J Rehbil Med 2011; 43: 156 161 ORIGINAL REPORT Ptient gols in post-cute geritric rehbilittion: gol ttinment is n indictor for improved functioning Sndr Kus, MPH 1,2, Mrtin Müller, RGN, Dipl. Nurs. Mngt. 1,2, Rlf Strobl, Dipl. Stt. 1,2 nd Ev Grill, DrPH, PhD 1,2 From the 1 Institute for Helth nd Rehbilittion Sciences (IHRS), Munich, Germny nd 2 ICF Reserch Brnch of WHO Collborting Centre for the Fmily of Inter ntionl Clssifictions in Germn, Nottwil, Switzerlnd Objective: To identify gols of older ptients in geritric rehbilittion nd to mesure their improvement in overll functioning. Design: A prospective multi-centre cohort study. Methods: A semi-structured questionnire ws used to identify ptient gols nd to ssess improvement in overll functioning from ptients nd helth professionls perspectives. Ptients gols were linked to the Interntionl Clssifiction of Functioning, Disbility nd Helth (ICF). Using residulized chnge score, we identified ptients who improved more thn sttisticlly expected. Results: A totl of 209 ptients gve 476 sttements. Of these, 346 (72.7%) sttements were linked to 58 different ICF ctegories. More thn 90% of the ICF ctegories were prt of the comprehensive geritric ICF Core Set. Wlking, getting rid of pin, utonomy nd returning home were the most frequently reported gols. Multivrible nlysis identified shorter length of inptient sty nd gol ttinment to be significnt predictors for n improvement in overll functioning from the ptients perspective. Conclusion: The ICF cn be used to identify nd structure ptients gols in geritric rehbilittion. The ssocition between gol ttinment nd improved overll functioning underlines the necessity of considering the ptients perspective in the rehbilittion process. Key words: ICF; gols; dvnce cre plnning; cohort study; rehbilittion; outcome ssessment; clssifiction; ged. J Rehbil Med 2011; 43: 156 161 Correspondence ddress: Ev Grill, Institute for Helth nd Rehbilittion Sciences, Ludwig-Mximilins-Universität München, DE-1377 Munich, Germny. E-mil: ev.grill@ med.uni-muenchen.de Submitted My 25, 2010; ccepted September 21, 2010 INTRODUCTION After n cute dverse event or n cute episode of illness, older ptients need specil ttention due to their higher vulnerbility to functionl decline during hospitliztion (1). This incresed risk of experiencing loss of functioning is due to comorbidities, high prevlence of cognitive impirment (2), in ddition to fctors such s depression (3), frilty (4) nd other pre-existing limittions in functioning (1, 5). To prevent chronic disbility, erly onset of rehbilittion is essentil (6). The Americn Geritrics Society (AGS) (7) defines rehbilittion s the mintennce nd restortion of physicl nd psychologicl helth necessry for independent living nd functionl independence. As such, restortion or mintennce of ptients functioning is the min objective of post-cute rehbilittion. Moreover, post-cute rehbilittion lso ims t preventing disbility nd the need for long-term cre s well s t promoting ptients utonomy (6). Idelly, n interdisciplinry tem of physicins, nurses nd therpists specilized in rehbilittion cre should cooperte to mnge the demnds of erly post-cute rehbilittion. Timely gol-setting in close consulttion with the ptient is essentil to rehbilittion success (8 9). Wde (10) considers gol s future stte tht is desired nd/or expected nd tht might refer to reltive chnges or to n bsolute chievement (p. 273). In this context gol comprises not only the ptients spirtions, but lso his environment, fmily, or ny other involved persons. Involving the ptients perspective by identifying his personl needs nd problems is considered to be bsic principle of the gol plnning process (10). Older, fril persons, in prticulr those t risk for functionl decline, hve lrge spectrum of needs, desires or gols relevnt to their rehbilittion. These gols my pertin to their prticulr helth condition or disbility, return to the home environment, ctivities of dily living, or emotionl sitution. The need for involving the ptients