Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2013;94:38-45

ORIGINAL ARTICLE

Assessing Stroke Patients for Rehabilitation During the Acute Hospitalization: Findings From the Get With The GuidelineseStroke 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, Michigan State University, East Lansing, MI; dDepartment of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; eDivision of 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 signicantly more likely to be assessed for rehabilitation were younger, male, black or of other nonwhite races (Asian, American Indian, Alaska Native, Native Hawaiian, or Pacic 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 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 supported 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/Sano 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 ofcial views of the funding agencies. No commercial party having a direct nancial interest in the results of the research supporting this article has or will confer a benet on the authors or on any organization with which the authors are associated.

Stroke is the leading cause of long-term disability among adults.1 In the United States, 15% to 30% of stroke survivors report signicant disabilities, 20% require institutional care, and 23% to 35% are rehospitalized within 3 months of discharge from acute care.1-3 Central to a stroke patients functional recovery, psychological adjustment, and prevention of complications is rehabilitation care. A considerable body of evidence indicates better clinical outcomes when stroke patients are treated in a setting that provides coordinated, multidisciplinary stroke-related evaluation and services that include rehabilitation.4 When initiated early after stroke, rehabilitation can enhance the recovery process, minimize functional disability, and reduce long-term medical expenditures.5-7

0003-9993/13/$36 - see front matter 2013 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2012.06.029

Assessed for rehabilitation Evidence for early initiation of rehabilitation therapy for stroke patients is clear and well establishedda national guideline class I recommendation supported with the highest level of evidence (level A).8,9 Both the U.S. stroke rehabilitation clinical guidelines9 and the stroke systems of care task force10 acknowledged the need for early stroke rehabilitation and recommended that all ischemic and hemorrhagic stroke patients receive a standardized screening and assessment during the acute hospitalization to determine the type and duration of rehabilitation needed.9,10 The clinical guidelines further recommend that rehabilitation professionals be consulted, that they assess needs, and then recommend the most appropriate plan of care, including the setting, to meet those needs. Beginning in 2013, the Centers for Medicaid and Medicare Services (CMS) have proposed to include an assessed for rehabilitation hospital reporting measure.11 To date, however, there has been no national study of the frequency and predictors of whether patients with an acute stroke receive this recommended assessment during their hospital stay. In this study, we examined rates of documented assessment for rehabilitation during the acute hospitalization and identied patient and hospital characteristics associated with rehabilitation assessment in a national sample of stroke patients. These analyses will help establish a foundation for standardizing the in-hospital evaluation for stroke patients and better direct rehabilitation service use so as to maximize the likelihood of benecial patient and health system outcomes.

39 ischemic stroke using International Classication of Diseases, 9th Revision (ICD-9) discharge codes (433.x, 434.x, 436).12,17 Hospitals could choose whether or not to record data from consecutive hemorrhagic stroke (ICD-9 430.x, 431.x, 432.x) and transient ischemic attack admissions with symptoms present on arrival (ICD-9 435.x). The eligibility of each stroke admission identied by discharge diagnosis or ICD-9 codes was conrmed by chart review before abstraction. Patient data were abstracted by trained hospital personnel using an internet-based Patient Management Toola (PMT) with predened logic features and user alerts to identify potentially invalid format or value entry. Sites received individual data quality reports to promote data completeness and accuracy. Additional descriptions of the case ascertainment, data collection, and quality auditing methods have been previously published.12,17 Hospitals with data in this study had been 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 optional until 2008 for GWTG-Strokeeparticipating hospitals and mandatory thereafter. Consequently, our study cohort included patients admitted to a GWTG-Strokeeparticipating hospital between January 1, 2008, and March 31, 2011. There were 962,856 stroke admissions from 1540 participating hospitals during 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 assessment for rehabilitation recommendation is specic to ischemic and hemorrhagic stroke patients.9 Patients who died in-hospital (nZ65,680), left the acute hospital against medical advice, discontinued care, or were missing a discharge code or date (nZ13,005) or those transferred in from another acute care facility or out to another acute or specialty (eg, psychiatric) facility (nZ65,280) were excluded because we were unable to conrm eligibility for an acute assessment of rehabilitation.

