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Assessment of Stroke Rehabilitation
in Nebraska Hospitals
PHOTO GOES HERE (Need higher resolution
Katherine J. Jones, PT, PhDTeresa Cochran, PT, DPT, GCS, MA
Lou Jensen, OTD, OT/LTammy Roehrs, PT, MA, NCS
Kathleen Volkman, PT, MS, NCSAmy Goldman PT, DPT
Feb 23, 2011
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Supported by the Nebraska Department of Health and Human Services, Cardiovascular Health Program
Funding & Acknowledgements• Supported by the Nebraska Department of
Health and Human Service, Cardiovascular Health Program
• Robin High, MA for assistance with statistical analysis
• Anne Skinner, RHIA for database construction• Andrea Bowen, BA for data entry and table
formatting• Clinicians across the state who assisted in
instrument construction 2
Objectives
• Explain a framework to assess health care quality
• Describe the structure and process of stroke rehabilitation in Nebraska hospitals
• Identify two factors that predict variability in the prevalence of evidence-based structures & processes
• Discuss options to improve access to evidence-based stroke rehabilitation for survivors of stroke in Nebraska
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Purpose of the Study
1. Assess the structure and process of acute stroke rehabilitation in a representative sample of Nebraska hospitals
2. Determine the extent to which reported structures and processes are consistent with current evidence relative to stroke rehabilitation
3. Develop an action plan to increase the prevalence of evidence-based structures and processes for acute stroke rehabilitation in Nebraska hospitals
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5
What is Quality?
•“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”*
•“The greatest good that is possible to achieve in any given situation.” – Donabedian, 1980
• Avoid “underuse, overuse, misuse…” – National Roundtable on Healthcare Quality, 1998
*Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
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Donabedian’s Framework to Assess Quality
• Quality is inferred by measuring elements of care– Structure–conditions under which care is provided (human
resources, equipment, environment)
– Process–what was done (diagnosis, treatment, rehabilitation, prevention, patient education)
– Outcome–changes in individuals and populations that are due to health care
Structure Process Outcomes
Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.
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Assessing Outcomes to Infer Quality
• Advantage– “Ultimate validator” of
quality
• Limitations– Determined by multiple
factors– Time to develop (survival)– Difficult to measure (role
resumption, attitudes)– Knowledge of relationship
between process and outcomes ?
– Ability to reveal processes responsible for outcomes?
Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.
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Assessing Structure to Infer Quality
• Advantages– Equivalent to system
design, capacity for work
– Major determinant of average quality of care
– Readily observable, easily documented, stable
• Limitation– Variations must be
large to validly judge quality
Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.
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Assessing Process to Infer Quality
• Advantages– Most closely related
to outcomes– Small variations in
process can be related to variations in outcomes
• Limitations– Must establish causal
relationship between process and outcomes
– Understand role of medical beliefs, traditions
– Understand complexity of process inputs
Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.
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Treatment CharacteristicsStructure of Care Process of Care
Outcomes of Care1. Patient
a. Disease specific – lab values, X-rayb. Holistic – quality of life, ADLs
2. Provider – infection rate3. Organization – Length of Stay,
Ambulatory Care Sensitive adms.4. Payer – Cost
Patient Clinical Risk Factors1. Baseline cognitive and functional status before disease or injury2. Clinical status (severity)
Patient Demographic &Psychosocial Risk Factors1. Age 6.
Occupation2. Gender 7. Education3. Race 8.
Depression4. Marital status 9.
Residence5. Social Support
Kane RL. Understanding Health Care Outcomes Research. Gaithersburg, MD: Aspen Publishers;1997.
Stroke Rehabilitation RationaleStroke rehabilitation is the holistic, comprehensive approach to addressing the physical, psychological, social, educational, and vocational needs of individuals with stroke.1 The structure and process of stroke rehabilitation determine its outcomes. Access to coordinated systems of stroke care may be limited in rural areas.2
1. Keith RA. The comprehensive treatment team in rehabilitation. Arch Phys Med Rehabil. 1991;72:269-274.
2. Schwamm LH, Pancioli A, Acker JE,3rd, et al. Recommendations for the establishment of stroke systems of care: Recommendations from the American Stroke Association's task force on the development of stroke systems. Stroke. 2005;36:690-703.
