Inpatient Rehabilitation Care Research Articles

The Increased Clinical and Economic Burden of Hyperkalemia in Medicare Patients Admitted to Long-Term Care Settings.

Older patients are at increased risk for hyperkalemia (HK). This study describes the prevalence, recurrence, and clinical and economic burden of HK in Medicare patients admitted to a long-term care (LTC) setting. Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) claims identified patients aged≥65years with index admission between 2017 and 2019 to a LTC setting (skilled nursing, home health, inpatient rehabilitation, or long-term acute care). Beneficiaries were required to have 12months continuous medical and pharmacy coverage prior to index LTC admission and≥30days after LTC discharge (follow-up). Patient characteristics, healthcare resource utilization, and costs were assessed. HK was defined as ICD-10 diagnosis code E87.5 in any claim position or Medicare Part D fill for oral potassium binder. Of 4,562,231 patients with a LTC stay, the prevalence of HK was 14.7% over the full study period (pre-index, index stay, and follow-up). Excluding those with HK only during the follow-up period resulted in 4,081,103 patients. Of these, 290,567 (7.1%) had HK and 3,790,536 (92.9%) did not have HK during or within 14days prior to index LTC stay. The HK recurrence rate during index stay and follow-up was 48.3%. Unmatched HK versus non-HK patients were more often male (43.0% vs. 35.4%), Black (13.5% vs. 8.0%), dual eligible for Medicaid (34.2% vs. 25.0%), with higher mean Charlson Comorbidity Index scores (6.2 vs. 3.9) (all p<0.0001). After propensity matching, HK patients were 2.2times more likely to be hospitalized, with higher mortality (30.8% vs. 21.5%) and higher total healthcare costs during both index stay (US$26,520 vs. $18,021; p<0.0011) and follow-up ($57,948 vs. $41,744 (p<0.0011) versus matched non-HK patients. Prevalence and recurrence of HK was high among LTC patients, and HK was associated with significantly greater clinical and economic burden during and post-LTC.

Rehabilitation care of patients with neurogenic bladder after spinal cord injury: A literature review.

This article reviews the research progress of rehabilitation treatment and nursing care of patients with neurogenic bladder after spinal cord injury, in order to provide reference for the rehabilitation treatment and nursing care of patients. We reviewed recent medical literature on patients with neurogenic bladder, focusing on neurogenic bladder caused by spinal cord injury. We analyzed 30 recent of publications in patients with neurogenic bladder after spinal cord injury, in addition to reviewing and evaluating the commonly used rehabilitation nursing methods for neurogenic bladder. Psychological counseling is a vital aspect which cannot be neglected in the process of neurogenic bladder rehabilitation. Hitherto, the commonly used drug and surgical treatments may have negatively impacted the mental health of patients in varying degrees. However, in clinical practice, applying intermittent catheterization in patients who have neurogenic bladder with spinal cord injury may help improve patients' life quality, mitigate psychological burden, and reduce negative emotions.

Opioid Utilization and Management in the Setting of Stewardship During Inpatient Rehab Care.

BackgroundOpioid utilization and management in an inpatient rehabilitation setting have not been widely described, despite the unique opportunities that exist in this setting to support opioid stewardship across transitions in care. We aimed to characterize opioid utilization and management by interprofessional teams across a large, inpatient rehabilitation setting after incorporation of opioid stewardship principles by pharmacists as part of their daily practice.Patients and methodsThis was a retrospective chart review at Toronto Rehab, University Health Network, Toronto, Canada. Patients with admission orders for any opioid from November 2017 to February 2018 were included. Complex continuing care and palliative care patients were excluded. Descriptive statistics were primarily used to describe the data as well as univariate linear regression to compare associations with milligram morphine equivalent (MME) reduction.ResultsA total of 448 patients were included. A reduction in total daily MME was seen in 49% (n=219) of the patients during their inpatient stay, with 73% (n=159) of these patients having a reduction of ≥50%. Sixty-nine percent (n=311) of the patients received an opioid prescription at discharge, with most scheduled (90%, n=98) with a supply of less than 30 days. Rehabilitation length of stay was correlated with a MME decrease during rehab (p<0.01), suggesting that longer lengths of stay contributed to a greater reduction in MME. Patients with chronic opioid use prior to acute care admission (p=0.01), and those who started extended-release opioids during acute care (p=0.02) were significantly less likely to discontinue opioids during rehab stay.ConclusionOpioid utilization and management in the setting of opioid stewardship across inpatient rehab and transitions of care were characterized. Opportunities exist for further quality improvement initiatives within inpatient rehabilitation and acute care settings to identify and support patients with complex pain management needs.