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

Outcome: assessed for rehabilitation

The outcome for this study was documentation in the PMT that the hospital personnel identied in the medical record that the patient was assessed for or received rehabilitation services. For the GWTG-Stroke program, acceptable evidence in the medical record for whether a patient was assessed for or received rehabilitation included documentation of (1) a consult by rehabilitation services; (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 rehabilitation services after discharge; and (6) reasons the patient was ineligible to receive services (symptoms resolved, patient returned to prior level of functioning, poor prognosis, or patient was unable to tolerate rehabilitation). Hospital personnel reviewed patients medical records for any one or combination of these 6 indications and documented in the PMT yes or no.

Case identication and data abstraction for GWTG-Stroke

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

List of abbreviations:
CI CMS GWTG-Stroke ICD-9 condence interval Centers for Medicaid and Medicare Services Get With The GuidelineseStroke International Classication of Diseases, 9th Revision NIHSSS National Institutes of Health Stroke Scale score OR odds ratio PMT Patient Management Tool

Patient characteristics
Patient characteristics in this study included both sociodemographics and clinical characteristics. Preexisting clinical characteristics included documentation on admission of patients

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40 medical history of 9 conditions and 1 behavior (smoking). Selfreported prestroke ambulatory status (unable to ambulate, with assistance from another individual, or independent with or without a device) was also recorded. Three in-hospital measures of health status included ambulatory status on admission, presence of stroke symptoms on admission, and initial National Institutes of Health Stroke Scale score (NIHSSS).

J.A. Prvu Bettger et al Multicollinearity was examined with the variation ination factor. SAS software version 9.2b was used for all analyses.

Results
Of the 616,982 eligible stroke patients cared for in 1532 GWTGStroke participating hospitals, 82.7% were patients with an ischemic stroke, 10.9% had an intracerebral hemorrhage, 3.4% had a subarachnoid hemorrhage, and 2.9% had a stroke not otherwise specied. The median age was 72 years (interquartile range, 60e82y), 52% were women, and 70% were white. An almost equal number of patients were Medicare beneciaries (41.5%) or had private, veteran, or other health insurance providers (43.6%). Seven percent of this sample was admitted from 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% had an assessment for rehabilitation documented. Tables 1 and 2 present the descriptive statistics for the entire sample and the comparison of patient and hospital characteristics for those with and without an acute assessment for rehabilitation services. Each patient and hospital characteristic was signicantly associated with the outcome (P<.000). Univariate analyses of patient characteristics found that patients with an assessment were younger, and there were a higher proportion who were men, nonwhite, and ambulating independently before admission than those without an assessment (see table 1). Stroke symptoms had resolved on admission for approximately 5% of each group, those with and without an assessment. The mean NIHSSS SD was higher (indicating more impairment) for those without an assessment (13.910.5) compared with those with an assessment (6.56.8). A higher proportion of patients with a rehabilitation assessment had an NIHSSS documented, a stroke consult, or received care in a stroke unit (see table 2). The mean SD length of stay was longer for patients with an assessment for rehabilitation compared with those without (6.27.3d vs 5.66.9d), but the median length of stay was 4 days for both groups. Almost 60% of patients with a rehabilitation assessment were discharged to postacute care compared with 20% of patients without an assessment. The largest proportion of patients with an assessment were discharged directly home without services (40.26%). The largest proportion of patients without an assessment were discharged to inpatient or home hospice (nZ29,923, 46.2%), but this number of patients was fewer than the proportion of patients without an assessment who also had care restricted to comfort measures during the acute stay (nZ37,222, 57.5%). In multivariable analyses, several factors remained independently associated with the likelihood of rehabilitation assessment (table 3). With every 10-year increase in age, the likelihood of an acute assessment for rehabilitation declined (odds ratio [OR] Z.84; 95% condence interval [CI], .82e.85). Women were also less likely to have an assessment documented (ORZ.89; 95% CI, .87e.90). Patients who were black or African American or of other races compared with white were more likely to be assessed. Patients with Medicaid or Medicare were more likely to be assessed than those with private or other insurance. Patients who had a stroke while in a rehabilitation, subacute, or long-term care facility (patient location before admission) were half as likely to have an assessment for rehabilitation (ORZ.45; 95% CI, .44e.47). Requiring assistance to ambulate or being unable to ambulate before admission also decreased the likelihood of an www.archives-pmr.org

