Revisiting Length of Stay in Stroke Rehabilitation in Turkey

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1 257 ORIGINAL ARTICLE Revisiting Length of Stay in Stroke Rehabilitation in Turkey Ozden Ozyemisci-Taskiran, MD, Zafer Gunendi, MD, Ozlem Aknar, MD, Gulcin K. Karatas, MD, Vesile Sepici, MD ABSTRACT. Ozyemisci-Taskiran O, Gunendi Z, Aknar O, Karatas GK, Sepici V. Revisiting length of stay in stroke rehabilitation in Turkey. Arch Phys Med Rehabil 2011;92: Objective: To investigate the parameters influencing length of stay (LOS) in stroke rehabilitation in Turkey. Design: Retrospective study. Setting: Rehabilitation ward in a university hospital, a referral center in the capital of Turkey. Participants: Consecutive inpatient stroke survivors (N 142) after ischemic or hemorrhagic cerebrovascular events rehabilitated in a university rehabilitation center between January 2005 and October Interventions: Not applicable. Main Outcome Measure: The primary study outcome measurement is LOS on the rehabilitation ward. Results: LOS was best predicted by Brunnstrom s motor recovery stages (BMRS) lower extremity on admission, BMRS hand on admission, and the presence of infections (LOS in days BMRS lower extremity 3.2 BMRS hand 10.3 presence of infections [infection; present 2, absent 1]; R 2.37). Conclusions: Motor impairments and infections were the parameters that most affected LOS in stroke rehabilitation. Prevention strategies for infections should be pursued more aggressively. The prevention of infections, which is an essential component of a patient s general well-being, also shortened LOS in stroke rehabilitation. High medical costs urge LOS to shorten in the developing countries hereafter. A national rehabilitation policy should be implemented to reach the same functional outcome with shorter LOS in stroke patients. Key Words: Infection length of stay; Rehabilitation; Stroke by the American Congress of Rehabilitation Medicine STROKE AND ITS RELATED physical, psychosocial, and economic consequences to the survivors, their families, and the community have been the subject of numerous studies. As the world ages, an increase in the prevalence of stroke is inevitable. Age-adjusted incidence rates of stroke in highincome countries (according to World Bank s country classification) decreased by 42% from the period between 1970 and 1979 to the period between 2000 and 2008, whereas these rates increased more than 100% in low-middle income countries From the Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine, Ankara, Turkey. Presented in part to the 5th World Congress of the International Society of Physical and Rehabilitation Medicine, June 13 17, 2009, istanbul, Turkey. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to Ozden Ozyemisci-Taskiran, MD, 78. Sokak 8/8, israilevleri/ Emek, Ankara, Turkey, ozdenozyemisci@yahoo.com /11/ $36.00/0 doi: /j.apmr during the same period. In low-middle income countries, the incidence of stroke reached an epidemic level. 1 In Turkey, national health registration systems are inadequate to properly identify the prevalence of stroke. Therefore data are calculated through estimation from different data sources in combination with incomplete health information systems. Cerebrovascular disease was the second leading cause of death after ischemic heart diseases for both men and women in 2000 in Turkey (men, 14.5%; women, 15.7%). 2 In the current health care system of Turkey, individual expenditures are strictly controlled and restrained by laws; instead comprehensive medical coverage is provided. In 2006, the Social Security Institution was established by the Social Security Institution Law. 3 With the enactment of social insurance and the universal health insurance law, regulations of financing and covering methods and principles of the health insurance system have begun to be executed. 4 With these financial regulations, the achievement of a more efficient health service becomes more important in Turkey. Fiscal constrictions are supposed to accelerate this process. The length of inpatient stays is one of the most important factors contributing to the total health care expenditure. 5 In stroke rehabilitation, standard admission criteria are used in some countries; for example, patients must be able to sit unsupported for at least 30 seconds, 6 and must be able to tolerate active rehabilitation for at least 1 hour a day. 7,8 In Turkey, a standard protocol for the selection of patients who should be included in the rehabilitation program cannot be used. Because long-term care facilities, nursing homes, and other care facilities are not available, all stroke patients have the legal opportunity to be rehabilitated on a rehabilitation ward. Also, there is no obligatory limit for the LOS. The number of rehabilitation beds in Turkey is also insufficient. Relatively longer onset admission intervals (63 76d) in our country reflect this deficiency. 