Meal and Rest Period Issues

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Research to Identify Trends and Opportunities: A Focus on Stroke

M. Elizabeth Sandel, MD Chief, PM&R, Napa Solano Service Area Director, Research and Training, Kaiser Foundation Rehabilitation Center and the Kabat-Knott Center for Rehabilitation Research Vallejo, CA

Three Areas of Focus in Stroke Rehabilitation

POST-ACUTE CARE/REHABILITATION  Disparities  Mortality  Functional Outcomes

Disparities in Stroke Rehabilitation Kabat-Knott Center for Rehabilitation Research Kaiser Foundation Rehabilitation Center, Vallejo, CA A Center of Excellence for Members with Disabilities: Institute for Culturally Competent Care

Multiple Sites of Care in KP System

Sites of Care % Receiving Each Pattern of PAC

25

20

15

10

5

0

IR F SNF HH OP

IR F S NF HH

IR F SNF OP

IR F SNF

IR F HH OP

IR F OP

IR F

SNF HH OP

SNF HH

SNF OP

SNF

HH OP

HH

OP

NONE

5

Research Team: Disparities in Stroke Rehab KFRC M. Elizabeth Sandel, MD, Principle Investigator Hua Wang, PhD, Research Scientist Richard Delmonico, PhD, Chief of Neuropsychology Kaiser Permanente Division of Research Joseph Terdiman, MD, PhD Steven Sidney, MD, PhD Charles Quesenberry, PhD Co-Investigators: Bernadette Ford Lattimer, CDC; Jeanne Hoffman, Marcia Ciol, University of Washington, and Leighton Chan, NIH Funding: CDC SIP 3-05 Sandel ME, et al, PM&R 2009;1:29-406

Research Questions: Disparities Study

 What are the referral and enrollment rates for rehabilitation (post-acute care) following discharge from the hospital after a stroke?  Are there disparities in care for patients in various settings based on variables such as: • Race/ethnicity • Gender • Age • Socioeconomic status • Hospital referral patterns • Rural/urban setting • Type of stroke 7

Research: Disparities Study

• Design: Retrospective Cohort Study • Site: The Northern California Kaiser Permanente Health System • Methods: Tracked rehabilitation services for 365 days following acute hospitalization for a first stroke • Participants: 11,119 stroke patients hospitalized for acute stroke from 1996-2003 • Outcome measures (service delivery): Inpatient rehabilitation hospital, skilled nursing facility, home health services, outpatient rehabilitation services • Variables: Age, gender, race/ethnicity, socioeconomic status (income, education), rural/urban residence, medical center referrals, type of stroke 8

Results: Disparities Study • Mean age: 69.7, 51% female • Race/ethnicity: 70.2% white, 10.8% black, 8.8% Asian, 7.4% Hispanic • Median household income: $56,750 • Median percentage with at least a high school education: 87%; 28% had 4 years or more of college education • Type of stroke: 85% ischemic, 15% hemorrhagic • LOS: Median = 3; mean = 5.2; patients discharged to IRH had longer LOS • • • •

White population older at the time of stroke Higher percentages of white and Hispanic populations living in rural areas Asians were more likely to have a hemorrhagic stroke Median household incomes lower for black and Hispanic populations

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Results: Disparities Study • Percentage discharged directly to IRH and home increased over time • Age: Younger patients more likely go to IRH; older patients to SNF • Gender: Female patients more likely to receive IRH and SNF care • Race/ethnicity: Asian and black patients more likely to receive IRH care than whites and Hispanics • Type of stroke: hemorrhagic stroke patients less likely to be treated in IRH • Rural patients, more remote from IRH less likely to receive IRH, HH, and more likely to have only OP care or no care at all • Socioeconomic status: Patients with higher income and more education more likely to go to IRH; patients with lower income more likely to go to SNF 10

Disparities Study: Discussion Points

 White women were more likely to be treated in an SNF: lack of caregivers?  Some minorities more likely to receive care in IRH: caregivers available?  Disparities in rehabilitation services provided after stroke may be caused by complex interrelationships of • • • • • • • •

