García-Rudolph, Alejandro PhDa,b,c,∗; Cegarra, Blanca MSca,b,c,d; Opisso, Eloy PhDa,b,c; Tormos, Josep María PhDa,b,c; Bernabeu, Montserrat MDa,b,c; Saurí, Joan PhDa,b,c
Editor(s): Khasawneh., Fadi T.
Author Information
doi: 10.1097/MD.0000000000022423
Abstract
Severe stroke patients are known to be associated with larger rehabilitation length of stay
(LOS) but other factors besides severity may be contributing. We aim to
identify LOS predictors within a population of mostly severe patients
and analyze the impact of socioeconomic situation in functionality at
admission.
A retrospective observational cohort study was conducted including 172 inpatients admitted to a rehabilitation
center between 2007 and 2019. Associations with LOS were examined among
30 potential predictor variables using bivariate correlations.
Significantly correlated (P < .002, Bonferroni adjustment) variables were entered into 9 different multiple linear regression models.
No mild participants were included, 63.37% severe and 36.63%
moderate. Most significant LOS determinants were: 1) total functional
independence measure (FIM) (P < .001) and hemiparesis (P = .0108) (adjusted R2 = 0.24), 2) cognitive FIM (P = .002) and severity (P = .001) (adjusted R2 = 0.22), and 3) home accessibility (P = .043) and hemiparesis (P = 0.032) (adjusted R2 = 0.19).
Known LOS predictors (e.g., depression, ataxia) within the full stroke severities were not found significant in our dataset.
Socioeconomic situation was found moderately correlated with total FIM (r = −0.32, P < .0001).
When stratifying the patients’ socioeconomic situation into
mild, important, and severe social risk, their respective median total
FIM at admission were 61.5, 50, and 41, with significant differences
between the mild and important group (P < .001); also significant differences were found between mild and severe groups (P < .001).
A few of the variables identified in the literature as significant predictors of LOS within the full stroke population were also significant for our dataset (National Institutes of Health Stroke
Scale, FIM, home accessibility) explaining less than 25% of the LOS
variance. Most of the 30 analyzed known predictors were not significant
(e.g., depression, age, recurrent stroke,
ataxia, orientation, verbal communication, etc) suggesting that factors
outside functional, socioeconomic, medical, and demographics not
included in this study (e.g., rehabilitation sessions intensity) have important influences on LOS for severe patients.
Patients at mild social risk obtained significantly higher
total FIM at admission than patients at important and severe social
risk. The importance of socioeconomic situation has been scarcely
studied in the literature in relation to functionality at admission; our
results suggest that it requires to be considered.
1 Introduction
Stroke rehabilitation length of stay
(LOS) is one of the most relevant quantitative indexes that measure
health service utilization within a hospital. LOS is the principal
predictive factor of medical expenses among variables that affect the
total costs during hospitalization.[1] The ability to accurately predict which stroke
patients are likely to require longer inpatient care is desirable for
both budgetary planning and healthcare providers’ considerations as well
as to manage emotional expectations when communicating with patients
and families.[2]
Many factors have been shown to influence subacute rehabilitation LOS, including stroke severity measured with the National institute of Health Stroke Scale (NIHSS),[3] ability to perform activities of daily living,[4] or admission Functional Independence Measure (FIM) score.[5] The presence of ataxia may increase LOS,[6] dysphagia,[7] as well as aphasia,[8] diabetes,[9] obesity,[10] and hypertension.[11] Besides, recurrent stroke patients have been previously reported requiring longer LOS.[12]
Furthermore, there is evidence that motor[13] and cognitive[14] rehabilitation after stroke should be started as early as possible. Nevertheless, time since stroke onset to rehabilitation admission has been scarcely included as covariate in LOS predictive models.
Falls are common post-stroke (12%–47%) and may extend inpatient stroke rehabilitation LOS[15] as well as depression.[16]
In terms of social factors, there are conflicting reports about whether
living alone predicts LOS, for example, Tan et al (longer LOS),[17] Saxena et al (shorter LOS).[18] Besides, inadequate family support[19] and environmental factors (e.g., home modifications) may delay LOS.[20]
A 2015 Lancet review[21] reports that socioeconomic status (SES) is reflected in short-term and long-term outcomes after stroke. Studies have demonstrated an association between lower SES and having more severe deficits after stroke assessed by NIHSS at admission.[22]
To our best knowledge there is a lack of similar studies addressing
associations between functional independence, for example, total
FIM(T-FIM), motor FIM (M-FIM), and cognitive FIM (C-FIM) at admission
and SES.
Although several researchers have previously examined the prediction of LOS within the full spectrum of stroke rehabilitation
patients (mild, moderate, and severe), different variables may have
different impact in LOS when excluding the population with mild
functional impairments. For example, while age has previously been
identified as a significant contributor of LOS, this variable may not
have the same impact for severe and milder patients as the latter group
tends to be younger.[5] To classify stroke severity at admission as mild, moderate, or severe, in this work, we apply the RPG benchmark (Rehabilitation Patient Groups), as in similar previous research.[23]
The objectives of the present study are to
analyze the associations between functional independence (T-FIM, M-FIM,
and C-FIM) at admission and SES within a population of ischemic and
hemorrhagic (moderate-RPG and severe-RPG) stroke patients admitted to an inpatient rehabilitation
hospital and predict their LOS from a wide range of potential
predictors, including the aforementioned demographics, clinical, and
social state-of-the-art variables.
It is hypothesized that M-FIM, C-FIM, and T-FIM
at admission will have a stronger association (negative correlation)
with SES than NIHSS.
It is also hypothesized that, while some of the
same variables that have been identified as significant predictors of
LOS within the full stroke
population will also emerge for this sample, a different composite of
predictors will best account for the variance associated with LOS for
patients admitted to stroke rehabilitation with severe and moderate functional impairments.