9,10 To provide an inpatient rehabilitation program for a majority of stroke survivors, the development of a shorter and more effective rehabilitation program is an important way to counteract the shortage of rehabilitation beds. The aim of this study is to identify the parameters affecting the LOS, and to determine whether any modifiable factors exist to decrease the LOS without sacrificing FIM gains. METHODS Participants Data were collected from prospective stroke registry and electronic medical records of the hospital between January BMRS FACS HAD LOS MMSE OAI List of Abbreviations Brunnstrom s motor recovery stages functional ambulation classification scale Hospital Anxiety and Depression length of stay Mini-Mental State Examination onset admission interval

2 258 LENGTH OF STAY IN TURKEY, Ozyemisci-Taskiran 2005 and October After the approval of the study by the local ethical committee, medical records of 212 consecutive stroke patients hospitalized at the university rehabilitation center were reviewed. Patients with Ischemic, hemorrhagic, and recurrent stroke were included in this study. Exclusion criteria were previous rehabilitation for the same stroke event, OAI longer than 180 days, unplanned discharges because of acute complications requiring transfer to other units, medical conditions contraindicating rehabilitation, will of the patient or the family to be discharged home before the rehabilitation program completed, death, and failure to participate in the rehabilitation program. Design In this center, more than 95% of stroke referrals are admitted for inpatient rehabilitation and put on a waiting list. Stroke survivors who cannot participate in an intensive rehabilitation program are also hospitalized on the rehabilitation unit. Lowto moderate-intensity rehabilitation programs are started, and the intensity is increased as the patient tolerates. The rehabilitation program is implemented by a multidisciplinary team approach. The team consists of physiatrists, rehabilitation nurses, physiotherapists, a cognitive therapist, an orthotist, a social worker, a dietician, and other hospital attendants. All patients receive physical therapy for 45 minutes to 3 hours a day, 5 days a week, along with cognitive therapy when needed. The rehabilitation program is coordinated through regularly scheduled team meetings. The progress of the rehabilitation program, daily activities, and management plans like prescription of orthosis and timing of discharge orthosis, planning, and suggestions regarding home arrangements after discharge are assessed by the team. A discharge plan is formulated based on a combination of several parameters, including attainment of rehabilitation goals, medical complications, and social factors such as postdischarge home and caregiver arrangements. Materials Each patient was evaluated within 72 hours after admission, and a second evaluation was performed within 72 hours before discharge. During the first evaluation, a form that included the following information was completed: sociodemographic data, prestroke systemic diseases, type of the clinical event, and stroke-related impairments such as the presence of aphasia, neglect, dysphagia, or urinary incontinence. Aphasia, neglect, memory impairments, or a combination of these were all classified as cognitive dysfunction. At discharge, complications such as shoulder problems, deep venous thrombosis, and pressure ulcers that occurred during the inpatient stay were noted. On admission and at discharge, a detailed physical examination including neurophysiologic assessments (motor impairments by BMRS) was performed, and functional disability was assessed with the FIM and FACS, cognitive status was tested with the Folstein MMSE, and mood was evaluated with the HAD Scale. 11 Some aphasic patients could not carry out the MMSE and HAD. The LOS is the total days spent on the rehabilitation ward between admission and discharge including holidays and weekends. Other outcome measures were FIM gain (the admission FIM score was subtracted from the discharge FIM score) and FIM efficiency (FIM gain divided by LOS). Statistical Analysis All statistical tests were conducted using SPSS version 11.5 software. a Descriptive statistics (mean and SD values for continuous variables, frequencies and proportions for categorical variables) were generated from all data. The category of marital status (single, married, widowed, divorced, separated) was collapsed to married and not married to create a binary outcome for analysis. To assess the importance of each independent variable on the LOS and FIM gain, independent samples t test and Pearson correlation for continuous variables, and analysis of variance for categorical variables were used. After analysis of variance, Tukey and Tamhane post hoc tests where appropriate were used to adjust for multiple