Socioeconomic factors Age Gender Race/ethnicity Geography Severity of stroke Differences in discharge planning processes or criteria for referral Education of patients and families and providers

Stroke Mortality in Post-Acute Care Kabat-Knott Center for Rehabilitation Research Kaiser Foundation Rehabilitation Center, Vallejo, CA A Center of Excellence for Members with Disabilities: Kaiser Permanente Institute for Culturally Competent Care

Research Team: Stroke Mortality in PAC

KFRC Principle Investigator: Hua Wang, PhD, Research Scientist M. Elizabeth Sandel, MD, Co-investigator Michelle Camicia, MSN, CRRN, Co-investigator Kaiser Permanente Division of Research Joseph Terdiman, MD, PhD Arthur Klatsky, MD Steven Sidney, MD, PhD Maryann Armstrong, PhD Funding: Community Benefits, KP 13

Research Questions: Stroke Mortality/PAC

 Does mortality rate vary with different types of post-acute services?  Does post-acute service delivery contribute to a lower mortality rate?  Is time from stroke onset to first rehabilitation treatment related to mortality rate?  Have there been changes in stroke incidence, mortality rate and PAC services in KPNC during the past decade?  Does the use of statins, other CV meds link to a reduction in mortality?  Does the prescription of anti-depressants link to a reduction in mortality?  Are there disparities in stroke mortality based on race/ethnicity, age, socioeconomic status, rural/urban residence, or other factors?

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Ischemic Stroke Mortality Study

 Design: A retrospective cohort study  Setting: The Kaiser Permanente Northern California (KPNC) health care system  Cohort: • 20,549 adult acute ischemic stroke cases between 19962004 • ICD-9: 433.x, 434.x, and 436.x except 5th digit=0 (no cerebral infarction)  Data Analysis: • Descriptive statistics • Bivariate analysis • Cox proportional hazard model

Results

 Age (mean±sd): 72.2±12.5  Gender: 52.5% female  Race: 7.3% Asian, 11.8% African American, 7.2% Hispanic, 70.8% Caucasain  Residential Area: 3.8% rural  Median Household Income (103): 22.7% $0-40, 57.2% $40-80, 16.1% $80+  Acute Care Facility: 30% central CA or Capital area  LOS (median, IQR): 3 (2,5)

Results

 30-Day Follow-up: • • • •

Deyo-Charlson Index: 17.3% (0), 63.3% (1-4), 19.4% (5+) Smoking: 11.7% smoker, 3.8% quit, 84.5% none Medication Prescription: 67.1% Highest Level of PAC: 6.3% IRH, 34.1% SNF, 15.3% HH, 31.2% OP, 12.1% None, 1.1% HP

Results

 1-Year Follow-up: • Deyo-Charlson Index: 13.6% (0), 59.9% (1-4), 26.5% (5+) • Smoking: 13.2% smoker, 6.2% quit, 80.6% none • Medication Prescription: 88.4% • Highest Level of PAC: 9.8% IRH, 41.9% SNF, 16.5% HH, 24.3% OP, 3.4% None, 4.2% HP

Health Care Delivery & Rehabilitation: Ischemic Stroke

Survival Distribution Function

1.00 1=IRH 2=OP

0.90

3=HH 4=NONE 0.80

0.70

5=SNF

0.60 0

100

200

300

Days

Mortality Study: Discussion Points

 Variation in mortality rates was related to whether rehabilitation services were provided in inpatient (IRH) and outpatient settings  Variation in medication prescription for prevention of cardiovascular or cerebrovascular events may be related to reduced mortality; limitation: patients in SNF not discharged home had no outpatient prescriptions to be analyzed  Variation in prescription of anti-depressants may also be related to post-stroke mortality; same limitation as above  What is the role for the physician/physiatrist, rehabilitation nurse, therapist, and other team members to the reduction in post-stroke mortality?