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Stroke Rehabilitation Rationale• Interprofessional team =
Foundation of structure• Standardized assessments =
Key element of process– Document baseline, progress,
outcomes– Identify pt’s at risk – Determine need for addl
therapies– Facilitate team communication,
planning12
Consistent with IOM Competencies
Institute of Medicine. Health Professions Education: Bridge to Quality. Washington, DC:The National Academies Press; 2003; p. 46. 13
Stroke Rehabilitation Rationale• Barriers to use of
Standardized assessments– Time– Lack of peer support– Lack of information systems– Lack of library of assessments– Difficulty interpreting– Perception that they are more
relevant to research than clinical care
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Limited Access in Rural?
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Short Length of Stay in IRFs•16.5 day…avg IRF LOS•58% discharged to home•20% discharged to SNF•Rural stroke survivors likely access post-IRF outpatient, home-health, or skilled nursing care from a CAH
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Methods• Instrument validated by expert panel• Design: cross-sectional mail survey Jan–Mar 2010• Stratified random sample of 53/84 Nebraska hospitals
that provide acute stroke rehabilitation• Verified target recipient: person most knowledgeable
about stroke rehabilitation in each facility• 36/53 hospitals returned survey (68% response rate)• Analysis
• PROC SURVEYMEANS to estimate statewide means, • Fisher’s Exact Test, ANOVA, and logistic regression to examine
associations between hospital size and team structure with practices consistent with current evidence for stroke rehabilitation
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47-689 beds
25 beds 20 - 24 beds
12 - 19 beds
Total 0
10
20
30
40
50
60
70
80
90
19
34
15 16
84
19 18
8 8
53
1512
5 4
36
Stroke Rehabilitation in Nebraska Hospitals: Stratified Random Sampling
NE Hospitals that provide services to patients with stroke
Study Hospi-tals
Respondent Hospitals
Bed Size Categories
Hospital Size
> 25 beds 25 beds 20 - 24 beds 12 - 19 beds Total Population of NE Hospitals that provide services to stroke survivors 19 34 15 16 84
Study Hospitals 19 18 8 8 53
Number to Achieve 60% response rate 11 11 5 5 32
Respondent Hospitals 15 12 5 4 36
Sampling Weight for Statewide Estimates 1.267 2.833 3.000 4.000
Methods: Sample Weighting
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Results
• Structure of stroke rehabilitation care– Professionals– Team structure– Access to specialized services– Use of standardized assessments
• Team Processes– Purpose of standardized assessments– Barriers to standardize assessments– Quality improvement
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Certified Rehabilitation Registered Nurse* Recreational Therapist
Physical Medicine & Rehab Physician*Advanced Practice Registered Nurse
Neurologist*Physician Assistant
Psychologist*Family Practice Physician
Radiologist*Internal Medicine Physician*
Spiritual care (pastoral services)Case manager*
Registered NurseNutrition Therapist (Dietitian)
Occupational TherapistPhysical Therapist
Social Worker (Master’s Prepared)*Speech and Language Pathologist
0 10 20 30 40 50 60 70 80 90 100
47-689 Beds, n=15 (%) CAH 14-25 Beds, n=21 (%)
* Statistically significant p< .05
Professionals Providing Stroke Rehabilitation Care in Nebraska Hospitals by Hospital Size
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Certified Rehabilitation Registered Nurse Recreational Therapist
Physical Medicine & Rehab PhysicianNeurologist
Psychologist Advanced Practice Registered Nurse
Internal Medicine PhysicianRadiologist
Social Worker (Master’s Prepared)Case Manager
Spiritual Care (Pastoral Services)Nutrition Therapist (Dietitian)
Occupational TherapistSpeech and Language Pathologist
Physician AssistantFamily Practice Physician
Registered NursePhysical Therapist
0 10 20 30 40 50 60 70 80 90 100
12
21
22
23
32
44
44
53
55
68
78
