Patients undergoing subacute rehabilitation have accurate expectations of their health-related quality of life at discharge

Background Expectations held by patients and health professionals may affect treatment choices and participation (by both patients and health professionals) in therapeutic interventions in contemporary patient-centered healthcare environments. If patients in rehabilitation settings overestimate their discharge health-related quality of life, they may become despondent as their progress falls short of their expectations. On the other hand, underestimating their discharge health-related quality of life may lead to a lack of motivation to participate in therapies if they do not perceive likely benefit. There is a scarcity of empirical evidence evaluating whether patients' expectations of future health states are accurate. The purpose of this study is to evaluate the accuracy with which older patients admitted for subacute in-hospital rehabilitation can anticipate their discharge health-related quality of life. Methods A prospective longitudinal cohort investigation of agreement between patients' anticipated discharge health-related quality of life (as reported on the EQ-5D instrument at admission to a rehabilitation unit) and their actual self-reported health-related quality of life at the time of discharge from this unit was undertaken. The mini-mental state examination was used as an indicator of patients' cognitive ability. Results Overall, 232(85%) patients had all assessment data completed and were included in analysis. Kappa scores ranged from 0.42-0.68 across the five EQ-5D domains and two patient cognition groups. The percentage of exact correct matches within each domain ranged from 69% to 85% across domains and cognition groups. Overall 40% of participants in each cognition group correctly anticipated all of their self-reported discharge EQ-5D domain responses. Conclusions Patients admitted for subacute in-hospital rehabilitation were able to anticipate the discharge health-related quality of life on the EQ-5D instrument with a moderate level of accuracy. This finding adds to the foundational empirical work supporting joint treatment decision making and patient-centered models of care during rehabilitation following acute illness or injury. Accurate patient expectations of the impact of treatment (or disease progression) on future health-related related quality of life is likely to allow patients and health professionals to successfully target interventions to priority areas where meaningful gains can be achieved.

High risk feet in subacute rehabilitation facilities : how many are there?

Background Australian subacute rehabilitation facilities face significant challenges from the ageing population with increased burden of chronic disease. High risk foot complications are a negative consequence of many chronic diseases. With the rapid expansion of subacute services, it seems imperative to investigate the prevalence of foot complications in this population. The primary aim of this study was to quantify the high risk foot complication prevalence in a subacute rehabilitation population. Methods Eligible participants were all adults admitted overnight, over two 4 week periods, into a large Australian subacute rehabilitation facility. Consenting participants underwent a short non-invasive foot examination by a podiatrist. The standard Queensland Health High Risk Foot Form collected data on age, sex, co-morbidities and foot complications. Descriptive statistics, logistic regression and odds ratios were used to determine the prevalence of foot complications and associations with explanatory variables. Results Overall, 85 of 97 eligible participants consented; mean age 80(9) and 71% were female. At least one foot complication was present in 56.5% participants; including 21.2% defined as high risk and 11.8% current foot ulcer. A previous diagnosis of neuropathy increased the risk of presenting with a high risk foot by 13-fold (OR 13.504, p = 0.001). Conclusion This study highlights the significance of foot complications in the subacute population. It appears that one in every two patients present with a foot complication and one in eight with a foot ulcer. It is suggested all patients admitted to subacute rehabilitation services should be screened for foot complications.

Physiotherapists have accurate expectations of their patients’ future health-related quality of life after first assessment in a subacute rehabilitation setting

BACKGROUND Expectations held by health professionals and their patients are likely to affect treatment choices in subacute inpatient rehabilitation settings for older adults. There is a scarcity of empirical evidence evaluating whether health professionals expectations of the quality of their patients' future health states are accurate. METHODS A prospective longitudinal cohort investigation was implemented to examine agreement (kappa coefficients, exact agreement, limits-of-agreement, and intraclass-correlation coefficients) between physiotherapists' (n = 23) prediction of patients' discharge health-related quality of life (reported on the EQ-5D-3L) and the actual health-related quality of life self-reported by patients (n = 272) at their discharge assessment (using the EQ-5D-3L). The mini-mental state examination was used as an indicator of patients' cognitive ability. RESULTS Overall, 232 (85%) patients had all assessment data completed and were included in analysis. Kappa coefficients (exact agreement) ranged between 0.37-0.57 (58%-83%) across EQ-5D-3L domains in the lower cognition group and 0.53-0.68 (81%-85%) in the better cognition group. CONCLUSIONS Physiotherapists in this subacute rehabilitation setting predicted their patients' discharge health-related quality of life with substantial accuracy. Physiotherapists are likely able to provide their patients with sound information regarding potential recovery and health-related quality of life on discharge. The prediction accuracy was higher among patients with better cognition than patients with poorer cognition.