Hospital characteristics
Data on structural characteristics of the participating hospitals (number of beds, geographic region, hospital type as academic or nonacademic, and urban or rural designation using the rural-urban commuting area codes) were obtained from the American Hospital Association database by the Duke Clinical Research Institute and included in this study.18 This study also explored 7 measures that reect hospital-based decisions for care or processes that are largely outside the patients control but may inuence the likelihood of whether a patient is assessed for rehabilitation. These included whether the patient had documentation of an NIHSSS, had a stroke consult, received care in a stroke care unit, received thrombolytic therapy, had documentation that care was restricted to comfort measures only, had documentation of length of stay, and was referred for rehabilitation after the hospital discharge.

Analyses
Patient and hospital characteristics were compared between stroke patients who did and did not have documentation of an acute assessment for rehabilitation. The P values are based on Pearson chi-square tests for all categorical variables and the Wilcoxon signed-rank test for all continuous/ordinal variables. All tests were 2-sided and calculated by comparing only nonmissing values. The P value <.01 was considered statistically signicant because of the large size of the sample. Although ambulatory status on admission, presence of stroke symptoms on admission, and documentation of care restricted to comfort measures were explored as additional indicators of stroke severity or care processes, they were only described in univariate tables because of the high proportion of missing data. Multivariable logistic regression with generalized estimating equations were performed to identify independent factors associated with an acute assessment for rehabilitation while accounting for within hospital correlation.19 Variables included age, sex, race, health insurance, patient location when stroke symptoms were discovered, ambulatory status before admission, 9 preexisting medical conditions and 1 behavior (smoking), whether the patient had a stroke consult, received care in a stroke unit, length of stay, number of hospital beds, geographic region, hospital type, and urban designation. The regression model with these factors was repeated in the subset of patients with a documented NIHSSS (nZ278,473) to determine the independent relationship between stroke severity and the likelihood of a rehabilitation assessment. Missing ambulatory status before admission was imputed to able to ambulate for patients who were able to ambulate independently at discharge. Missing insurance status for patients 65 years and older was imputed to Medicare and imputed for patients younger than 65 years to private/other insurance, the most frequent health insurance categories for those age groups. Model discrimination was assessed by determining the C-index for each model.

Assessed for rehabilitation

Table 1 Patient characteristics comparing those with and without an assessment for rehabilitation Assessed for Rehabilitation nZ552,222 (89.5%) 69.4814.74 28,3371 (51.31) 382,310 94,126 15,121 22,437 (69.23) (17.04) (2.74) (4.06)

41

Variable, Level Sociodemographics Age (y) Sex (women) Race and ethnicity White Black or African American Other race: Asian Other race: Native Hawaiian, Pacic Islander, American Indian, Alaskan Native, or unable to determine Hispanic Health insurance* Self-pay/no insurance Medicare Medicaid Private/VA/CHAMPUS/other insurance Before admission patient in a rehabilitation, subacute, or long-term care facility Medical history (obtained on admission) Ambulatory status before stroke admission* Unable to ambulate Ambulating with person assist Ambulating independently with or without a device (no person assist) Previous stroke/transient ischemic attack Atrial brillation or utter Coronary artery disease or prior myocardial infarction Carotid stenosis Diabetes mellitus Dyslipidemia Heart failure Hypertension Peripheral vascular disease Smoker In-hospital measures of health status Ambulatory status at admission* Unable to ambulate Ambulating with person assist Ambulating independently with or without a device (no person assist) Stroke symptoms resolved on admission* First total NIHSSS*

Overall NZ616,982 70.1114.91 321,556 (52.12) 432,110 100,947 16,452 25,145 (70.04) (16.36) (2.67) (4.07)

Not Assessed for Rehabilitation nZ64,760 (10.5%) 75.4815.26 38,185 (58.96) 49,800 6821 1331 2708 (76.90) (10.53) (2.06) (4.18)

40,908 (6.63) 39,030 256,312 52,868 268,772 42,991 (6.33) (41.54) (8.57) (43.56) (7.03)

37,062 (6.71) 36,545 225,729 47,813 242,135 31,166 (6.62) (40.88) (8.66) (43.85) (5.69)

3846 (5.94) 2485 30,583 5055 26,637 11,825 (3.84) (47.23) (7.81) (41.13) (18.53)

