10-Year Trends in Pediatric Inpatient Rehabilitation

10-YEAR TRENDS IN PEDIATRIC INPATIENT REHABILITATION

Newswise — SACRAMENTO, CALIF. – The way in which pediatric rehabilitation services are delivered has changed in the last decade, according to research presented this week at the Association for Academic Physiatrists Annual Meeting in Sacramento, Calif.

The changing healthcare landscape has placed emphasis on improving the health of patient populations as well as the quality of care and care experience of patients – all at a lower cost to the health care system. This quest for what is called the Triple Aim, has led to the standardizing of the process of care delivery in the United States, yet there is currently no consensus on the optimal delivery of rehabilitation care, especially in pediatrics.

Recent studies have highlighted discrepancies in the structures and processes of pediatric rehabilitation both within and between different rehabilitation facilities. Other studies have looked at what determines a child’s length of stay when admitted to an inpatient rehabilitation program. When looking at these various studies as a whole, it would seem that age, diagnosis, and a child’s functional status when admitted are all factors in determining length of stay; however, no studies have addressed national trends.

Researchers recently sought to fill this research gap with a retrospective study that evaluated overall trends in pediatric inpatient rehabilitation and how care is changing in regard to patient demographics, health and functional characteristics as well as the characteristics of facilities in which care is delivered.

Additionally, they sought to identify characteristics of patients and facilities that predict length of stay and effectiveness of treatment as well as characterize differences in rehabilitation care based on the different regions of the United States.

Using a standardized reporting system that reviews the operation and performance of health centers, the researchers looked at WeeFIM data – which assigns points for independence based on how well a child performs daily tasks such as walking, communicating and getting dressed – from 67 pediatric inpatient rehabilitation centers in the U.S between 2004 and 2014. This data represented 42,702 inpatient pediatric rehabilitation admissions.

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The researchers looked at the length of stay for patients during this decade as well as their WeeFIM scores at admission, WeeFIM functional gains and WeeFIM efficiency. They also looked at 11 different variables that could impact overall trends, including length of stay, patient age, co-existing diseases and conditions, gender, race, region in which the rehabilitation facility was located, insurance type (i.e., public vs. private), admission WeeFIM score, facility type (i.e., freestanding or hospital-unit based), facility size (i.e., number of beds) and discharge year.

Length of stay varied as widely as one to 944 days over the decade studied, with the average length of stay being 28 days. More specifically, the average length of stay dropped from 31 days in 2004 to 24 days in 2014.

“Our study tells us that the number of days children spent in inpatient rehabilitation decreased during the last 10 years,” says Tracy Knippel, MD; 3rd year resident, University of Pittsburgh Medical Center and Amy Houtrow, MD, PhD, MPH; associate professor of PM&R and pediatrics; University of Pittsburgh. “Our study doesn’t tell us why it happened, but we do know that the number of days adults spend in inpatient rehabilitation has decreased as well in the recent past. We think that children and adults are spending less time in inpatient rehabilitation in part because the process of rehabilitation care has gotten more efficient and in part due to pressures from insurance companies to get patients home as quickly as possible.”

Drs. Knippel and Houtrow also noted WeeFIM scores at admission remained relatively stable over the decade studied; WeeFIM efficiency improved significantly over time; and WeeFIM gain decreased significantly. This decrease in WeeFIM gain indicates a trend toward more children being discharged home with more functional limitations, which shifts recovery to an outpatient setting.

Drs. Knippel and Houtrow found some children improved more than others during their time doing inpatient rehabilitation. They also noted older children, children with private insurance, children who stayed only a short time in inpatient rehabilitation and children who lived in the Northeast did the best in inpatient rehabilitation, but say more research is needed to figure out why this is the case.

Next, Drs. Knippel and Houtrow evaluated trends at the facility level and found the total number of freestanding facilities remained stable over the decade studied, but decreased as a percentage of total facilities providing pediatric rehabilitation services (dropping from 26 percent in 2004 to 20 percent in 2014) showing a trend toward hospital-based rehabilitation. They also found the largest number of inpatient rehabilitation facilities during this time period were located in the Northeastern U.S.