Demographics and discharge outcomes of dysvascular and non-vascular lower limb amputees at a subacute rehabilitation unit: A 7-year series

Objective To examine personal and social demographics, and rehabilitation discharge outcomes of dysvascular and non-vascular lower limb amputees. Methods In total, 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission and discharge descriptive statistics (frequency, percentages) were calculated and compared by aetiology. Results Participants were male (74%), aged 65 years (s.d. 14), born in Australia (72%), had predominantly dysvascular aetiology (80%) and a median length of stay 48 days (interquartile range (IQR): 25–76). Following amputation, 56% received prostheses for mobility, 21% (n = 89) changed residence and 28% (n = 116) required community services. Dysvascular amputees were older (mean 67 years, s.d. 12 vs 54 years, s.d. 16; P < 0.001) and recorded lower functional independence measure – motor scores at admission (z = 3.61, P < 0.001) and discharge (z = 4.52, P < 0.001). More nonvascular amputees worked before amputation (43% vs 11%; P < 0.001), were prescribed a prosthesis by discharge (73% vs 52%; P < 0.001) and had a shorter length of stay (7 days, 95% confidence interval: –3 to 17), although this was not statistically significant. Conclusions Differences exist in social and demographic outcomes between dysvascular and non-vascular lower limb amputees.

Prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility: a cross-sectional prevalence study

Background Australian subacute inpatient rehabilitation facilities face significant challenges from the ageing population and the increasing burden of chronic disease. Foot disease complications are a negative consequence of many chronic diseases. With the rapid expansion of subacute rehabilitation inpatient services, it seems imperative to investigate the prevalence of foot disease and foot disease risk factors in this population. The primary aim of this cross-sectional study was to determine the prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility. Methods Eligible participants were all adults admitted at least overnight into a large Australian subacute inpatient rehabilitation facility over two different four week periods. Consenting participants underwent a short non-invasive foot examination by a podiatrist utilising the validated Queensland Health High Risk Foot Form to collect data on age, sex, medical co-morbidity history, foot disease risk factor history and clinically diagnosed foot disease complications and foot disease risk factors. Descriptive statistics were used to determine the prevalence of clinically diagnosed foot disease complications, foot disease risk factors and groups of foot disease risk factors. Logistic regression analyses were used to investigate any associations between defined explanatory variables and appropriate foot disease outcome variables. Results Overall, 85 (88%) of 97 people admitted to the facility during the study periods consented; mean age 80 (±9) years and 71% were female. The prevalence (95% confidence interval) of participants with active foot disease was 11.8% (6.3 – 20.5), 32.9% (23.9 – 43.5) had multiple foot disease risk factors, and overall, 56.5% (45.9 – 66.5) had at least one foot disease risk factor. A self-reported history of peripheral neuropathy diagnosis was independently associated with having multiple foot disease risk factors (OR 13.504, p = 0.001). Conclusion This study highlights the potential significance of the burden of foot disease in subacute inpatient rehabilitation facilities. One in eight subacute inpatients were admitted with active foot disease and one in two with at least one foot disease risk factor in this study. It is recommended that further multi-site studies and management guidelines are required to address the foot disease burden in subacute inpatient rehabilitation facilities. Keywords: Subacute; Inpatient; Foot; Complication; Prevalence

Functional independence following subacute inpatient rehabilitation was not affected by age among older patients recovering from cardiac-related hospital admissions

Introduction Older people recovering from cardiac events requiring an acute hospital admission may experience a decline in physical function limiting their ability to return home to their previous accommodation. Subacute inpatient rehabilitation therapies have potential to assist recovery of physical functioning. However, it is unknown whether age influences the length of stay or physical functioning at discharge from subacute inpatient rehabilitation for this population. Objectives This study examined the outcomes of a cohort of older patients recovering from a cardiac event requiring hospitalisation to investigate the association between age and physical function at discharge, as well as age and length of rehabilitation stay. Methods Participants included 145 consecutive inpatient admissions to a subacute geriatric assessment and rehabilitation unit with a cardiac condition as their primary reason for hospital admission. Participants were required to complete a multi-disciplinary physical functioning assessment within 72 hours of admission to the unit, and again within 72 hours prior to discharge from the unit. The primary outcome measure was the Functional Independence Measure motor score. Demographic and clinical information, including length of stay and discharge destination, were also recorded. Results A total n=126 (87%) participants, with a mean (standard deviation) age of 79 (10) years, had both assessments completed and were included in analyses. Participants who had passed away (n=4, 3%), or did not have both assessments completed per protocol were excluded from analyses. Discharge destinations included home (n=101, 80%), residential aged care (n=17, 13%) and another hospital (n=8, 6%). The (median, interquartile range) Functional Independence Measure motor score was higher at discharge (79, 71 to 84) than admission (61, 48 to 71); z=7.75 p<0.001. Age was not associated with Functional Independence Measure motor score at discharge (t= -0.18, p=0.86), or length of stay in the rehabilitation unit (t= -0.52, 0.60). Conclusion Any perception that age may be associated with longer lengths of stay and reduced physical function outcomes among patients with cardiac conditions admitted for subacute inpatient rehabilitation for older adults is not supported data from this investigation. Older age should not be considered a disincentive when considering the suitability of patients with cardiac diagnoses for this type of inpatient rehabilitation or their potential physical functioning outcome.