What Determinants Affect Inpatient Satisfaction in a Post-Acute Care Rehabilitation Hospital?

ObjectiveTo examine how specific hospital service domains (personal issues domain, discharge domain, rehabilitation doctor domain, nursing domain, physical therapist domain, occupational therapist domain, and food domain) influence final patient satisfaction scores, the overall quality of care, and willingness to recommend the hospital to others among patients in an inpatient rehabilitation hospital. DesignLongitudinal study. SettingPatient-level data from electronic medical records were joined with Press Ganey (www.pressganey.com) satisfaction data for a single post-acute care inpatient rehabilitation facility in northeast Florida. ParticipantsPatients who participated in the inpatient rehabilitation survey (N=4,785). InterventionsNot applicable. Main Outcome MeasuresMain outcome measures included final patient satisfaction scores, overall rating of care during the stay, and willingness to recommend the hospital to others. ResultsThis study found the personal issues domain to be the most important factor in determining the final patient satisfaction score, overall rating of care, and likelihood to recommend the hospital to others, followed by the physical therapist, nurse, discharge, and food domains (P<.0001). Within the personal issues domain score, staff promptness and explanation upon arrival were areas identified as opportunities to make improvements that would result in the greatest positive effect. ConclusionsThis work represents novel findings by investigating the major determinants of positive patient experience in a rehabilitation hospital setting. These findings provide actionable information to improve patient experience as well as where to focus improvement efforts using limited resources.

Assessment of the individual and compounding effects of marginalization factors on injury severity, discharge location, recovery, and employment outcomes at 1 year after traumatic brain injury.

ObjectiveThe aim of this study is to examine the effect of eight distinct marginalized group memberships and explore their compounding effect on injury severity, recovery, discharge location, and employment outcomes 1-year after traumatic brain injury (TBI).MethodsIndividuals with medically confirmed, complicated mild-severe TBI (N = 300) requiring inpatient rehabilitation care between the ages of 18 and 65 were recruited at two urban (public and private) health systems between 2013 and 2019. Data were collected from self-report and medical record abstraction. Marginalized group membership (MGM) includes racial and ethnic minority status, less than a high school diploma/GED, limited English proficiency, substance abuse, homelessness, psychiatric hospitalizations, psychiatric disorders, and incarceration history. Membership in four or more of these groups signifies high MGM. In addition, these factors were explored individually. Unadjusted and adjusted linear and logistic regressions and Kruskal–Wallis tests were used to assess the associations of interest in RStudio.ResultsAfter adjusting for age, sex, and cause of injury, compared to TBI patients with low MGM, those with high MGM experience significantly longer post-traumatic amnesia (95% CI = 2.70, 16.50; p = 0.007) and are significantly more likely to have a severe TBI (per the Glasgow-Coma Scale) (95% CI = 1.70, 6.10; p ≤ 0.001) than a complicated mild-moderate injury. Individuals with high MGM also are significantly less likely to be engaged in competitive paid employment 1 year after injury (95% CI = 2.40, 23.40; p = 0.001). Patients with high MGM are less likely to be discharged to the community compared to patients with low MGM, but this association was not significant (95% CI = 0.36, 1.16; p = 0.141). However, when assessing MGMs in isolation, certain associations were not significant in unadjusted or adjusted models.ConclusionThis exploratory study's findings reveal that when four or more marginalization factors intersect, there is a compounding negative association with TBI severity, recovery, and employment outcomes. No significant association was found between high MGM and discharge location. When studied separately, individual MGMs had varying effects. Studying marginalization factors affecting individuals with TBI has critical clinical and social implications. These findings underline the importance of addressing multidimensional factors concurrent with TBI recovery, as the long-term effects of TBI can place additional burdens on individuals and their economic stability.

