC), Trident University International; grants/grants pending (money to institution), sub-contract National Institutes of Health-ICAREstudy, USC primary grant

    C.B. Samuel Oschin Comprehensive CancerInstitute, Cedars-Sinai Medical Center, LosAngeles, CADisclosure: nothing to disclose

    G.Z. Department of Rehabilitation, Cedars-Sinai Medical Center, Los Angeles, CADisclosure: nothing to disclose

    R.V.R. Department of Rehabilitation, Cedars-Sinai Medical Center, Los Angeles, CADisclosure: nothing to disclose

    A.R. Samuel Oschin Comprehensive CancerInstitute, Cedars-Sinai Medical Center, LosAngeles, CA

    publication: employ-ical Center; grants/o author and institu-

    a & Jesse Garberh

    October 24, 2013;14.PM&R1934-1482/14/$36.00

    Printed in U.S.A.

    2014 by the American Academy of Physical Medicine and RehabilitationVol. -, 1-6,- 2014 the most profound functional decline as a result of their cancer or its treatment,evidence and guidelines for the most appropriate and cost-effective use of rehabilitationservices are needed. The most intensive level of rehabilitation, known as acute rehabili-tation, is furnished at an inpatient rehabilitation facility (IRF) [13]. Care at an IRF providesan intense level of daily rehabilitation that typically focuses on improving overall functionand integrates comprehensive medical care such as pain management, wound care, res-piratory care, and psychological services.

    (money to author and insDisclosures outside thisment, Cedars Sinai Medgrants pending (money ttion), NIHResearch support: DonnAward in Cancer Researc

    Submitted for publicationaccepted January 12, 20issues related to the rehabilitation of patients with cancer have arisen. For patients who Disclosures related to this publication: granttitution), NIHpresence of a feeding tube or a modied diet.PM R 2014;-:1-6


    Cancer and its treatment sequelae can have a profound inuence on a persons functionalstatus and quality of life. Historically, the rehabilitation of patients with cancer wasmarginalized because of the perception that cancer represented an inevitably progressiveand terminal disease [1]. In 2012, the incidence of cancer cases in the United States wasestimated at more than 1.6 million, with approximately 14 million cancer survivors alivetoday [2]. As cancer treatments have become more sophisticated and mortality rates inisolation are no longer an adequate outcome measure, issues related to quality of life andfunction have become increasingly more relevant for patients and clinicians. For manypatients, the fear of death is outweighed by the fear of loss of independence and functionaldecline [3]. Rehabilitation services can help patients with cancer and long-term survivorsregain and improve physical, psychosocial, and vocational functioning within the limita-tions imposed by the disease and its treatment [4-12].

    With improved survival rates and an increasing number of cancer survivors, a myriad ofpredictor for TRIPBAC in patients with cancer admitted to our IRF, followed by the Disclosures outside this publication: boardmembership, California Hospital AssociationeTransferring Inpatient Rehabilitation Facility CPatients Back to Acute Care (TRIPBAC)Arash Asher, MD, Pamela S. Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQCatherine Bresee, MS, Garret Zabel, Richard V. Riggs, MD, Andre Rog

    Objective: To determine predictive factors for TRansferring Inpatient rehabilitationfacility (IRF) cancer Patients Back to Acute Care (TRIPBAC).Design: A retrospective chart review of patients with cancer admitted to an IRF from2009 to 2010 because of a functional impairment that developed as a direct consequence oftheir 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 onanalysis 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 forTRIPBAC were postneurosurgical complications (31%). Factors associated with TRIPBACwere a motor Functional Independence Measure score of 35 points or lower on admission(odds ratio 4.01, 95% condence interval 1.79-8.98; P .001) and the presence ofa feeding tube or a modied diet (odds ratio 3.18, 95% condence interval 1.44-7.04;P .004).