Patients Undergoing Subacute Physical Rehabilitation following an Acute Hospital Admission Demonstrated Improvement in Cognitive Functional Task Independence

Objective. This study investigated cognitive functioning among older adults with physical debility not attributable to an acute injury or neurological condition who were receiving subacute inpatient physical rehabilitation. Design. A cohort investigation with assessments at admission and discharge. Setting. Three geriatric rehabilitation hospital wards. Participants. Consecutive rehabilitation admissions () following acute hospitalization (study criteria excluded orthopaedic, neurological, or amputation admissions). Intervention. Usual rehabilitation care. Measurements. The Functional Independence Measure (FIM) Cognitive and Motor items. Results. A total of 704 (86.5%) participants (mean age = 76.5 years) completed both assessments. Significant improvement in FIM Cognitive items (-score range 3.93–8.74, all ) and FIM Cognitive total score (-score = 9.12, ) occurred, in addition to improvement in FIM Motor performance. A moderate positive correlation existed between change in Motor and Cognitive scores (Spearman’s rho = 0.41). Generalized linear modelling indicated that better cognition at admission (coefficient = 0.398, ) and younger age (coefficient = −0.280, ) were predictive of improvement in Motor performance. Younger age (coefficient = −0.049, ) was predictive of improvement in FIM Cognitive score. Conclusions. Improvement in cognitive functioning was observed in addition to motor function improvement among this population. Causal links cannot be drawn without further research.

Patients with physical debility undergoing subacute physical rehabilitation following an acute hospital admission demonstrated improvement in cognitive functional task independence

Background: Hospitalised older adults often experience a decline in physical functioning and mobility in the lead up to (or during) an acute hospital admission. During acute illness and hospitalisation, older adults may also experience a decline or fluctuation in their cognitive functioning. Previous studies have demonstrated that patients with or without reduced cognitive functioning on admission to subacute inpatient rehabilitation have considerable potential to improve their physical functioning and quality of life.

A stepped-wedge cluster randomised controlled trial for evaluating rates of falls among inpatients in aged care rehabilitation units receiving tailored multimedia education in addition to usual care : a trial protocol

Introduction Falls are the most frequent adverse event reported in hospitals. Approximately 30% of in-hospital falls lead to an injury and up to 2% result in a fracture. A large randomised trial found that a trained health professional providing individualised falls prevention education to older inpatients reduced falls in a cognitively intact subgroup. This study aims to investigate whether this efficacious intervention can reduce falls and be clinically useful and cost-effective when delivered in the real-life clinical environment. Methods A stepped-wedge cluster randomised trial will be used across eight subacute units (clusters) which will be randomised to one of four dates to start the intervention. Usual care on these units includes patient's screening, assessment and implementation of individualised falls prevention strategies, ongoing staff training and environmental strategies. Patients with better levels of cognition (Mini-Mental State Examination >23/30) will receive the individualised education from a trained health professional in addition to usual care while patient's feedback received during education sessions will be provided to unit staff. Unit staff will receive training to assist in intervention delivery and to enhance uptake of strategies by patients. Falls data will be collected by two methods: case note audit by research assistants and the hospital falls reporting system. Cluster-level data including patient's admissions, length of stay and diagnosis will be collected from hospital systems. Data will be analysed allowing for correlation of outcomes (clustering) within units. An economic analysis will be undertaken which includes an incremental cost-effectiveness analysis. Ethics and dissemination The study was approved by The University of Notre Dame Australia Human Research Ethics Committee and local hospital ethics committees. Results The results will be disseminated through local site networks, and future funding and delivery of falls prevention programmes within WA Health will be informed. Results will also be disseminated through peer-reviewed publications and medical conferences.