comparisons. Linear regression analysis was performed to determine factors independently influencing LOS. A forward selection procedure was used for regression. RESULTS Of the 212 stroke patients, 41 were not enrolled into the study because they were rehospitalized after a preceding inpatient rehabilitation stay for the same cerebrovascular event. Among the 171 patients who were admitted to our rehabilitation center for the first time, 2 died during the inpatient rehabilitation program, and 20 were discharged unplanned. Another 7 patients were excluded from the study because the OAI was more than 180 days. The study was conducted on the remaining 142 patients. Seven of these patients were transferred to another unit in the same hospital and returned to our unit after medical stabilization. Only the days spent in the rehabilitation unit were counted as LOS. The characteristics of 142 stroke patients included in the study are shown in table 1. Their mean age was 61.7 years (range, 15 86y). There were 59 men and 83 women in the study. Sixty-eight percent were married, and 28.8% were employed before the stroke. The mean OAI was 44.9 days. Hypertension and hyperlipidemia were the most prevalent systemic diseases. Other coexisting systemic diseases are listed in table 1. Neurologic impairments related to stroke and complications during inpatient rehabilitation are listed in table 2. Shoulder problems consist of pain, joint instability, or contracture at the shoulder. A patient who had a shoulder contracture was coded as having a shoulder problem, not a contracture. Urinary tract infections, epididymoorchitis, cellulitis, and pulmonary infections were the infections observed during the inpatient stay. Cognitive dysfunction was present in 51.9% of the patients. Neglect could not be evaluated in 11.4% of the patients. The most frequent complications encountered were shoulder problems, pain, depression, sleep problems, and infections. The diagnosis of these complications, with the exception of infections, was based on clinical evaluation. FIM scores on admission and at discharge are shown in figure 1. The improvements in FIM motor, cognitive subscores, and total scores between admission and discharge were significant (P.001). The mean LOS was 59.8 days (table 3). When the holidays and weekends were excluded, LOS decreased to 41.6 days; rehabilitation treatment was not provided on 30.4% of total bed days. The mean FIM gain and efficiency were 18.5 and.35, respectively. The improvements observed in the median values of FAS scores and BMRS scores of the lower extremity, the upper extremity, and the hand are shown in figure 2. The differences in all of these parameters between admission and discharge were statistically significant (P.001). There were significant improvements in MMSE and HAD scores at discharge (table 4). Sixteen patients (11.3%) with cognitive impairments could not complete the MMSE. Results of univariate analysis of the effect of sociodemographic and clinical variables, neurologic impairment, and complications on LOS and FIM gain are shown in table 5. Valvular heart disease/atrial fibrillation, cognitive dysfunction,

3 LENGTH OF STAY IN TURKEY, Ozyemisci-Taskiran 259 urinary incontinence, neglect, shoulder problems, depression, infections, deep venous thrombosis, and pressure ulcers were associated with an increased LOS. The LOS of patients with complex regional pain syndrome was greater than that of patients without complex regional pain syndrome, although the significance of this variable is borderline (P.055). Analysis of variance demonstrated that LOS was significantly different among stages of BMRS of the lower extremity (P.001), the upper extremity (P.001), and the hand (P.001) on admission. Post hoc (Tukey) analyses of LOS among different admission BMRS stages are shown in figure 3. There were some differences in LOS, FIM gain and FIM efficiency (P.001, P.001, and P.012, respectively) in patients with different stages of FACS on admission. Differences in LOS resulted mainly from FACS 0 and 1. Patients with admission FACS 0 and 1 had a longer LOS than did patients with other scores. When FIM gain and efficiency and related factors were analyzed, it was found that patients with shoulder problems had higher FIM gains. Patients with joint instability showed a trend for higher FIM gains (P.086). The associations with other parameters and FIM gain were not statistically significant. In the case of FIM efficiency, only dysphagia was significantly associated with decreased FIM efficiency (with dysphagia.23 and without dysphagia.38; P.007). In analysis of variance, Table 1: Sociodemographic and Clinical Features of the Patients (N 142) Characteristics Values Age (y) Sex Men 41.5 Women 58.5 Marital status (n 88) Married 68.2 Not married 31.8 Prestroke employment status (n 118) Retired/housewife 71.2 Employed 28.8 Education years