Stroke Outcomes Monitoring Study Kabat-Knott Center for Rehabilitation Research Kaiser Foundation Rehabilitation Center, Vallejo, CA A Center of Excellence for Members with Disabilities: Kaiser Permanente Institute for Culturally Competent Care

Research Team: OMS Study KFRC M. Elizabeth Sandel, MD, Principle Investigator Jed Appelman, PhD, Research Project Manager Hua Wang, PhD, Research Scientist Richard Delmonico, PhD, Chief of Neuropsychology, KFRC Michelle Camicia, MSN, CRRN, Director of Rehab Operation Division of Research: Joseph Terdiman, MD, PhD NIH: Leighton Chan, MD, MPH; Elizabeth Rasch, PT, PhD Boston University Alan Jette, PT, PhD Richard Moed, PhD Funding: National Institutes of Health Clinical Center; ARRA Challenge Grant (just awarded)

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Research Questions: OMS Study

 What is the feasibility of using a computer-based assessment of functional outcomes (stroke patients) across the continuum of post-acute care?  What is the variation, if any, in functional outcomes, of patient across multiple sites of care in a 6-month period after an acute stroke?  What is the variation, if any, in hospital readmission or mortality rates of patients across the care continuum during the 6 months after the stroke?  Are there disparities in stroke mortality based on race/ethnicity, age, socioeconomic status, rural/urban residence, or other factors in the study cohort?

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Study Overview: OMS

Study Goals To implement a functional outcomes monitoring system (OMS) across the continuum of care and test its feasibility To assess the functional outcomes of stroke patients using the OMS in multiple post-acute care (PAC) settings To compare the outcomes in various PAC sites

Study Method Use a computerized assessment instrument, eCAT, developed at Boston University (AM-PAC)

Study Participants From 4 KP Service Areas

Study Duration Follow participants for a minimum of six months following discharge from acute care 24

OMS: Study Procedure

 Up to now: recruited 265 study participants  A total of 500 will be evaluated  Referrals from HBS physicians, neurologists, physiatrists, discharge planners; review EMR each morning  Consent patients, and use surrogate decision-makers as approved by the IRB  Assess study participants using NIH stroke scale and then computerized eCAT assessment instrument  Most participants need assistance; research assistant performs assessments on site or occasionally by phone  Follow study participants for six months following discharge from acute care

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OMS: Study Visits

 Initial contact with study participants is prior to discharge from acute care • • • •

In hospital In person with study staff member Consent First eCAT assessment

 Second contact with study participants is prior to discharge from post acute care (such as SNF or Home Health) • In person with study staff member or by telephone • Second eCAT assessment

 Follow up contacts prior to discharge from any additional care  Substudy: proxy vs. patient vs. clinician assessments at 6 months

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Outcomes Measure

eCAT Instrument  Computer assessment can be completed by study participant, caregiver, family member, or study staff with input from care providers  Measure function in three areas • Mobility • Self-care • Cognition  It’s fast! Takes about ten minutes to set up a new study participant and complete the assessment  Can measure functioning along the complete range in each of the three areas  Shows changes over time with repeated assessments K

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AM-PAC or eCAT Functional Outcome Report

Patient

Facility

Episode Visits

Admission

Discharge Bending over: No Difficulty

Bending over: A Lot Difficulty

Walk fast mile: No Difficulty Low Couch: A Little Difficulty

Walking outdoors: A Little Difficulty Stand from chair: A Lot of Difficulty

Run short : No Difficulty

Walking indoors: A Little Difficulty

Run 10 min: No Difficulty Vigorous activities: Limited a Little Sharp turns: A Little Difficulty

Total score: 54.7 (2.3)

Total score 70.9 (2.7) Admission ■■ ■■

0

50

[

54.7

]

Discharge ■ ■■■ ■ ■ ■

[70.8 ]

100

AM-PAC Recovery Pathways: Stroke

Change: Mobility on Two Care Paths 60

eCAT Scores

50

Any SNF no IRF 40 30 20

Any IRF

10 0

Baseline

Visit 2

Visit 3

6 Mo

Time Points

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American Recovery and Reinvestment Act, 2009

“… the stimulus package signed into law by President Barack Obama on February 17, 2009 directs $1.1 billion to support…” “… the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies, including through efforts … that conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions.”