personl perspective in the rehbilittion process hd been noted previously (11 12). In this context, the relevnce of gol ttinment for n evlution of outcome is of interest in clinicl prctice (12). Argubly, the ctul ttinment of ptients gols is ssocited with improvement in overll functioning s subjectively perceived by the ptient, nd objectively recorded by the helth professionl. However, there is no consensus on how to ssess systemticlly the ptients perspective, nor is it obvious whether the ttinment of gols relly indictes improvement in mesured outcomes (12 14). The Interntionl Clssifiction of Functioning, Disbility nd Helth (ICF) is globlly ccepted lnguge to communicte bout functioning with considertion of body function, utonomy of the individul, nd enggement in society (15 16). In order to enhnce the pplicbility of the ICF in clinicl prctice nd reserch nd to overcome prcticl concerns relting to the gret number of ctegories fforded within the ICF, comprehensive ICF Core Set for ptients in gerit- 2011 The Authors. doi: 10.2340/16501977-0636 Journl Compiltion 2010 Foundtion of Rehbilittion Informtion. ISSN 1650-1977
Ptient gols in geritric rehbilittion 157 ric post-cute rehbilittion fcilities ws creted to provide stndrds for multi-professionl ptient ssessment. This Set ws designed to include the typicl spectrum of problems in functioning encountered in older ptients, so s to permit the coding of ptients gols. The objectives of this study were to identify the rehbilittion gols of ptients in erly post-cute geritric rehbilittion by using the ICF, nd to exmine the ssocition of gol ttinment with mesures of improvement in overll functioning, s perceived by the ptients nd ccording to helth professionls. METHODS Study design The study design ws prospective multi-centre cohort study conducted from My 2005 to August 2008. The study popultion ws recruited from geritric wrds nd units in 3 Germn hospitls, nd 2 Austrin hospitls; pproximtely 62% of the ptients were recruited from the Germn centres. Ptients were eligible for inclusion if they were over 65 yers of ge, nd fulfilled the criteri for post-cute geritric rehbilittion, ccording to their need for ongoing medicl nd nursing cre in ddition to rehbilittion. Informed consent ws obtined prior to the study. For ptients who were incpble of providing written, informed consent, the principl crer signed the informed consent form for prticiption. The study ws pproved by the institutionl ethics committees. Mesures The cse record form comprised socio-demogrphic dt nd min dignoses. Furthermore, it included semi-structured questionnire for ptient nd helth professionl to identify ptient gols nd ssess overll functioning from the ptients nd helth professionl s perspectives. The dt were collected by interview bout 24 h fter dmission (bseline), nd within 36 h before dischrge (end-point). Ptients were sked t bseline to report up to 10 importnt spects relted to their helth condition nd their hospitliztion. These spects were expecttions, desires, hopes, gols s well s fers, doubts or problems due to the underlying helth condition, the hospitliztion or ssocited with the physicl nd socil environment. In ddition, ptients were sked t end-point to decide which of the spects or gols mentioned t bseline they hd ttined during the inptient sty. Ptients were lso sked to ssess their overll functioning t dmission nd t dischrge on numericl rting scle (where 0 = complete limittion in ll spects of functioning nd 10 = no limittion in functioning). To gin informtion from the expert s perspective s well, helth professionls were independently sked to ssess ptients overll functioning using the sme numericl scle. Linking process Ptients sttements were trnslted into the ICF terminology following stndrdized linking procedure, which is bsed on estblished linking rules (17 18). We used the frmework of the ICF to specify nd group the informtion derived from the ptients, nd by these mens enble further sttisticl nlysis. In the first step of the linking