Life expectancy of coal miners with an established diagnosis of occupational diseases

Introduction. It is known that workers employed in harmful and dangerous working conditions initially have better health characteristics compared to the population as a result of medical and professional selection. Harmful production factors cause significant damage to health and can lead to the formation of occupational diseases. Preventive medical and rehabilitation care for patients with occupational pathology, combined with social and economic support measures, contributes to maintaining health and increasing life expectancy. It is important to understand how medical and social assistance to patients compensates for the damage caused to the health of workers by harmful working conditions. The study aims to compare the life expectancy of coal miners with an established diagnosis of occupational disease (OD) and the male population of the same region. Materials and methods. The researchers formed a cohort of coal miners in the Rostov region based on the materials of the database of the State Medical Institution of the Rostov region "Medical and Rehabilitation Center No. 2". All surveyed coal miners have established occupational diseases in different years. The observation period was 26 years from 01.01.1990 to 31.12.2015. Of the total cohort at the end of the observation period, 1,898 people were alive, 8082 people died. The experts examined the working conditions of miners, the average age of registration of the OD, depending on the nosological form. The researchers have conducted a comparative assessment of their life expectancy and the life expectancy of the male population of the same region, calculated from mortality tables. Results. The calculation of the average life expectancy of miners showed that its value in subgroups with different forms of OD differed significantly depending on the diagnosis: from 58.7 to 68.2 years. A comparative analysis of the life expectancy of coal miners with an established diagnosis of OD and in population control revealed a lower life expectancy of miners. The smallest differences in life expectancy we have noted in those miners who have a diagnosis of pneumoconiosis. Their life compared to the men of the Rostov region was shorter by less than a year. At the same time, miners with a diagnosis of occupational bronchitis lived 5.3 years less and with a diagnosis of vibration disease - 4.8 years compared to the population control. Conclusion. The study showed that coal miners diagnosed with occupational diseases have a lower average life expectancy than in the population, despite the "healthy worker effect", which we have as a result of medical selection and self-selection of persons to work in contact with harmful production factors. The lower life expectancy of workers with a diagnosis of occupational diseases we trace both in total for all diseases, and for individual forms of OD. Ethics. The authors have conducted the study in compliance with Ethical standards.

Association Between Delayed Discharge From Acute Care and Rehabilitation Outcomes and Length of Stay: A Retrospective Cohort Study

ObjectiveTo examine the association between discharge delays from acute to rehabilitation care because of capacity strain in the rehabilitation units, patient length of stay (LOS), and functional outcomes in rehabilitation. DesignRetrospective cohort study using an instrumental variable to remove potential biases because of unobserved patient characteristics. SettingTwo campuses of a hospital network providing inpatient acute and rehabilitation care. ParticipantsPatients admitted to and discharged from acute care categories of Medicine and Neurology/Musculoskeletal (Neuro/MSK) and subsequently admitted to and discharged from inpatient rehabilitation between 2013 and 2019 (N=10486). InterventionsNone. Main Outcome MeasuresRehabilitation LOS, FIM scores at admission and discharge, and rehabilitation efficiency defined as FIM score improvement per day of rehabilitation. ResultsThe final cohort contained 3690 records for Medicine and 1733 for Neuro/MSK categories. For Medicine, 1 additional day of delayed discharge was associated with an average 5.1% (95% confidence interval [CI], 3%-7.3%) increase in rehabilitation LOS and 0.08 (95% CI, 0.03-0.13) reduction in rehabilitation efficiency. For Neuro/MSK, 1 additional day of delayed discharge was associated with an average 11.6% (95% CI, 2.8%-20.4%) increase in rehabilitation LOS and 0.08 (95% CI, −0.07 to 0.23) reduction in rehabilitation efficiency. ConclusionsDelayed discharge from acute care to rehabilitation because of capacity strain in rehabilitation had a strong association with prolonged LOS in rehabilitation. An important policy implication of this “cascading” effect of delays is that reducing capacity strain in rehabilitation could be highly effective in reducing discharge delays from acute care and improving rehabilitation efficiency.

A Microanalysis of Mood and Self-Reported Functionality in Stroke Patients Using Ecological Momentary Assessment.