21,603 (3.50) 31,590 (5.12) 482,267 (78.17) 184,067 99,632 151,284 23,939 185,716 240,888 46,218 459,115 27,175 112,193 (32.51) (17.60) (26.72) (4.23) (32.81) (42.55) (8.16) (81.10) (4.80) (19.82)

15,485 (2.80) 25,870 (4.68) 442,067 (80.05) 162,981 84,089 133,825 20,659 168,890 218,021 39,113 412,122 23,732 104,518 (32.14) (16.58) (26.39) (4.07) (33.31) (43.00) (7.71) (81.27) (4.68) (20.61)

6118 (9.45) 5720 (8.83) 40,200 (62.08) 21,086 15,543 17,459 3280 16,826 22,867 7105 46,993 3443 7675 (35.72) (26.33) (29.57) (5.56) (28.50) (38.73) (12.03) (79.60) (5.83) (13.00)

123,958 (20.09) 94,591 (15.33) 143,454 (23.25) 32,891 (5.33) 7.107.42

102,479 (18.56) 90,081 (16.31) 132,678 (24.03) 29,685 (5.38) 6.496.75

21,479 (33.17) 4510 (6.96) 10,776 (16.64) 3206 (4.95) 13.8610.52

NOTE. Values are mean SD or n (%). All tests treat the column variable as nominal. All variables signicant 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%; rst NIHSSS, 48%.

assessment. Being a smoker, having hypertension, dyslipidemia, diabetes, or a prior stroke increased the odds of having an assessment, but a history of atrial brillation, carotid stenosis, or heart failure decreased a patients odds of having an assessment. Of the hospital characteristics examined, receiving care in a stroke unit increased the odds of an acute assessment (ORZ1.63; 95% CI, 1.55e1.71). Receiving a stroke consult on admission and care in the Northeast also increased the odds of an assessment. Variation ination factor values for each variable were low, indicating

the degree of collinearity between variables was low. The C-index of .6843 suggests that beyond the included factors there remained a signicant amount of unexplained variance in this model. We also assessed these independent associations in a sample with NIHSSS (nZ278,473). This model had better discrimination (CZ.7562). A higher NIHSSS (higher stroke severity) decreased the likelihood of receiving an acute assessment for rehabilitation (ORZ.91; 95% CI, .91e.91; c2Z386.35). After the NIHSSS was included, prior stroke or transient ischemic attack, history of

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42
Table 2 Hospital characteristics comparing those with and without an assessment for rehabilitation Assessed for Rehabilitation nZ552,222 (89.5%) 442.51337.12 96,616 204,529 109,702 141,375 (17.50) (37.04) (19.87) (25.60)

J.A. Prvu Bettger et al

Variable, Level Structural characteristics Hospital beds* Geographic region of the country West South Midwest Northeast Hospital type* Nonacademic Academic Urban/rural designation by rural urban commuting area codes Rural Urban Care delivery NIHSSS (total) documented Patient had a stroke consult* Received care in a stroke unit* Received thrombolytic therapy, IA or IV tPA Comfort care measures onlyy Referred for rehabilitation at discharge No rehabilitation (discharge home no services) Discharged to postacute care Inpatient rehabilitation unit or facility Skilled nursing facility or Medicare equivalent subacute unit (swing bed) Home with home health Long-term acute hospital No rehabilitation (poor prognosis) Discharge to hospice Discharge to long-term care Length of stay (d)

Overall NZ616,982 438.62337.23 108,497 229,958 122,634 155,893 (17.59) (37.27) (19.88) (25.27)

Not Assessed for Rehabilitation nZ64,760 (10.5%) 404.46336.32 11,881 25,429 12,932 14,518 (18.35) (39.27) (19.97) (22.42)

234,131 (37.95) 336,929 (54.61)

206,870 (37.46) 305,368 (55.30)

27,261 (42.10) 31,561 (48.74)

25,923 (4.20) 585,783 (94.94) 322,870 402,234 367,841 35,412 37,621 (52.33) (65.19) (59.62) (5.74) (6.10)

22,072 (4.00) 525,481 (95.16) 296,125 363,460 337,262 32,503 399 222,319 328,245 143,772 114,099 (53.62) (65.82) (61.07) (5.89) (0.08) (40.26) (59.44) (26.04) (20.66)