Length of Stay, Discharge Destination, and Functional Improvement: Utility of the Australian National Subacute and Nonacute Patient Casemix Classification

Background and Purpose - Although implemented in 1998, no research has examined how well the Australian National Subacute and Nonacute Patient (AN-SNAP) Casemix Classification predicts length of stay (LOS), discharge destination, and functional improvement in public hospital stroke rehabilitation units in Australia. Methods - 406 consecutive admissions to 3 stroke rehabilitation units in Queensland, Australia were studied. Sociode-mographic, clinical, and functional data were collected. General linear modeling and logistic regression were used to assess the ability of AN-SNAP to predict outcomes. Results - AN-SNAP significantly predicted each outcome. There were clear relationships between the outcomes of longer LOS, poorer functional improvement and discharge into care, and the AN-SNAP classes that reflected poorer functional ability and older age. Other predictors included living situation, acute LOS, comorbidity, and stroke type. Conclusions - AN-SNAP is a consistent predictor of LOS, functional change and discharge destination, and has utility in assisting clinicians to set rehabilitation goals and plan discharge.

Whole of life cycle cost analysis in bridge rehabilitation

The report presents a methodology for whole of life cycle cost analysis of alternative treatment options for bridge structures, which require rehabilitation. The methodology has been developed after a review of current methods and establishing that a life cycle analysis based on a probabilistic risk approach has many advantages including the essential ability to consider variability of input parameters. The input parameters for the analysis are identified as initial cost, maintenance, monitoring and repair cost, user cost and failure cost. The methodology utilizes the advanced simulation technique of Monte Carlo simulation to combine a number of probability distributions to establish the distribution of whole of life cycle cost. In performing the simulation, the need for a powerful software package, which would work with spreadsheet program, has been identified. After exploring several products on the market, @RISK software has been selected for the simulation. In conclusion, the report presents a typical decision making scenario considering two alternative treatment options.

User friendly guide for rehabilitation or strengthening of bridge structures using fiber reinforced polymer composites

A worldwide interest is being generated in the use of fibre reinforced polymer composites (FRP) in rehabilitation of reinforced concrete structures. As a replacement for the traditional steel plates or external post-tensioning in strengthening applications, various types of FRP plates, with their high strength to weight ratio and good resistance to corrosion, represent a class of ideal material in external retrofitting. Within the last ten years, many design guidelines have been published to provide guidance for the selection, design and installation of FRP systems for external strengthening of concrete structures. Use of these guidelines requires understanding of a number of issues pertaining to different properties and structural failure modes specific to these materials. A research initiative funded by the CRC for Construction Innovation was undertaken (primarily at RMIT) to develop a decision support tool and a user friendly guide for use of fibre reinforced polymer composites in rehabilitation of concrete structures. The user guidelines presented in this report were developed after industry consultation and a comprehensive review of the state of the art technology. The scope of the guide was mainly developed based on outcomes of two workshops with Queensland Department of Main Roads (QDMR). The document covers material properties, recommended construction requirements, design philosophy, flexural, shear and torsional strengthening of beams and strengthening of columns. In developing this document, the guidelines published on FIB Bulletin 14 (2002), Task group 9.3, International Federation of Structural Concrete (FIB) and American Concrete Institute Committee 440 report (2002) were consulted in conjunction with provisions of the Austroads Bridge design code (1992) and Australian Concrete Structures code AS3600 (2002). In conclusion, the user guide presents design examples covering typical strengthening scenarios.

Decision support tools for concrete infrastructure rehabilitation (using FRP composites)

This report presents a summary of the research conducted by the research team of the CRC project 2002-005-C, “Decision support tools for concrete infrastructure rehabilitation”. The project scope, objectives, significance and innovation and the research methodology is outlined in the introduction, which is followed by five chapters covering different aspects of the research completed. Major findings of a review of literature conducted covering both use of fibre reinforced polymer composites in rehabilitation of concrete bridge structures and decision support frameworks in civil infrastructure asset management is presented in chapter two. Case study of development of a strengthening scheme for the “Tenthill Creek bridge” is covered in the third chapter, which summarises the capacity assessment, traditional strengthening solution and the innovative solution using FRP composites. The fourth chapter presents the methodology for development of a user guide covering selection of materials, design and application of FRP in strengthening of concrete structures, which were demonstrated using design examples. Fifth chapter presents the methodology developed for evaluating whole of life cycle costing of treatment options for concrete bridge structures. The decision support software tool developed to compare different treatment options based on reliability based whole of life cycle costing will be briefly described in this chapter as well. The report concludes with a summary of findings and recommendations for future research.