O'Donnell J C, Hamilton B B
Rehabilitation Services Research and Development Unit, Department of Veterans Affairs Medical Center, Durham, NC 27705, USA.
Arch Phys Med Rehabil. 1997 Sep;78(9):929-37. doi: 10.1016/s0003-9993(97)90052-6.
To assess the relation between the source of stroke patients' referral to the rehabilitation unit and rehabilitation outcome.
Multivariate analysis of rehabilitation outcomes prospectively collected and supplemented by data from Department of Veterans Affairs (VA) administrative records.
Fifty-three hospital-based VA rehabilitation units located nationwide.
A total of 2,031 first-admission stroke patients discharged from VA rehabilitation units in fiscal years 1993-1994.
Observational study.
Functional Independence Measure (FIM) at admission, gains in motor and cognitive function, rehabilitation length of stay (LOS), and the probability of discharge to home.
Controlling for clinical, demographic, and unit characteristics, referral source predicted admission function, LOS, and home discharge (p < or = .0001), but did not predict motor or cognitive gain (p > .05). Patients referred from long-term care and other acute hospitals (Acute Other) had significantly lower adjusted admission FIM scores than patients referred directly from home (respectively, 12.9 and 17.0 FIM units lower), and from the acute care services of the VA hospital providing rehabilitation (4.8 and 8.9 units lower). Acute Other referrals had longer risk-adjusted LOS than referrals from any other source (4.6 to 6.4 days longer), and patients from both Acute Other and long-term care had a lower probability of home discharge than the remaining two referral groups (reduction in probability range: .06 to .27).
VA administrators and clinicians need to consider referral source when evaluating and comparing unit performance in stroke rehabilitation. Patients referred from Acute Other and long-term care settings may require more intensive management to offset their functional and social deficits, and to reduce LOS and increase home discharge rates. Referral source also identified highly functional patients who possibly could be cared for approximately in less costly rehabilitation settings. These issues warrant further research especially as the VA seeks to achieve cost savings in this era of reduced funding.
评估中风患者转入康复单元的来源与康复结果之间的关系。
对前瞻性收集的康复结果进行多变量分析，并由退伍军人事务部（VA）行政记录数据进行补充。
全国范围内的53个基于医院的VA康复单元。
1993 - 1994财年从VA康复单元出院的共2031例首次入院的中风患者。
观察性研究。
入院时的功能独立性测量（FIM）、运动和认知功能的改善、康复住院时间（LOS）以及出院回家的概率。
在控制临床、人口统计学和单元特征后，转诊来源可预测入院功能、LOS和出院回家情况（p≤0.0001），但不能预测运动或认知功能的改善（p＞0.05）。从长期护理机构和其他急症医院（急性其他）转诊的患者，其调整后的入院FIM评分显著低于直接从家中转诊的患者（分别低12.9和17.0个FIM单位），以及从提供康复服务的VA医院急症护理服务转诊的患者（分别低4.8和8.9个单位）。急性其他转诊患者的风险调整后LOS比其他任何来源的转诊患者都长（长4.6至6.4天），并且来自急性其他和长期护理机构的患者出院回家的概率低于其余两个转诊组（概率降低范围：0.06至0.27）。
VA管理人员和临床医生在评估和比较中风康复单元的表现时需要考虑转诊来源。从急性其他和长期护理机构转诊的患者可能需要更强化的管理，以弥补其功能和社会缺陷，并减少LOS和提高出院回家率。转诊来源还识别出功能良好的患者，他们可能可以在成本较低的康复环境中得到照料。这些问题值得进一步研究，特别是在VA试图在资金减少的时代实现成本节约的情况下。