procedure, two reserchers independently identified ll meningful concepts contined in the ptients sttements. A meningful concept cn be described s specific component of text, consisting either of few words or few sentences hving common motif (19). In second step, the two versions of the concepts identified s being meningful were compred. Structured discussion nd informed decision of third expert were used to resolve disgreements between the two versions. Then the finl version of meningful concepts ws linked to the most closely corresponding ICF ctegories by the two independent reserchers ccording to the defined linking rules. The results of the two experts were gin compred; in the event of disgreement, structured discussion nd consulttion with third expert ws used to rrive t decision. In cses when ptients gol could not be linked to the ICF, e.g. becuse the sttement ws too generl for linking, or if the contents were not covered by the ICF, we summrized nd grouped the dt so s not to lose tht informtion nd to enble subsequent nlysis. Dt nlysis We used bsolute nd reltive frequencies to describe ptients gols. Bsed on the sttements on gol ttinment t dischrge, we mde binry clssifiction of the individuls (0 = no gol ttined, 1 = t lest one gol ttined). In generl, estimting chnge by clculting the difference between dmission score nd dischrge score cn be bised by n effect clled regression to the men, wherein those individuls who scored higher t bseline re likely to score lower on re-test, wheres those who scored low t bseline re likely to score higher on re-test (20 21). As result of these tendencies, difference scores (bsolute chnges) cn overestimte the effect of bseline differences on re-test scores (22). To void this effect in ssessing chnge between two mesurements, Cronbch & Furby (23) suggest clculting residulized gin score, which we used to determine chnge in functioning from the ptients nd helth professionl s perspectives. We clculted the residuls using mixed regression model. This llows the integrtion into the model of differing length of inptient sty s rndom effect. With the mixed model, the sttisticlly predicted dischrge vlues were clculted for the whole study popultion. Subtrcting the vlues predicted by the regression model from the observed vlues then gives the residulized score, which is the proportion of chnge not predicted from the bseline score, nd controlled for length of inptient sty. For subsequent regression nlyses we defined binry outcome vrible ccording to the vlues of the residulized gin score. A gin score of 0 or less signified n improvement in overll functioning s less thn or equl to the sttisticlly expected chnge (0), wheres gin score bove 0 signified n improvement in overll functioning exceeding tht which is sttisticlly expected (1). To nlyse the predictors for n improvement in functioning, we used logistic regression models with improvement in overll functioning s the dichotomous dependent vrible (0 = improvement in overll functioning s or less thn expected; 1 = improvement in overll functioning more thn expected). Independent vribles exmined were ge, sex, length of inptient sty, time from event to rehbilittion onset, number of comorbidities, living sitution prior to hospitliztion, yers of eduction nd gol ttinment. To decide which vribles should enter the model, the reltionship of ech independent vrible with the dichotomous outcome ws ssessed using bivrite χ 2 tests. Fisher s exct test ws used when necessry. We strtified by sex in the bivrite nlyses in order to test for potentil gender interctions. A vrible ws considered to be potentil predictor if it hd p-vlue of < 0.20 in the bivrite test, or ws of clinicl relevnce. To void collinerity, vribles would only be selected for the multiple logistic regression model if the Spermn s correltion coefficient ws < 0.5. Two logistic regression models were then used to select the finl set of predictors bsed on bckwrd elimintion (p < 0.05 to remove), 1 for overll functioning from the ptients perspective