Post-stroke depression has been repeatedly associated with the degree of functional and cognitive impairment. The present study aimed to conduct a microanalysis on this association and examined the association between mood and self-reported functionality in 20 stroke patients (6 females, age: M = 59.9, SD = 5.2) using ecological momentary assessments (EMA), a structured diary method capturing moment-to-moment variations. Mood and self-reported functionality were recorded via a smartphone-app eight times a day for seven consecutive days during inpatient rehabilitation care. The patients answered on average to 73.2% of the received prompts. Variability in patients' responses was caused by differences both between and within patients. Multilevel regression analyses revealed that mood and self-reported functionality were significantly associated at the same point in time, but only patients' mood predicted their self-reported functionality at the next assessment point in time-lagged analyses. These results remained stable after controlling for between-person differences as patients' age, staff-ratings of their awareness of illness, and their degree of functional independence. Patients' mood appeared to affect their future ratings of their functionality but not the other way around.

Inequalities in utilization of institutional care among older people in Estonia

The purpose of this study is to shed light on various sources of inequalities in the utilization of institutional care among the Estonian elderly. We apply two-part hurdle and zero-inflated negative binomial models to analyze the association between various socioeconomic determinants and other factors on the one hand and the use of inpatient care and rehabilitation care services on the other. We discriminate between the two types of models using the new approach to comparing nonnested models – the HPC test. Applying the Lewbel estimator, we also explore the association between the utilization of inpatient care and rehabilitation. The evidence supports the existence of a pro-rich and pro-educated gradient in the needs-adjusted utilization of inpatient and rehabilitation care services among older people in Estonia. At the same time, we find no tangible urban/rural or ethnic barriers to the use of these services. The obtained results suggest the necessity of facilitating the accessibility of rehabilitation care services by mitigating both demand-side and supply-side barriers.

SCiPad: evaluating telemedicine via iPad facetime for general spinal cord injury care

Study designUncontrolled clinical pilot study.ObjectivesTo assess usage, perceived impact, and satisfaction with a telemedicine program among individuals with spinal cord injury (tele-SCI).SettingCommunity-based.MethodsParticipants (N = 83) were recruited from acute SCI inpatient rehabilitation and outpatient SCI care at a community hospital to participate in a 6-month tele-SCI intervention administered by SCI subspecialty board-certified physiatrists via iPad FaceTime. In addition to monthly follow up interview calls, psychosocial and Quality of Life (QoL) measures were collected at baseline and post-intervention. A program satisfaction survey was also collected post-intervention.ResultsSeventy-five percent of participants engaged in tele-SCI visits (Median [IQR]: 2.5 [2.0, 4.0]) for a total of 198 tele-SCI visits. Bladder and bowel concerns were the leading topics discussed during tele-SCI visits, followed by neurological, pain, and functional concerns. Tele-SCI users resided further away (Median miles [IQR] – 114[73–177] vs. 81[46–116], p = 0.023) and reported seeking more clinical advice (Median [IQR] – 1.5[0–4.0] vs. 0[0–1.0], p = 0.002) compared to non-tele-SCI users. All other clinical utilization, baseline characteristics, psychosocial measures, and QoL did not differ among those who used tele-SCI and those who did not. The satisfaction survey suggested satisfaction with the tele-SCI intervention (89%), study equipment (89%), staff responsiveness (100%), and improved motivation for self-monitoring of health (71%).ConclusionStudy findings suggest that tele-SCI is a feasible modality for providing general SCI care. Further research is required to examine longer-term efficacy of remotely-provided care among individuals living with SCI.