3851 (5.95) 60,302 (93.12) 26,745 38,774 30,579 2909 37,222 21,744 12,950 1514 9034 (41.30) (59.87) (47.22) (4.49) (57.48) (33.58) (20.00) (2.34) (13.95)

244,063 (39.56) 341,195 (55.30)

31,446 (5.10)

6.107.29

63,651 (11.53) 6723 (1.22) 1411 (0.26) 9 (0.01) 1402 (0.25) 6.167.34

1784 (2.75) 618 (0.95) 30,035 (46.38) 29,923 (46.21) 112 (0.17) 5.626.87

NOTE. Values are mean SD or n (%). All tests treat the column variable as nominal. All variables are signicant 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.

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

Discussion
Poststroke complications and impairment can be minimized when rehabilitation professionals are consulted and therapeutic intervention is initiated early in acute care.9,20,21 Early initiation of therapy is a class I level A recommendation for stroke care.9 Our study found that most stroke patients in this U.S. sample have

documentation of an acute assessment for rehabilitation. We also identied patient and hospital factors that were associated with receiving an assessment. In this study, 90% of stroke patients discharged alive from the hospital had documentation of an assessment for rehabilitation, that rehabilitation was provided, or there was a referral for postacute rehabilitation. This translates to more than 20,000 U.S. stroke admissions a year not being assessed for rehabilitation. Of those without an assessment, 62% were ambulating independently before admission, and only 20% were discharged to a setting or service that provides postacute care as dened by CMS. More than 40% were discharged to hospice. Patients without an acute assessment were also more likely to be older and exhibiting other characteristics of chronic illness such as comorbid heart failure. www.archives-pmr.org

Assessed for rehabilitation

43

Table 3 Multivariable logistic regression demonstrating characteristics independently associated with the receipt of an assessment for rehabilitation Multivariable Model Variable* Patient characteristics Age (per 10-y increase) Sex (woman) Race (reference: white) Black or African American Other (Asian, American Indian, Alaska Native, Native Hawaiian, or Pacic Islander) Health insurance (reference: private/VA/other) Medicaid Medicare Before admission patient in a rehabilitation, subacute, or long-term care facility Medical history Ambulatory status before admission (reference: independent) With assistance Unable to ambulate Previous stroke/transient ischemic attack Atrial brillation or utter Carotid stenosis Diabetes mellitus Dyslipidemia Heart failure Hypertension Smoker Hospital characteristics Patient had a stroke consult Received care in a stroke unit Length of stay (d) Geographic region (reference: West) Northeast Academic hospital type (reference: nonacademic) Urban designation (reference: rural) OR 0.84 0.89 1.38 1.05 Lower (95% CI) 0.82 0.87 1.37 1.01 Upper (95% CI) 0.85 0.90 1.38 1.10 P <.000 <.000 <.000 .007 34.01 1.08 1.07 0.45 1.04 1.05 0.44 1.12 1.10 0.47 .000 <.000 <.000 c2 284.94 131.93 176.03

460.04

0.73 0.44 1.03 0.81 0.79 1.21 1.19 0.85 1.22 1.18 1.33 1.63 1.01 1.33 1.00 1.11

0.70 0.42 1.01 0.79 0.73 1.19 1.16 0.82 1.19 1.14 1.26 1.55 1.00 1.19 0.92 0.98

0.76 0.46 1.05 0.83 0.87 1.24 1.21 0.88 1.25 1.21 1.41 1.71 1.01 1.48 1.08 1.26

<.000 <.000 .003 <.000 <.000 <.000 <.000 <.000 <.000 <.000 <.000 <.000 <.000 <.000 .967 .117

143.48 394.78 8.15 202.67 18.78 228.62 193.99 78.30 176.30 98.45 83.80 181.08 17.76 53.41 0.00 2.24

Abbreviation: VA, Veterans Administration. * Not signicant 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).