Illiterate y y 35.5 OAI (d) Etiology of stroke Ischemia 79.6 Hemorrhage 20.4 Recurrent stroke 18.6 Side of stroke Right 47.9 Left 51.4 Both 0.7 Systemic diseases Hypertension 68.1 Hyperlipidemia 32.9 Smoking 31.0 Diabetes mellitus 29.8 Atherosclerotic heart disease 18.7 Valvular heart disease/atrial 15.0 fibrillation Peripheral vascular diseases 9.3 Congestive heart failure 5.6 Cancer 3.6 NOTE. Values are percentage of patients or mean SD. Table 2: Neurologic Impairments and Complications Related to Stroke Impairments and Complications Percentage of Patients (N 142) Neurologic impairments Cognitive dysfunction 51.9 Urinary incontinence 36.0 Aphasia 30.8 Dysphagia 23.1 Neglect 13.8 Complications Shoulder problems 66.2 Pain 55.4 Depression 48.4 Sleep problems 41.2 Infections 40.3 Respiratory complications 10.7 Complex regional pain 10.0 syndrome Orthostatic hypotension 9.2 Contracture 6.6 Convulsion 5.0 Deep vein thrombosis 5.0 Pressure ulcers 4.3 Joint instability 3.6 FIM gains were statistically different in patients with different admission BMRS of the lower (P.025) and the upper extremity (P.029). However, FIM efficiency was not different among different admission BMRS stages. FIM gain was highest in FACS 0; there were no differences in other FACS scores with respect to FIM gain. FIM efficiency was highest in FACS 2. LOS was positively correlated with FIM gain (r.276, P.006) and negatively correlated with FIM efficiency (r.241, P.016). Lower admission total and motor FIM scores were associated with an increased likelihood of a longer LOS (r.308, P.001; and r.357, P.001, respectively). Also, higher admission HAD depression (r.342, P.006) and anxiety scores (r.307, P.014) tend to lengthen LOS. There were no statistically significant correlations between LOS and other continuous variables including OAI and age. In forward multiple regression analysis, LOS can be best predicted by admission BMRS lower extremity, admission BMRS hand, and presence of infections (LOS in days BMRS lower extremity 3.2 BMRS hand 10.3 presence of infections [infection; present 2, absent 1]; R 2.37). Fig 1. Mean motor, cognitive subscores, and total FIM scores on admission and at discharge.

4 260 LENGTH OF STAY IN TURKEY, Ozyemisci-Taskiran Table 3: Mean, Minimum, and Maximum Values of LOS, FIM Gain and Efficiency Variables Values LOS (d) (14, 152) LOS without holidays (d) (10, 108) FIM gain ( 1, 61) FIM efficiency (.04, 1.64) Table 4: MMSE and HAD Scores on Admission and at Discharge Measures Admission Discharge P MMSE score HAD anxiety score HAD depression score NOTE. Values are mean SD or as otherwise indicated. Values are mean SD (minimum, maximum). DISCUSSION In the present study, admission BMRS lower extremity was the strongest predictor of LOS. However, admission BMRS hand and presence of infections were also predictors of LOS using the regression model. Valvular heart disease or atrial fibrillation was the only comorbidity influencing LOS in univariate analysis. Neurologic impairments and medical complications were significant parameters of a longer LOS, supporting the findings in previous studies. 6,12 Stroke survivors admitted with greater motor impairments and functional disabilities (reflected by BMRS, FACS scores, and FIM scores on admission, respectively) stayed longer in the hospital. However, FIM scores on admission did not remain independent predictors after the regression analysis in our study. LOS increase was associated with an increase in FIM gain and a decrease in FIM efficiency, parallel with other studies. 10 However Ottenbacher et al 5 found that LOS had little influence on the functional status at discharge. Over the past decade, the relevant literature is enriched by data from different countries worldwide. Functional outcome is an important outcome parameter and literature shows that it predicts LOS. 6,7,9,10 However, the methodologies used in these studies were not uniform. Characteristics of study settings (community hospitals, 12 rehabilitation centers, 6,10,13,14 rehabilitation units in a tertiary general hospital, 9,15 specialized stroke services, 16 or population-based cohort 17 ), patient selection (only elderly patients 7,15 ), functional measurements (FIM 7,9,10,18 or Barthel index 12-14,17, or other functional scales 19 ), and the intensity of rehabilitation programs (weekend or evening services 5,13,14 ) differed among studies. Some researchers did not give information about comorbidities 6,7,13,18,19 or complications. 6,13,15,17,20 The present center is a comprehensive tertiary university hospital providing management of any medical condition. Rehabilitation patients with acute medical complications were rarely transferred to other wards; instead further management was carried out in the rehabilitation ward via specialist consultation. These days were also counted for rehabilitation days even if the intensity of the rehabilitation program was reduced Fig 2. Median values of BMRS and FACS scores on admission and at discharge. dramatically or even ceased. These medical complications increased LOS, but not premature discharges, in contrast to other studies. 