Finally, Drs. Knippel and Houtrow evaluated specific impairment groups and the percentage change in rehabilitation admissions each experienced during the decade studied. Physical weakness, or debility, accounted for zero percent of inpatient rehabilitation admissions in 2004 and increased to five percent by 2014. In 2004, musculoskeletal conditions accounted for 15 percent of admissions; this decreased to 8.6 percent in 2014. By comparison, acquired brain injuries consistently represented about 50 percent of all inpatient rehabilitation admissions throughout the study period.

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Overall, this retrospective study indicates inpatient pediatric rehabilitation has changed significantly in the past decade. Some of the change – like more efficient care – is positive, according to Drs. Knippel and Houtrow. But, they also found issues of concern, such as variability in care and children being discharged from inpatient rehabilitation earlier. “As we work to provide the highest quality of care for children, we need to make sure they are getting the rehabilitation services they need to be as healthy and functional as possible so that they can do the things in life that they want to do,” conclude Drs. Knippel and Houtrow.

###The Association of Academic Physiatrists (AAP) is the only academic association dedicated to the specialty of physiatry in the world. AAP is an organization of leading physicians, researchers, in-training physiatrists, and others involved or interested in mentorship, leadership, and discovery in physiatry. AAP holds an Annual Meeting, produces a leading medical journal in rehabilitation, AJPM&R, and leads a variety of programs and activities that support and enhance academic physiatry. To learn more about the Association and the field of physiatry, visit our site at physiatry.org and follow us on Twitter using @AAPhysiatrists. To learn more about the 2016 AAP Annual Meeting, visit http://www.physiatry.org/AAP2016.

AbstractTen Year Trends in Pediatric Inpatient Rehabilitation: Predicting Length of Stay and Rehabilitation Outcomes Using WeeFIM DataTracy Knippel, MD; Amy Houtrow, MD, PhD, MPH

Objectives: Using small samples, recent studies have highlighted discrepancies in structures and processes of pediatric inpatient rehabilitation care. Our objective was to evaluate variations in care in terms of populations served, functional gains, length of stay (LOS) and WeeFIM efficiency using national data.

Design: We retrospectively analyzed WeeFIM data (N=42,702) collected from 67 participating pediatric inpatient rehabilitation programs in the USA between 2004-2014. Changes over time in LOS, WeeFIM scores, and WeeFIM efficiency were analyzed using ANOVA and Tukey HSD post hoc comparisons. Hierarchical linear modeling was used to determine predictors of WeeFIM efficiency. We analyzed how admission diagnoses changed over time.

Results: Overall mean LOS was 28 days, median 19 days. From 2004-2014, mean LOS decreased (F=27.6, p < 0.0001). Average LOS in 2014 was 24 days compared to 31 days a decade earlier. Admission mean Total WeeFIM Score was stable over the 10 year period (range 49.62–52.36). WeeFIM efficiency improved over time (F=23.3, p < 0.0001) but WeeFIM gain decreased (F=6.9, p < 0.0001). The average WeeFIM gain in 2004 was 24.6, compared to 22.5 in 2014. WeeFIM efficiency showed a nearly linear increase over the study period.

Shorter LOS, older age, having private insurance, and facilities in the Northeast were associated with higher WeeFIM efficiency in the heirarchical linear model (R2=0.22).

In 2004, debility accounted for 0% of admissions, increasing to 5% by 2014. Acquired brain injury consistently represented half of inpatient rehabilitation admissions.

Conclusions: Average LOS decreased and WeeFIM efficiency increased recently. Children were admitted with similar functional levels but were discharged with lower WeeFIM gains. This means that children were being discharged with more functional limitations, shifting recovery to the outpatient sector. WeeFIM efficiency was predicted by numerous factors, which may be amenable to intervention to further advance care delivery.