nd 1 for overll functioning from the helth professionl s perspective. The potentil predictors ge, length of inptient sty, time from event to rehbilittion onset nd number of comorbidities entered the model s continuous vribles. The vrible living sitution prior to hospitliztion ws coded s nominl (0 = living in home for older people/nursing home, 1 = living lone or with nother person, being in need of cre, 2 = living lone or with nother person, not being in need of cre). To determine the predictive bility of the finl models we considered the c-vlue, which gives n estimte of the re under the receiver operting chrcteristic (ROC) curve (re under the curve; AUC) (24). The AUC cn ttin vlues between 0.0 nd 1.0, with prcticl lower bound vlue 0.5, nd 1.0 indicting perfect predictive bility of model.
158 S. Kus et l. RESULTS A totl of 209 ptients from 5 different rehbilittion fcilities were included in the study. Ptients rnged in ge from 57 to 101 yers, with medin ge of 80 yers (men 80 yers (95% confidence intervl (CI) (79; 81)). Sixty-seven percent of the ptients were femle. The most common resons for dmission were injuries nd frctures, principlly femur frctures, in ddition to diseses of the circultory system, principlly cerebrovsculr diseses. Medin length of sty ws 21 dys (men 23 dys, 95% CI (21; 25)). Medin time from event to rehbilittion onset ws 13 dys (men = 15 dys, 95% CI (13; 18)). Eighty-nine percent of the individuls were dmitted from home, nd 75% were dischrged to home. Mini-Mentl Stte Exmintion yielded medin of 26 points (men 24.2 points). Demogrphic chrcteristics nd ssessment of overll functioning from ptients nd helth professionl s perspective re summrized in Tble I. Most frequent dignoses responsible for inptient sty re reported in Tble II. Tble I. Demogrphic chrcteristics nd overll functioning of the study popultion (n = 209) Chrcteristics Gender, femle, 140 (67.0) Age, yers, men (95% CI) [medin] 79.9 (78.9 80.9) [80] Durtion of inptient rehbilittion, dys, men (95% CI) [medin] 23.1 (21.3 24.9) [21] Time from event to rehbilittion onset, dys, men (95% CI) [medin] 15.4 (13.0 17.8) [12.5] Number of comorbidities, men (95% CI) [medin] 6.6 (6.3 7.0) [7.0] Overll functioning Helth Professionl b, men (95% CI) [medin] Bseline (n = 190) 5.3 (5.1 5.6) [5.0] Dischrge (n = 190) 6.8 (6.5 7.1) [7.0] Overll functioning Ptient c, men (95% CI) [medin] Bseline (n = 202) 5.0 (4.8 5.3) [5.0] Dischrge (n = 172) 6.8 (6.5 7.0) [7.0] Living Sitution prior to hospitliztion, Living lone 71 (34.0) Living lone with need for cre 21 (10.2) Living with nother person 61 (29.2) Living with nother person with need for 29 (13.9) cre Living with nother person nd cres for this 3 (1.4) person Home for older people/nursing home 24 (11.5) Living Sitution fter dischrge, Home 156 (74.6) Bck to cute medicl cre 13 (6.2) Chnge into home for older people/nursing home 33 (15.8) Deth 3 (1.4) Not specified 4 (1.9) n = 208. b For nlysing chnge in overll functioning, n = 186 due to missing vlues for dmission or dischrge dt. c For nlysing chnge in overll functioning, n = 167 due to missing vlues for dmission or dischrge dt. CI: confidence intervl. Tble II. Most frequent dignoses responsible for inptient sty (Interntionl Clssifiction of Diseses 10) (n = 209) Dignosis Injuries (S00 T14) 54 (25.8) Injuries of hip nd thigh (S70 S79) 35 (16.7) Diseses of the circultory system (I00 I99) 45 (21.5) Cerebrovsculr disese (I60 I69) 19 (9.1) Symptoms, signs nd bnorml clinicl nd lbortory findings (R00 R99) 28 (13.4) Diseses of the musculoskeletl system nd connective tissue (M00 M99) 16 (7.7) Diseses of the nervous system (G00 G99) 13 (6.2) Certin infectious nd prsitic diseses (A00 B99) 12 (5.7) Only dignoses with prevlence of t lest 5% re reported. A totl of 202 ptients (97%) reported t lest one gol, wheres 87% reported up to 3 gols (men = 2, medin = 2). A totl of 476 gols were reported. A totl of 346 (73%) gols could be linked to 58 different ICF ctegories nd 5 different chpters of the ICF. A totl