80
82
87
91
92
95
100
Weighted Proportion of Nebraska Hospitals (n=84)
Professionals Providing Stroke Rehabilitation Care in Nebraska Hospitals
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Dedicated stroke rehabilita-tion team*
General rehabilitation team
No formal team organization
0 5 10 15 20 25 30 35 40 45 50 55 60 65
7.5
53.2
39.2
33.3
46.7
20
0
57.1
42.9
CAH 14-25 Beds (n=21)
47-689 Beds (n=15)
Weighted Proportion of Nebraska Hospitals (n=84)
Proportion * Statistically significant p = 0.008
Team Structure of Stroke Rehabilitation Care in Nebraska Hospitals
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Use of Standardized as-sessments**
Access to Specialized services*
0 5 10 15 20 25 30
15.8
17
21.5
27.4
14.2
14
CAH 14-25 Beds (n=21) 47 - 689 Beds (n=15)
Weighted Proportion of Nebraska Hospitals (n=84)
Frequency Count
*Statistically significant p <.001**Statistically significant p=.024
Use of Standardized Assessments and Access to Specialized Services in Stroke Rehabilitation by Hospital Size
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Conduct research
Compare performance across departments
Compare performance across professionals
Compare patient outcomes across conditions*
Improve communication*
Evaluate effectiveness of practice*
Measure progress and outcomes*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
5%
6%
8%
28%
52%
55%
77%
2%
2%
2%
2%
8%
27%
50%
Purpose for Use of Standardized Assessments in Stroke Rehabili-tation by Team Structure
No Team (n=12) % Team (n=24) %
Proportion of Sample Hospitals *p<0.05)
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Lack access to library of assessments
Assessments take too much time to complete, analyze
We do not have a database
Assessments more relevant to research than clinical
practice
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
33%
29%
16%
28%
43%
22%
9%
76%
34%
75%
30%
33%
44%
5%
10%
49%
Barriers to Use of Standardized Assessments in Stroke Rehabilita-tion by Team Structure
No Team (n=12) % Team (n=24) %
Proportion of Sample Hospitals *p<0.05)
Stroke Rehabilitation Quality Improvement by Team Structure and Hospital Size
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Stroke rehabilitation QI project in past year†
% of stroke survivors discharged to community†
Re-hospitalization rate within 30 days of discharge†
Outcome Data Collected
Discharge Criteria*
Admission Criteria*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
29%
48%
59%
52%
51%
62%
0%
9%
18%
16%
62%
73%
12%
31%
27%
43%
71%
85%
1%
17%
47%
21%
41%
44%
No Team Team CAH 47-689 Beds
*p<.05 No team vs. team† p<.05 47 – 689 Beds vs CAH
Strengths and Limitations
• Strengths– Expert panel ensured face validity of instrument– Stratified random sample enabled statewide est.– Adequate response rate (68%)
• Limitations– Assessed structure and process by self report– Did not assess outcomes– Small sample size limits power
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Summary• Stroke survivors receiving rehabilitation in CAH setting
– Limited access to interprofessional team care– Limited access to specialized services– Less likely to receive standardized assessments
• Stroke rehabilitation care in CAHs– Less likely to collect outcome data or engage in QI
• Barriers to use of standardized assessments do not vary by hospital size– Hospitals with formal teams use assessments to guide care
• 60% of hospitals interested in collaboration to improve use of standardized assessments, access to services
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ConclusionDue to short lengths of stay in IRFs, the structure and process of stroke rehabilitation must be consistent with the IOM competencies across the continuum of settings. Future research needed: (1) Is team structure a determinant of post-IRF
stroke rehabilitation outcomes?(2) What are the specialized service needs of rural
stroke survivors and their caregivers?(3) How can technology facilitate use of stroke
rehabilitation standardized assessments?30