  • included in the CMS 60% rule. Therefore more research is

    2. What is the frequency of TRIPBAC?

    2 Asher et al TRANSFERRING IRF CANCER PATIENTS BACK TO ACUTE CAREInsurers and IRFs have admission criteria to identifypatients who would most likely benet from care at the IRFlevel [14]. Two key requirements include the need for closemedical supervision by a physician with specialized trainingin rehabilitation and the ability of the patient to toleratea therapy program consisting of at least 3 hours of therapyper day, 5 days per week (ie, the 3-hour rule). Theserequirements can result in a difcult predicament for phys-iatrists, in that the medical problem must be signicantenough to require physician supervision but stable enoughto not interfere with the patients ability to attend andtolerate an average of 3 hours of rehabilitation per day.

    It is thus important for physicians who make decisionsregarding the candidacy of patients with cancer for IRFadmission to identify patients who can complete the pro-grammatic requirements for an IRF. Compared with patientswho have diagnoses other than cancer, research hasdemonstrated a higher rate of transfer of patients with cancerfrom the IRF back to acute care as the result of medicalproblems and complications, with rates ranging from21%-41% [9,11,15,16]. In contrast, 10%-19%, 10%-11%,and 12%-22% of patients with stroke, traumatic spinal cordinjury, and traumatic brain injury, respectively, requiredtransfer back to acute care [15,17-19].

    A higher transfer rate from an IRF is an indication ofmedical instability or specialized medical or proceduralinterventions. Patients with cancer generally tend to have amore inherently unpredictable medical course [5,9,11,13].Identifying risk factors that might predict a poor likelihoodof successfully completing an inpatient rehabilitation coursewould be very valuable for physiatrists, allowing them tomake evidence-based decisions regarding successful inpa-tient rehabilitation admission for patients with cancer. Thisability is also important because of its impact on coordina-tion of care and decision making regarding the use of limitedresources.

    A retrospective study completed within a rehabilitationunit of a comprehensive cancer center identied severalsignicant risk factors associated with TRansferring IRFcancer Patients Back to Acute Care (TRIPBAC): a low albu-min level, an elevated creatinine level, tube feeding, and useof a Foley catheter [9]. However, this tertiary cancer center isatypical in that it carries a diagnostic criteria waiver.Therefore the IRF at this hospital did not have to follow the75% rule (later changed to the 60% rule). In brief, the 75%rule put forth by the Centers for Medicare and MedicaidServices (CMS) stipulated that at least 75% of the IRFsoverall patient population must have any one of 13 speciedconditions [20]. Cancer is not one of the 13 conditions,although some patients such as those with brain tumors,spinal cord tumors, amputation, or pathologic hip fracturesfall within the 13 CMS categories. Many patients with cancerexperience problems such as severe deconditioning, gait and

    mobility problems, decits in activities of daily living,generalized weakness, and asthenia that are not included3. What are the reasons for TRIPBAC?4. Are any laboratory and clinical factors associated with


    We hypothesized that among cancer rehabilitationpatients of a typical IRF, an elevated level of creatinine, a lowlevel of albumin, tube feeding, or use of a Foley catheter canpredict transfer to acute care from the IRF.


    After obtaining approval from our institutional review board,we used a retrospective design to perform this study. The IRFPatient Assessment Instrument (IRF-PAI), which representsthe source of the majority of the information for this study, isrequired to be fully completed per Medicare regulations forevery licensed IRF in the United States [21]. All staff memberswho enter data into the IRF-PAI at our institution have beencredentialed through the Uniform Data System for MedicalRehabilitation [22]. Etiologic diagnosis and comorbid con-ditions from the IRF-PAI are completed by certied coderswith the use of standard coding guidelines.

    Study Population

    Inclusion Criteria. Patients with any cancer diagnosis whowere admitted for the rst time to the IRF at our institutionfrom 2009 through 2010 were reviewed for study eligibility.Our institution is a community-based academic tertiary carefacility that includes an inpatient rehabilitation unit withinneeded to determine whether these clinical factors areassociated with transfer out of an IRF in a setting outside ofan exclusive cancer institution. Similarly, categorizing andconrming the most common reasons for TRIPBAC mayimprove awareness of the most signicant medical compli-cations that can affect the rehabilitative potential of theirpatients with cancer. In addition, anticipatory strategies canbe implemented to prevent and manage these complications.

    The goal of this retrospective study was to answer thefollowing questions regarding patients with cancer in atypical IRF:

    1. What are the characteristics of patients with cancer in theIRF?among the 13 specied conditions [6]. Therefore thesepatients are less often candidates for IRF admission in mosthospitals throughout the United States that do not have anexemption for the diagnostic criteria waiver.