The association between pharmaceutical innovation and both premature mortality and hospital utilization in Switzerland, 1996\u20132019

We analyze the association that pharmaceutical innovation had with premature mortality from all diseases in Switzerland during the period 1996–2018, and its association with hospital utilization for all diseases in Switzerland during the period 2002–2019. The analysis is performed by investigating whether the diseases that experienced more pharmaceutical innovation had larger subsequent declines in premature mortality and hospitalization. Pharmaceutical innovation is measured by the growth in the number of drugs used to treat a disease ever registered in Switzerland. Utilization of a chemical substance reaches a peak 9–12 years after it was first launched, and then declines. Our estimates indicate that the number of years of potential life lost before ages 85, 75, and 65 is significantly inversely related to the number of chemical substances ever registered 6–9, 3–9, and 0–9 years earlier, respectively. The new chemical substances that were registered during the period 1990–2011 are associated with reductions in the number of years of potential life lost before ages 85, 75, and 65 in 2018 of 257 thousand, 163 thousand, and 102 thousand, respectively. The number of hospital days is significantly inversely related to the number of chemical substances ever registered 8–10 years earlier. The new chemical substances that were registered during the period 1994–2010 are associated with reductions in the number of hospital days in 2019 of 2.07 million. Average length of inpatient hospital stays is significantly inversely related to the number of chemical substances ever registered 2–10 years earlier. The new chemical substances that were registered during the period 1999–2015 are associated with reductions in the average length of stays in 2019 of 0.4 days. Under the assumption that pharmaceutical innovation is exogenous with respect to premature mortality and hospitalization, and that it is uncorrelated with other potential determinants of health outcomes, if we ignore the reduction in hospital utilization associated with previous pharmaceutical innovation, a rough estimate of the cost per life-year before age 85 gained in 2018 is € 14,310. However, about 85% of the 2018 expenditure on drugs registered during the period 1990–2011 may have been offset by the reduction in expenditure on inpatient curative and rehabilitative care. The net cost per life-year before age 85 gained in 2018 may therefore have been € 2201.

The 2021 Joseph St Geme, Jr, Leadership Award Address: The Role of Structural Racism in Injuries to Children and Adolescents.

The 2021 Joseph St Geme, Jr, Leadership Award Address: The Role of Structural Racism in Injuries to Children and Adolescents.

Factors Affecting the Implementation of Early Rehabilitation Care in Patients with Traumatic Brain Injury: A Multidisciplinary Perspective.

Background: Traumatic brain injury is now regarded as the silent epidemic. This disease can cause some physical, cognitive, and psychological impairments that require proper and early rehabilitation interventions. Therefore, the aim of this study was to explore the factors affecting early rehabilitation care in patients with traumatic brain injury based on the experiences of the rehabilitation team. Methods: This qualitative study was conducted as a conventional content analysis from September 2019 to August 2020. For this purpose and given the maximum diversity, 22 members of the rehabilitation team, patients, and their caregivers in trauma level 1 hospitals affiliated with Tehran University of Medical Sciences were selected based on a purposeful sampling method. The data were also collected using semi-structured interviews until data saturation is obtained. Graneheim and Lundman's content analysis method was performed to analyze the data. Results: The data analysis results eventually led to the introduction of three main themes and eight categories. The main themes were associated with early rehabilitation barriers, which included cultural factors and rehabilitation infrastructures. Rehabilitation management was regarded as the main theme regarding the early rehabilitation facilitator. Conclusion: Early rehabilitation is considered a vital rehabilitation stage for patients with traumatic brain injury. Hence, accurate identification of the influential factors on early rehabilitation can help the rehabilitation team promote early rehabilitation care among these patients; it can lead to the revival of the patients' abilities and the improvement of their quality of life.

Necrotizing Soft Tissue Infection in the Elderly: Effect of Pre-Operative Factors on Mortality and Discharge Disposition.

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Oral care practices in stroke: findings from the UK and Australia

AimsTo examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia.BackgroundPoor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries.DesignA cross-sectional survey.MethodsQuestionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times.ResultsCompleted questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents.ConclusionUnacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing individual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes.

The patient-driven payment model: A missed opportunity for patient-centered cancer care.

