Examination of the association between two federal quality indicators and established patient functional indicators in inpatient rehabilitation facilities
DiVita, Margaret A.
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Objective: To examine risk factors for two quality of care indicators, the incidence of new or worsened pressure ulcers, and discharge to an acute care hospital. These measures are required by the Centers for Medicare and Medicaid Services (CMS) for report by inpatient rehabilitation facilities. Further, examine the association of new or worsened pressure ulcers with rehabilitation related outcomes. Background: Inpatient rehabilitation facilities (IRFs) are subject to federal mandates, including report of two quality indicators. Beginning in October 2012, all IRFs were required to begin tracking incidence of new or worsened pressure ulcers as a quality indicator. In addition, while still in the planning phases, CMS has proposed 30-day readmission as a quality measure. However, there is a paucity of data on either indicator as an indicator of quality of care among patients in rehabilitation. Methods: The Uniform Data System for Medical Rehabilitation (USDMR) data for patients discharged from IRFs in the United States from October 2008 to September 2011 were used for these analyses. In chapter three, risk factors for development of a new or worsened pressure ulcer during the rehabilitation stay were examined. In chapter four, the association of developing a new or worsened pressure ulcer with rehabilitation related outcomes, such as functional change from admission to discharge and discharge disposition from the IRF, community versus non-community were examined. In chapter five significant risk factors for early transfer to an acute care hospital among cardiac inpatient rehabilitation patients were examined. Results: In four separate models, one for all impairments and three separate for impairments at high risk of developing a new or worsened pressure ulcer (orthopedic cases, spinal cord injury cases, and amputation cases), admission FIM® total, a measure of functional disability, was the factor with the highest odds ratios associated with developing a new or worsened pressure ulcer. When compared to an admission FIM® total of at least an 80 (two hours of burden of care required or less), patients with an admission FIM® total of 37 to 79 and patients with an admission FIM® total of less than 37 were at significantly increased risk of developing a new or worsened pressure ulcer, odds ratio (OR) = 2.9 and 4.6, respectively (p < 0.001). In addition, patients who developed a new or worsened pressure ulcer were more likely to be discharged to a non-community setting (OR = 1.2, p < 0.01), more likely have a lower discharge FIM® total (discharge FIM® <78 OR = 1.8, p <0.001), and made significantly less functional gain from admission to discharge (4.5 FIM® points less, p <0.001) when compared to patients who did not develop a new or worsened pressure ulcer. Among cardiac patients, admission FIM® total was again the factor with the highest odds ratios associated with early discharge to an acute care hospital. When compared to patients with an admission FIM® total of at least 80, both patients with an admission FIM® total of 37 to 79 and patients with an admission FIM® total of less than 37 were at significantly increased risk of early transfer to an acute care hospital (OR = 7.0 and 15.1, respectively, p value < 0.001). Conclusions: These findings add to the understanding of two quality indicators identified as important for all inpatient rehabilitation facilities by federal regulations. The results emphasize that functional status at admission, as measured through the FIM® instrument was strongly associated with quality outcomes. (Abstract shortened by UMI.)