    The predictive value of the factors identied in the studyby Guo et al [9] at the tertiary cancer center has not beenevaluated for patients with cancer in a hospital that isthe hospital. Patients were screened for eligibility in reversechronologic order from December 31, 2010. We extracted

  • associated with TRIPBAC:

    BAC was identied among any specic category of patients

    PM&R Vol. -, Iss. -, 2014 31. Length of stay, in days, in acute care before admission tothe IRF; these data were collected from the IRF-PAI.

    2. Laboratory values (ie, blood urea nitrogen, creatinine,albumin, prealbumin, hemoglobin, sodium, potassium,chloride, bicarbonate, calcium, absolute neutrophilcount, white blood cell count, and platelet count) uponadmission to the IRF; these data were obtained from thepatient chart.

    3. The presence or absence of metastatic disease status wasobtained by reviewing documentation from the patientchart.

    4. The presence of a Foley catheter and use of tube feedingupon admission to the IRF were obtained from the IRF-PAI.

    5. Functional Independence Measure (FIM) total, motor,and cognitive scores upon admission to the IRF from thethese diagnostic data from the IRF-PAI by reviewing theetiologic diagnosis and comorbid conditions.

    Exclusion Criteria. Only patients who were admitted to theIRF because of a functional impairment that developed as adirect consequence of their cancer or its treatment wereanalyzed. For example, a patient with a previous history ofbreast cancer in remission who was admitted to the IRF fortraumatic brain injury rehabilitation unrelated to her previ-ous cancer diagnosis did not qualify. The inclusion andexclusion criteria were applied by a physiatrist, whoreviewed each case individually. A sample of patients whowere screened for the study was reviewed by a secondphysiatrist to conrm that the exclusion and inclusioncriteria were met. A 100% concordance rate was foundbetween the 2 clinicians.

    Data Collected

    To characterize the patients with cancer in the IRF, thefollowing information was collected from the IRF-PAI:primary cancer diagnosis, complications during the IRFstay, age, ethnicity, gender, and marital status. The fre-quency and reasons for TRIPBAC also were obtained fromthe IRF-PAI. Reasons for TRIPBAC were grouped into thefollowing categories: oncology treatment (chemotherapy,surgery, or radiation therapy) or an unanticipated med-ical complication attributable to cardiac complications,neurosurgical complications, infection, seizure, venousthromboembolism, respiratory distress, gastrointestinalcomplications, wound complications, change in mentalstatus, tumor recurrence or progression, or other. Thereason for transfer was determined by a review of the pa-tient chart. The following information was collected todetermine whether any laboratory and clinical factors wereUDS-PRO database (The UDS-PRO System; Amherst,NY).with cancer. The average age of patients admitted to the IRFwas 61.4 years (standard deviation, 15.9 years). The medianlength of stay for previous acute care was 8 days, with arange of 0-137 days. The median length of stay in the IRFwas 10.5 days, with a range of 0.5-44 days. A total of 31% ofthe patients had metastatic disease, 22% had a Foley catheterupon admission, and 5% had a feeding tube upon admis-sion. Table 2 summarizes the laboratory values of patients atthe time of admission to the rehabilitation unit.

    Overall, we observed a TRIPBAC rate of 17.4% (95%condence interval [CI], 11.9-22.9), which is signicantlygreater than the overall national 2010 rate of 10.3%(P .003) and our hospital TRIPBAC rate of 9.9% [22].Reasons for TRIPBAC are summarized in Table 3. The mostfrequent reason for TRIPBAC was related to post-neurosurgical complications (eg, hematoma, cerebrospinaluid leak, and hydrocephalus).

    Table 4 summarizes the risks associated with TRIPBACfrom a variety of clinical factors. None of the followingfactors was associated with TRIPBAC: gender, tumor diag-nosis, presence of metastatic disease or the use of a Foleycatheter. No laboratory value at the time of admission to theStatistical Methods

    All data were rst inspected graphically to conrm overalldata distributions and investigate for outliers. Data are pre-sented as counts...


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