Hospitalized older patients with advanced cancer who were discharged to a skilled nursing facility (SNF) for rehabilitation are unlikely to receive future cancer treatment, have high 30-day readmission rates, and high mortality yet minimal hospice use. The Medicare SNF benefit was designed to be a bridge and provide short-term nursing and rehabilitation care for patients after a hospitalization. However, advanced cancer patients churn through the health system cycling between the hospital, post-acute care facilities, and home in the last months of life. This article explores the potential impact of the patient-driven payment model, a new SNF reimbursement model introduced by the Center for Medicare and Medicaid Services in 2019, on the experience of older cancer patients. Previously, SNF reimbursement was based on the hours of rehabilitative therapy provided to patients, unintentionally incentivizing SNFs to provide more therapy resulting in long lengths of stay and increased Medicare expenditure. The new patient-driven payment model bases reimbursement on patient clinical characteristics and resources utilized during their SNF stay. We discuss the impact this payment model might have on cancer patients in the SNF setting and highlight the importance of access to palliative care for this population. We discuss challenges policymakers face in creating palliative care guidelines and developing palliative care delivery models in SNFs. We highlight the policy gaps that remain in creating a system that achieves high-quality SNF care and conclude by offering suggestions that might better incorporate a patient's illness trajectory, prognosis, and goals of care.

Does Health Literacy Reinforce Disease Knowledge Gain? A Prospective Observational Study of Hungarian COPD Patients.

We set out to measure the health literacy (HL) of COPD patients using the Short Test of Functional Health Literacy (S-TOFHLA), perception-based screening questions (BHLS), and a specific disease knowledge test (COPD-Q). Our main focus is the relationship between functional HL and patients’ disease-knowledge, which contributes to the clarification of the relationship between the different kinds of HL. In two prospective observational studies, 151 COPD patients (80 males, mean age: 62 ± 9 years) completed a questionnaire containing HL measurements, psychological tests (e.g., the Self-Control and Self-Management Scale), and questions regarding subjective health status. Medical data of the patients from the MedSole system were added. The HL scores of the COPD patients were compared to a representative sample using a t-test. Furthermore, correlations of HL with demographic, psychological, and medical variables were calculated within the patient group. The relations among the different HL measurements were tested by chi-square trials. COPD patients had significantly lower HL, as measured by S-TOFHLA. Younger and higher educated patients possessed higher S-TOFHLA scores. Unlike the demographic variables, general self-management showed significant correlations with both BHLS and with COPD-Q. Out of the medical variables, objective health status was associated with BHLS and COPD-Q. Neither BHLS nor S-TOFHLA had a correlation with COPD-Q, but they correlated with each other. We found S-TOFHLA to be a better tool in the medical context. There is a clear gap between self-perceived/functional HL and the necessary disease knowledge. Rehabilitation care for patients with lower HL was more advantageous.

The Impact of Opioid Medications on Sleep Architecture and Nocturnal Respiration During Acute Recovery From Moderate to Severe Traumatic Brain Injury: A TBI Model Systems Study.

To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications. Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI). A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites. Cross-sectional, secondary analyses. The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index. After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids. Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

Effects of the Affordable Care Act Medicaid Expansion on in‐Hospital Mortality, Access to Rehabilitation, and Readmission Rates Among Young Adult Trauma Patients