6,12,14 In some of the studies, 12,14 patients with communication difficulties were not included in the study. In many studies, stroke patients with high potential for recovery were selected for hospitalization or included in the analysis. Patients who were unable to sit unsupported for at least 30 seconds, 6,14 unable to participate in active rehabilitation for at least 1 hour, 7,8 had poor cognitive function, poor family support, 20 or had medical complications 21 were excluded. This approach might give rise to a shorter LOS than was found in the present study. Age, 17 sex, and etiology of stroke were not significant determinants of prolonged LOS in our study, similar to findings in other studies. 12,15 Appelros 17 found that stroke severity was an independent factor predicting LOS. In another study, 7 an inverse relationship was found between increased age and outcome, but age was less predictive of the outcome than were functional and cognitive impairments on admission. Outcome parameters in stroke rehabilitation are functional status at discharge, discharge destination, and LOS. 6,7,13,19,20 Among all rehabilitation patients, stroke survivors in developed countries were the least likely to be discharged home or living at home during follow-up. 20 In Turkey, discharge destination is not an applicable outcome measure because a lack of nursing homes and specialized long-term care facilities makes the patient s home an obligatory destination. From Turkey, Tur et al 9 and Gökkaya et al 10 used functional status at discharge as the rehabilitation outcome. 9,10 There is no mandatory limit for LOS in Turkey, which is similar to the policies in some other countries such as Japan, Thailand, and Italy. 13,20,22 Along with many other factors, rehabilitation in these countries is characterized by a longer LOS. In Japan, LOS was reported to range from 73 to 116 days, 13,18 in contrast to United States (16d 5 ) and some other countries. 12,14 The LOS measured in the present study was similar to that found in other studies from Turkey (69.7d, 9 45d 10 ) and other countries. 6,7 In Turkey, among communitybased rehabilitation programs, outpatient rehabilitation programs are scarce. Difficulties in caregiver availability and transport limit the utilization of outpatient programs to only a minority of patients with slight to moderate disabilities and good family support. Very few patients benefit from home rehabilitation through out-of-pocket expenses because the insurance system does not cover home care services. Longterm care facilities, nursing homes, and intermediate care facilities are extremely few in number. Thus, stroke patients who are only able to tolerate low-intensity rehabilitation programs are also hospitalized. These patients are more severely disabled, and their medical problems are more complex as well. Medical complications and the level of functional dependence determine the intensity of rehabilitation. Increasing the rehabilitation intensity shortens the LOS. 5,23 In the United States, condensing the rehabilitation program by adding evening and weekend services did not change the number of

5 LENGTH OF STAY IN TURKEY, Ozyemisci-Taskiran 261 Table 5: Univariate Analysis of Effect of Sociodemographic and Clinical Variables on LOS and FIM Gain Variables LOS (d) P FIM Gain P Sociodemographic Variables Sex Men Women Marital status Married Not married Prestroke employment status Unemployed Employed Education years Illiterate y y Clinical Variables Etiology of stroke Ischemia Hemorrhage Side of stroke Right Left Recurrent stroke Absent Present Hypertension Absent Present Hyperlipidemia Absent Present Smoking Absent Present Diabetes mellitus Absent Present Atherosclerotic heart disease Absent Present Valvular heart disease/atrial fibrillation Absent Present Peripheral vascular diseases Absent Present Congestive heart failure Absent Present Cancer Absent Present Neurologic Impairments Cognitive dysfunction Absent Present Urinary incontinence Absent Present