These patients are at high risk for preventable complications and hospital readmissions.22 We also found that those cared for in a designated stroke unit were more likely to have a rehabilitation assessment. This nding is consistent with those of others,4,23 and is indicative of other measures demonstrating that specialization of care results in more complete, high-quality services. In this sample, it appears hospitals inconsistently applied the criteria when reviewing medical records for evidence of an assessment. If we were to add the 1514 patients without an assessment but who were transferred or discharged to inpatient rehabilitation (medical record options 4 and 5), the 29,923 patients discharged to hospice as evidence of poor prognosis (option 6), or the 37,222 patients with comfort care measures as evidence of being unable to tolerate rehabilitation (option 6), then almost 95% of patients would have been assessed for or received rehabilitation using the current denition. However, the current structure of the question and denition merits consideration. First, the inclusion criteria give equal credit for a physician determination www.archives-pmr.org

of prognosis or ability to tolerate rehabilitation with a rehabilitation team members patient assessment and receipt of therapy. An assessment of needs, functioning, and disability should be completed by trained clinicians to be able to determine the type of rehabilitation services needed and the optimal frequency, intensity, and duration. Research has not conrmed whether this assessment and determination of service need can be completed by clinicians without rehabilitation training. Second, equal credit is given for the receipt of rehabilitation postdischarge. Giving credit for discharge to a postacute rehabilitation facility in the absence of any assessment or therapy in the acute setting might lead to worse patient outcomes if therapy is delayed until after discharge. Finally, assessing patients needs such as safety, equipment, training, functioning, and disability are separate and different evaluations than determining the need for rehabilitative services. The current structure of the question and criteria for inclusion do not distinguish one component from the other. It is likely that across the 1500 participating hospitals, there is substantial

44 variability in the process and the quality of this assessment of rehabilitation needs and factors that are considered for recommending rehabilitation therapy. Without a standard process, assessment, and algorithm for referral in the acute hospital, the reliability of referral will be low and the likelihood of misuse of rehabilitation services could be highdvarying potentially from hospital to hospital and even from patient to patient within the same institution. Quality metrics that isolate each component in the process (ie, refer stroke patients to rehabilitation professionals in acute care; rehabilitation professionals complete assessment of functioning and disability; stroke team uses assessment to make an evidence-based recommendation for rehabilitation services based on need) may be important for examining both underuse of effective care and overuse of ineffective care at a signicant cost to both patients and the health system. Several denitions for an assessed for rehabilitation acute stroke care quality measure currently exist in the United States. Since 2004, states funded to implement the Paul Coverdell National Acute Stroke Registry have measured whether patients at participating hospitals were assessed for or received rehabilitation, and of those included, hospitals reported 94% adherence in 2008.24 An assessed for rehabilitation measure was added to the American Heart Association GWTG-Stroke hospital-based data registry and quality improvement program in 2008, and performance on this quality measure was also 94% in 2008.1 The Joint Commission (Joint Commission on Accreditation of Healthcare Organizations) has included the assessed for rehabilitation measure for acute hospital stroke center certication since 2006, and the National Quality Forum endorsed the measure in 2008 as part of a measure set for acute stroke care.25 Performance for Joint Commission stroke-certied hospitals is not publicly reported, and a specic benchmark has not been established by the National Quality Forum for the assessed for rehabilitation quality measure. The 3 programs, Coverdell, GWTG-Stroke, and Joint Commission, use different denitions for evidence of an assessment, the denominator exclusion criteria differ, and none assess patients functioning separate from assessing and determining the need for rehabilitative services. An important opportunity exists for all acute stroke quality initiatives to achieve consensus on dening an evidence-based quality measure that will best support patient-centered outcomes and appropriate use of rehabilitation services both in the hospital and after discharge. Unfortunately, at this time, it is not clear what performance would be if all programs endorsed the same inclusion and exclusion criteria. Nor is it clear what performance would be if the only medical record indication for an assessment for rehabilitation would be functional status assessments by members of the rehabilitation team. A more stringent and specic measure would either reveal much lower compliance rates or a more accurate account of who was assessed.