of 130 gols (27%) were not specific enough to be linked to single ICF ctegories. Tble III shows the most frequent gols coded with ICF ctegories. Fifty-eight different second-level ICF-ctegories were used for coding. Autonomy, returning home nd improvement of the generl condition were the most frequently stted mong those gols which could not be coded with the ICF. Forty-two (9%) of the reported gols were linked to ICF ctegories not presently included in the comprehensive ICF Core Set for older ptients. Among them domestic life (d6) nd recretion nd leisure (d920) were the most frequent coded ICF ctegories not comprised in the ICF Core Set for older ptients (Tble IV). A totl of 170 ptients (81%) gve informtion on gol ttinment. Two hundred nd forty-three (51%) of the 476 gols were reported s ttined t dischrge. One hundred nd thirty-six ptients (80%) hd ttined t lest one of their personl gols, but 34 ptients (20%) climed no ttinment in ny of their gols. Men overll functioning score from the ptients perspective ws 5 (medin = 5) on dmission nd 7 (medin = 7) on dischrge. Men overll functioning score from the helth professionl s perspective ws 5 (medin = 5) on dmission nd 7 (medin = 7) on dischrge. From the ptients perspective 59% (n = 167), nd from the helth professionl s perspective 63% (n = 186) of the ptients improved in overll functioning more thn would be sttisticlly expected. Seven vribles met the inclusion criteri for the multivrible logistic models nd were consequently selected s potentil predictors: ge, sex, length of inptient sty, time from event to rehbilittion onset, number of comorbidities, living sitution prior to hospitliztion nd gol ttinment. Given tht the bivrite nlyses gve differing effects in men nd women, n interction term of sex nd gol ttinment ws included. From the ptients perspective, length of inptient sty nd gol ttinment remined in the finl model fter bckwrd elimintion. A person who ttined t lest one personl gol ws more thn 5 times s likely to improve in overll
Ptient gols in geritric rehbilittion 159 Tble III. Gols (n = 476) in erly post-cute geritric rehbilittion for 209 ptients Ctegory Totl gols (n = 476) Attined gols in ctegory Gols coded b1 Mentl functions 18 (3.8) 7 (41.2) 17 (8.6) b152 Emotionl functions 7 (1.5) 3 (42,9) 7 (3.3) b2 Sensory function nd pin 36 (7.6) 21 (58.3) 36 (17.2) b280 Pin 31 (6.5) 20 (64.5) 31 (14.8) b4 Functions of the crdiovsculr, hemtologicl, immunologicl nd respirtory systems 10 (2.1) 5 (50.0) 8 (3.8) b440 Respirtion functions 6 (1.3) 3 (50.0) 6 (2.9) b7 Neuromusculoskeletl nd movement relted functions 27 (5.7) 15 (55.5) 23 (11.0) b710 Mobility of joint functions 7 (1.5) 5 (71.4) 5 (2.4) b770 Git pttern functions 6 (1.3) 5 (83.3) 6 (2.9) d4 Mobility 174 (36.6) 86 (49.4) 140 (67.0) d450 Wlking 99 (20.8) 53 (53.5) 92 (44.0) d465 Moving round using equipment 16 (3.4) 9 (56.3) 16 (7.7) d410 Chnging bsic position 7 (1.5) 2 (28.6) 7 (3.3) d440 Fine hnd use 8 (1.7) 4 (50.0) 7 (3.3) d5 Self-cre 18 (3.8) 11 (61.1) 16 (7.7) d6 Domestic life 16 (3.4) 8 (50.0) 12 (5.7) d920 Recretion nd leisure 8 (1.7) 4 (50.0) 6 (2.9) e1 Products nd technology 9 (1.9) 0 (0.0) 7 (3.3) e3 Support nd reltionship 14 (2.9) 11 (78.6) 14 (6.7) e355 Helth professionls 13 (2.7) 10 (76.9) 13 (6.2) Gols not coded b Autonomy 32 (6.7) 16 (50.0) 32 (15.3) Returning home/stying home 33 (6.9) 23 (69.7) 33 (15.8) Generl condition/helth 28 (5.9) 13 (46.4) 28 (13.4) Others 23 (4.8) 10 (43.5) 20 (9.6) Only frequencies > 5 reported. 