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Initial physical grades and cognitive stages after acute stroke: who receives comprehensive rehabilitation services?

Stineman MG, Bates BE, Kurichi JE, Kwong PL, Ripley DC, Vogel WB, Xie D. Initial physical grades and cognitive stages after acute stroke: who receives comprehensive rehabilitation services? PM & R : the journal of injury, function, and rehabilitation. 2013 Dec 1; 5(12):1007-18.

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Abstract:

OBJECTIVES: To study the degree to which initial physical grades and cognitive stages of independence assessed by physical medicine and rehabilitation (PMandR) staff early after hospitalization for acute stroke relate to the decision to either provide rehabilitation in consultation or admission to a specialized rehabilitation unit (SRU) for comprehensive, high-intensity, multidisciplinary rehabilitation. DESIGN: An observational study. SETTING: Early rehabilitation assessment by PMandR staff during patients' acute hospitalization for stroke in 112 Veterans Affairs facilities. PATIENTS: The sample included 8,783 veterans who were assessed by PMandR staff. METHODS: Shortly after hospital admission, functional status was determined according to 7 physical grades and 7 cognitive stages of increasing independence. Patients' physical grades and cognitive stages ranged at initial PMandR assessment from the lowest and most dependent "I" through intermediate "II, III, IV, V, or VI," and ended with the highest at total independence "VII." To assess the statistically independent effects of physical grade and cognitive stage, a multivariable generalized estimating equation was applied to account for within Veterans Affairs facilities correlation and to adjust for demographics, stroke type, comorbidities, clinical events before PMandR assessment, and facility-related factors. MAIN OUTCOME MEASUREMENTS: The decision to admit patients to an SRU for comprehensive rehabilitation. RESULTS: Only 11.2% of those patients assessed after stroke were admitted to an SRU after the acute management phase. After statistical adjustment, patients at the lowest physical grade (I) of independence had a 9-fold increased odds of admission to an SRU compared with those at the highest combined physical grades VI/VII (adjusted odds ratio 9.15, 95% confidence interval 4.31-19.39). In contrast, patients at intermediate cognitive stages of independence were the most likely to be admitted to an SRU. The presence of an SRU within the treating Veterans Affairs facility was strongly related to admission. CONCLUSIONS: Patients' physical grades and cognitive stages assessed early after stroke are strong determinants of referral for comprehensive rehabilitation.





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