Research ObjectiveTrauma is the leading cause of death and disability among young adults. Prior to the implementation of the Affordable Care Act (ACA), more than 30% of young adult trauma patients were uninsured, and uninsured patients had higher in‐hospital mortality rates and worse access to rehabilitation. We aimed to assess the impact of the ACA Medicaid expansion on insurance coverage and rates of in‐hospital mortality, access to rehabilitation, and unplanned readmissions and return emergency department (ED) visits in young adult trauma patients. Expansion States Non‐expansion States Difference‐in‐Differences Estimate (95% CI) P 2011–2013(N = 56,196) 2014–2017 (N = 62,893) 2011–2013 (N = 104,344) 2014–2017 (N = 143,595) Uninsured 27.1 9.7 32.7 31.8 −16.50 (−17.08 to −15.93) &lt;0.001 In‐hospital mortality 2.22 2.03 2.04 1.78 0.07 (−0.34 to 0.47) 0.74 Discharged to inpatient rehabilitation 6.18 8.07 5.91 6.47 1.33 (0.68 to 1.97) &lt;0.001 Discharged to a skilled nursing facility 1.97 2.24 1.76 1.61 0.42 (0.11 to 0.73) 0.008 Discharged to home healthcare 8.25 7.85 7.77 7.59 −0.22 (−1.51 to 1.07) 0.74 30‐day unplanned readmission 7.47 7.88 8.09 8.20 0.30 (−0.70 to 1.31) 0.55 30‐day return ED visit 18.31 18.96 21.58 22.67 −0.44 (−1.66 to 0.78) 0.48 Risk‐adjusted marginal percentages are shown. Study DesignWe used the state inpatient databases of 5 states that expanded Medicaid through the ACA (Arkansas, Iowa, Illinois, Kentucky, and Maryland) and 5 states that did not (Florida, Georgia, Kansas, Missouri, North Carolina) to perform a difference‐in‐difference (DD) analysis comparing changes in insurance coverage and risk‐adjusted outcomes in young adults hospitalized for traumatic injuries before (2011–2013) and after (2014–2017) Medicaid expansion and open enrollment.Population StudiedWe included adults aged 19–44 years who were hospitalized for traumatic injury in their state of residence. Patients admitted electively or for burn injuries were excluded.Principal FindingsOf the 367,028 trauma patients included, 26.7% were women and the mean age was 30.8 years. As shown in the table, Medicaid expansion was associated with a more than 16 percentage point decrease in the uninsured rate. This drop increased over time, with the annual DD estimates for 2014–2017 being −11.9, −17.4, −17.8, and − 19.3 percentage points respectively. Medicaid expansion was not associated with decreases in in‐hospital mortality or 30‐day readmission or return ED visit rates. It was associated with increases in access to inpatient rehabilitation, and this access grew over time (annual change in the DD: 0.8 percentage points, p &lt; 0.001).ConclusionsAmong young adult trauma patients, Medicaid expansion increased insurance coverage and access to inpatient rehabilitation, and these increases have grown over time. It has not reduced in‐hospital mortality or readmission rates.Implications for Policy or PracticeMedicaid expansion has enabled more young adults with serious injuries to access inpatient rehabilitative care, likely resulting in improved functional outcomes. However, given the unexpected nature of traumatic injury and the long recovery period that is sometimes required, these benefits may be eliminated if Medicaid waivers adding work requirements or eliminating retroactive Medicaid eligibility go into effect.Primary Funding SourceNational Institutes of Health.

ОБЕСПЕЧЕННОСТЬ РЕАБИЛИТАЦИОННЫМИ МЕРОПРИЯТИЯМИ ПАЦИЕНТОВ, ПЕРЕНЕСШИХ СЕРДЕЧНО-СОСУДИСТЫЕ КАТАСТРОФЫ, В АСТРАХАНСКОЙ ОБЛАСТИ

The relevance of the study is explained by the need to increase attention to the situation with acute cardiovascular diseases and the creation of an accessible system of medical rehabilitation for patients with cardiovascular diseases in the region. The aim of the study is to analyze the provision of rehabilitation measures for patients who have suffered cardiovascular accidents in the Astrakhan region. Materials and methods - based on the data of the annual reporting statistical forms No. 12 "Information on the number of diseases registered in patients living in the service area of the medical institution" and No. 14 "Information on the activities of the hospital", the calculation and analysis of indicators of general and primary morbidity was carried out ( on appeal), hospitalized morbidity, hospital mortality, the need for rehabilitation measures and their provision of adult patients aged 18 years and older with diseases of the circulatory system, including cardiovascular accidents in the Astrakhan region. Results and discussion - the article shows the general situation with the incidence of diseases of the circulatory system of the adult population, including acute coronary syndrome and acute cerebrovascular accident in dynamics from 2014 to 2020, discloses the organizational and structural aspects of the existing system of organizing rehabilitation care in the region. The results of assessing the satisfaction of the needs of the adult population of the region in neuro- and cardiac rehabilitation by medical organizations licensed for medical activities with an indication of the work (services) for medical rehabilitation and participating in the federal and territorial program of state guarantees of free provision of medical care to citizens in the region are presented. It was revealed that less than half of those in need receive medical rehabilitation assistance at the expense of the mandatory medical insurance fund. Proposals have been formulated to increase the availability of rehabilitation care for patients who have undergone cardiovascular accidents. Conclusion. The obtained research data can be used for further organizational, methodological and coordination work to provide modern medical and rehabilitation care to patients with acute cardiovascular accidents at the regional level.