346 of ll gols were coded s Interntionl Clssifiction of Functioning, Disbility nd Helth (ICF) ctegories. b 130 of ll gols could not be coded s ICF ctegories. Ptients with t lest 1gol in ctegory (n = 209) functioning (odds rtio = 5.5). From the helth professionl s perspective length of inptient sty gol ttinment nd dditionlly number of comorbidities remined in the finl model. A person who ttined t lest one personl gol ws 3 times s likely to improve in overll functioning. Length of sty ws inversely ssocited with improvement in overll functioning. The interction term of sex nd globl ttinment ws not significnt. Tble V summrizes the results of both multivrible logistic regression models. Predictive bility of both models ws dequte s rted by the c-vlue. Tble IV. Ptient gols in erly post-cute geritric rehbilittion not covered in the Interntionl Clssifiction of Functioning, Disbility nd Helth (ICF) Core Set for geritric ptients (n = 209) Ctegory Totl gols (n = 42) Ptients with t lest 1 gol in ctegory (n = 209) n (% Gols coded d455 Moving round 4 (0.8) 4 (1.9) d470 Using trnsporttion 3 (0.6) 2 (1.0) d6 Domestic life 16 (3.4) 12 (5.7) d920 Recretion nd leisure 8 (1.7) 6 (2.9) Only frequencies > 2 reported. Ptients reported 42 gols not covered in the ICF Core Set for geritric ptients. Tble V. Results of the multivrible logistic regression model Prmeter p-vlue Point estimte (OR) 95% confidence intervl Ptient perspective b Length of inptient sty <0.0001 0.93 0.90 0.96 Gol ttinment 0.0004 5.52 2.16 14.12 c-vlue (finl model) = 0.77 Age 0.3498* Number of comorbidities 0.2725* Living sitution prior to hospitliztion 0.1382* Sex 0.3816* Sex gol ttinment 0.1094* Helth professionl perspective c Length of inptient sty < 0.0001 0.93 0.90 0.96 Number of comorbidities 0.0142 0.81 0.68 0.96 Gol ttinment 0.0348 2.68 1.07 6.71 c-vlue (finl model) = 0.72 Age 0.2376* Living sitution prior to hospitliztion 0.3674* Sex 0.1042* Sex gol ttinment 0.3733* Finl model describing vribles ssocited with the outcome improvement in overll functioning, with p < 0.05 on the Wld test. Not significnt; b n = 158 due to missing vlues for the response or explntory vribles; c n = 155 due to missing vlues for the response or explntory vribles. OR:odds rtio.
160 S. Kus et l. DISCUSSION In this study, older ptients undergoing erly post-cute rehbilittion reported regining mobility/wlking bility nd utonomy, getting rid of pin, returning home nd improving their generl helth condition s their min gols of the rehbilittion process. Gols could be stndrdized nd nlysed in meningful wy by using the ICF. Gol ttinment s result of the rehbilittion process ws independently ssocited with improvement in ptients overll functioning, both from the ptients perspective, nd tht of helth professionls. Current reserch on ptient gols confirms tht mobility is the min issue for older ptients, e.g. fter stroke (25). Being ble to wlk is strongly ssocited with independent living, s recently shown in similr smple of older individuls undergoing erly post-cute rehbilittion (26). Eqully, independence in self-cre nd domestic life contribute to the generl gol of utonomy. The centrl importnce of utonomy for ptients in erly post-cute geritric rehbilittion reflects in prctice fundmentl humn need (27). Bsed on this theoreticl bckground, it is obvious tht the ptients perspective must be prt of the gol-setting process in modern rehbilittion (9). Interestingly, ptients hd quite concrete ides regrding their gols. Aprt from some more generl spects, such s improvement of their generl helth condition or utonomy, the gols reflect prototypicl spectrum of impirments, limittions nd restrictions s described by the comprehensive ICF Core Set for older ptients (28). This repliction in n independent group of ptients gin confirms the fce vlidity of the comprehensive ICF Core Set, which consistently provided useful frmework to ctegorize nd stndrdize ptients gols. The concurrence is potentilly importnt result of this study, since common nd ccepted wy to involve the ptient perspective in gol-setting hs been lcking (13, 29). While some uthors fvour structured tool to integrte the ptient perspective (8, 30), others prefer or recommend unstructured, open methods to record ptients needs (11, 14, 31). Since communiction with older persons is sometimes difficult, we used n open-ended questionnire for evluting the ptients perspective. In nswering the questions, ptients were ssisted by trined interviewers. We found this method in prctice to be the simplest strtegy for consistently