J.A. Prvu Bettger et al representative of the overall U.S. hospital population. However, patient admissions in GWTG-Stroke appear to be representative of the overall U.S. stroke population in terms of age, demographics, and medical comorbidities.13 No external audit of case ascertainment is in place, and variation in patient selection at the local hospital level could have occurred. Although the commitment to quality may be high in GWTGStrokeeparticipating hospitals, we did nd that the assessment of stroke severity as documented by the NIHSSS (also a class I level A recommendation) was frequently missing. Restricting our sample to patients with stroke severity documented would have introduced signicant selection bias. Similarly, this study used an assess for rehabilitation analysis construct where patients with acute care restricted to comfort measures only were still considered eligible for a rehabilitation assessment. Although clinical guidelines state that patients with severe stroke, who are maximally dependent for basic activities of daily living and have poor prognosis for functional recovery, are not candidates for rehabilitation therapies,9 the level of evidence for completing an assessment for rehabilitation, or tailoring an assessment for these patients has not been examined. It is likely that care partners could benet from education and training from rehabilitation professionals in several areas, from swallowing techniques to passive range of motion to assisted self-care tasks. As such, patients with comfort care measures were considered eligible for an assessment and not excluded.

Conclusions
Most patients in this sample had documentation of an assessment for rehabilitation as it is currently dened. Patients without an acute assessment for rehabilitation were more likely to be unable to ambulate or ambulating with assistance before admission; admitted from a chronic care, inpatient rehabilitation, or skilled nursing facility; did not receive a stroke consult or care in a stroke unit; and were treated at a Western region hospital (compared with the Northeast). This study will ideally facilitate hospital quality improvement efforts that actively engage members of the rehabilitation team to address barriers to completing an acute assessment for rehabilitation for all patients. This study also serves as the foundation for a discussion on how to better dene what constitutes an acute assessment for rehabilitation, a discussion that may be crucial before the start of CMS-required hospital reporting of acute stroke care. Mixed-method study designs are needed to explore the unexplained variance related to acute assessment and provision of rehabilitation, and the decision process that occurs. 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 patients needs.

Study limitations
This study has several limitations. Given the inherent limitations of the assessment for rehabilitation questions structure, we are unable to discern who was appropriately assessed, received the recommended type and intensity of therapy during acute care, and was appropriately referred for rehabilitation care at discharge. Participation in GWTG-Stroke is voluntary, and hospitals that participate are more likely to have a strong interest in stroke and quality improvement; therefore, participating hospitals may not be

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

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12. Fonarow GC, Reeves MJ, Smith EE, et al. Characteristics, performance measures, and in-hospital outcomes of the rst one million stroke and transient ischemic attack admissions in Get With The Guidelines-Stroke. Circ Cardiovasc Qual Outcomes 2010;3:291-302. 13. Reeves MJ, Fonarow GC, Smith EE, et al. Representativeness of the Get With The Guidelines-Stroke Registry: comparison of patient and hospital characteristics among Medicare beneciaries hospitalized with ischemic stroke. Stroke 2012;43:44-9. 14. Reeves MJ, Grau-Sepulveda MV, Fonarow GC, Olson DM, Smith EE, Schwamm LH. Are quality improvements in the Get With The Guidelines: Stroke program related to better care or better data documentation? Circ Cardiovasc Qual Outcomes 2011;4:503-11. 15. Reeves MJ, Fonarow GC, Zhao X, Smith EE, Schwamm LH. Quality of care in women with ischemic stroke in the GWTG program. Stroke 2009;40:1127-33. 16. Schwamm LH, Fonarow GC, Reeves MJ, et al. Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation 2009;119:107-15. 17. Fonarow GC, Reeves MJ, Zhao X, et al. Age-related differences in characteristics, performance measures, treatment trends, and outcomes in patients with ischemic stroke. Circulation 2010;121:879-91. 18. Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-toneedle times within 60 minutes. Circulation 2011;123:750-8. 19. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986;42:121-30. 20. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientic statement from the American Heart Association. Stroke 2010;41:2402-48. 21. Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientic statement from the American Heart Association. Stroke 2009;40:2911-44. 22. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418-28. 23. Langhorne P, Pollock A. What are the components of effective stroke unit care? Age Ageing 2002;31:365-71. 24. Centers for Disease Control and Prevention. Use of a registry to improve acute stroke caredseven states, 2005-2009. MMWR Morb Mortal Wkly Rep 2011;60:206-10. 25. Agency for Healthcare Research and Quality, National Quality Measures Clearinghouse. Stroke: percent of ischemic or hemorrhage stroke patients who were assessed for rehabilitation services. Available at: http://www.qualitymeasures.ahrq.gov/summary/summary. aspx?doc_idZ12206. Accessed December 12, 2009.

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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