Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals.

摘要

OBJECTIVE: To examine the relationship of services for post-acute care (PAC) to stroke patient outcomes. DATA SOURCES/STUDY SETTING: Veterans Health Administration (VHA) hospitals from two facility-level surveys and extant data files. STUDY DESIGN: Cross-sectional study of veterans hospitalized with acute stroke during the period June 1995 through May 1996 in one of 182 geographically distinct locations within the VHA. Study variables included (1) a typological classification of hospitals according to the level of PAC; (2) a taxonomy of rehabilitation characteristics, including personnel, physical facilities, coordination of care, and hospital characteristics; and (3) patient outcomes (discharge destination, length of stay). DATA COLLECTION/EXTRACTION METHODS: Data were collected from two mailed surveys and extant data files. Rehabilitation variables were identified for the study in conjunction with a panel of expert rehabilitation researchers and clinicians, using an a priori model for measuring rehabilitation characteristics. Two sets of variables were derived to categorize these rehabilitation characteristics: (1) a rehabilitation typology, classifying the VA hospitals according to the continuum of PAC settings in the facility, and (2) a rehabilitation taxonomy that used an empirical approach to derive a list of key rehabilitation characteristics. PRINCIPAL FINDINGS: Twenty-seven percent of veterans with acute stroke were cared for in VA hospitals with neither a geriatric nor a rehabilitation unit, and 50 percent were cared for in hospitals without a rehabilitation unit. Hospitals with rehabilitation units had the greatest sophistication, and those with geriatric units had intermediate sophistication in rehabilitation organization and resources. Statistically significant differences were found in outcomes for stroke patients cared for in hospitals classified according to the continuum of post-acute care on site. Exploratory multivariable analyses revealed independent associations between stroke patient outcomes and (1) staffing ratios for nurses and physicians, (2) the diversity of physician and rehabilitation staff, (3) presence of a simulated home environment, and (4) the total number of care settings on site. CONCLUSIONS: The PAC continuum defines an important hierarchy of stroke rehabilitation services.