6 262 LENGTH OF STAY IN TURKEY, Ozyemisci-Taskiran Table 5: Univariate Analysis of Effect of Sociodemographic and Clinical Variables on LOS and FIM Gain (Cont d) Variables LOS (d) P FIM Gain P Aphasia Absent Present Dysphagia Absent Present Neglect Absent Present Complications Shoulder problems Absent Present Pain Absent Present Depression Absent Present Sleep problems Absent Present Infections Absent Present Respiratory complications Absent Present Complex regional pain syndrome Absent Present Orthostatic hypotension Absent Present Contracture Absent Present Convulsion Absent Present Deep vein thrombosis Absent Present Pressure ulcers Absent Present Joint instability Absent Present NOTE. Values are mean SD or as otherwise indicated. Values in boldface indicate those with P values that are less than.05. therapy hours provided, and the functional status remained relatively stable; however, the rehabilitation efficiency index increased (1.2 in 1994 and 1.7 in 2001). 5 Functional impairment on admission is the most common determinant predictive of LOS in many studies. 7,12,15,19 It is not surprising that most patients with greater impaired function require a longer LOS to achieve the rehabilitation goals. In the present study, FIM scores on admission were not an independent predictor of LOS. This finding may have resulted from including admission BMRS parameters in the regression analysis. Other studies did not present information about admission BMRS 6,13,14,18,19 or include it in the regression analysis. 9 When admission BMRS parameters were not included in our study analysis, admission FIM also emerged as an independent predictor. The other predictor of LOS was the presence of infections. Shoulder problems, deep venous thrombosis, and pressure ulcers were also significant parameters in univariate analysis. Because the number of patients with pressure ulcers

7 LENGTH OF STAY IN TURKEY, Ozyemisci-Taskiran 263 CONCLUSIONS Motor impairments and infections were the factors found to be predictive of LOS in stroke rehabilitation. Of these 2 parameters, the presence of infections is the only modifiable variable. Prevention strategies for infections should be pursued more aggressively. The prevention of infections, which is an essential component of patient general well-being, also shortened LOS in stroke rehabilitation. High medical expenses urge LOS to shorten in the developing countries hereafter. A national rehabilitation policy should be implemented to reach the same functional outcome with shorter LOS in stroke patients. Early and intensive rehabilitation is critical for successful outcomes. 22 A sufficient number of rehabilitation facilities and specific rehabilitation team members, such as occupational and cognitive therapists are essential to administer a properly structured rehabilitation program. A Turkish rehabilitation database system should be founded to develop national stroke rehabilitation data. Besides inpatient rehabilitation, well-organized home health care systems, outpatient rehabilitation services, and nursing home and long-term care facilities are other rehabilitation routes to increase the efficiency of resource utilization and provide rehabilitation care to a larger number of stroke survivors. Fig 3. LOS among different admission BMRS. P values between different groups are indicated at the top of the graph. and deep venous thrombosis was limited, they were not included in the regression analysis. Among these complications, only the presence of infections independently influenced LOS. Infections prolonged the rehabilitation program. Denti et al 7 found that the most frequent medical complication was urinary tract infections; however, the total number of complications was included in the analysis instead of individual complications. Infections were also found to be the most common reason for early unplanned transfers from inpatient rehabilitation. 8,24 In addition to motor impairments, other impairments in balance and aphasia also have important predictive effects on FIM scores and LOS. Wee and Hopman 6 suggested that in the acute care settings where FIM application is not practical, bedside evaluation of impairments can guide the clinician in predicting LOS and discharge functional status. Cognitive impairments also affected LOS in the present study; however, they did not predict LOS independently. Study Limitations The results of this study were limited to one rehabilitation center, making it difficult to generalize to the whole country. These results could not be compared with national data because a national rehabilitation database system does not exist, so the only comparison that was made was with the results of other studies. Because the study was from a referral center, more complex cases were managed and rehabilitated. Rehabilitation patients with acute medical complications were rarely transferred to other wards; instead further management was carried out in the rehabilitation ward via consultation. This lowered the intensity of the rehabilitation program and increased the LOS. The social insurance system in Turkey is evolving and there are no exact rules as it is in some other countries, so fiscal considerations had little influence on LOS. The results of this study should be compared with those of future studies carried out after implementation of the structured insurance system is completed. References 1. Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol 2009;8: Akgün S, Rao C, Yardim N, et al. 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