obtining uthentic sttements from the individul ptients. In older persons, helth conditions re chrcterized by their complexity nd grvity (5). By trnslting the ptients gols into stndrdized lnguge it becomes obvious tht ptients express their notions of gols in very generl terms. For instnce, individuls mke sttement such s I wnt to hndle ll ctivities on my own, I wnt to regin my strength, or I wnt to cre for myself gin rther thn mking specific sttements such s I wnt to be ble to open bottle with my right hnd or I wnt to strengthen the muscles of my ffected leg. It is up to the helth professionl to clrify the generl gols in more detiled wy nd to deconstruct them into the components tht cn be ddressed by therpy (25). Bsed on our experience the ICF cn be seen s tool tht offers helpful terminology to trnslte unstructured informtion into structured form, which cn be nlysed nd reported in stndrdized wy, nd cn guide the rehbilittion process. Unsurprisingly, gol ttinment ws ssocited with improvement in overll functioning, independent of the perspective tken. In n erlier study of neurologicl rehbilittion, gol ttinment ws likewise shown to be ssocited with improvements in functioning (14). In nother study, this ssocition ws shown to be independent of ptients chrcteristics such s min dignosis nd ge (12). When ssessing chnge of functioning there frequently rises the problem of how to interpret nd nlyse the chnge score (32). We mde the decision to use mixed effects regression to model the verge chnge in overll functioning. Only individuls who showed t lest this verge mount of chnge were considered s improved. The use of this strict criterion is very conservtive pproch, which hs been recommended to eliminte potentil regression-to-the-men effects (22 23). Since rehbilittion effectiveness is chnge by length of sty, it is importnt to include length of sty in ny model of chnge. The mixed effects regression model is lso method to djust for length of inptient sty. Typiclly, in Germny nd Austri s in mny other helth systems, length of sty in rehbilittion fcility is not primrily determined by gol chievement but lso by reimbursement sitution. Some limittions of the study merit comment. First, ptients were interviewed by helth professionls in fce-to-fce sitution, such tht the ptients could potentilly hve been influenced by the interviewer s expecttions. To void this, the interviewers hd been trined in structured trining meetings, nd were provided with mnul nd list of stndrdized questions (5). Secondly, ptients were not sked bout mesurble, relistic gols, but rther were sked to report the 10 most relevnt spects of functioning pertining to their disese nd hospitliztion. Nevertheless, these 10 spects were generlly reflective of ptients personl desires nd expecttions concerning their disese nd hospitliztion, such tht we feel justified in considering these spects to be synonymous with gols (10). An dditionl point of concern is the prevlence of cognitive impirment in older rehbilittion ptients. It is not cler to wht extent older ptients with cognitive impirment re ble to prticipte in relistic gol setting. In our study, prt of the popultion hd lest first signs of mild cognitive impirment, s mesured by the Mini-Mentl Stte Exm; however, this might hve been positive selection towrds the mentlly fit persons. Studies on gol setting in severely cognitively impired persons re difficult to conceive. In conclusion, we found the ICF to be useful frmework to identify nd structure ptients sttements bout their gols in geritric erly post-cute rehbilittion. Wlking, llevition of pin, regining utonomy, returning home nd improvement of the generl condition could be identified s the most importnt nd most frequent spects from the ptient perspective. The positive ssocition between gol ttinment nd improved functioning emphsizes tht it is essentil to involve the ptient in the rehbilittion plnning process, with the im of obtining n optiml outcome.
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