LETTERS TO THE EDITOR
RE: IMPACT OF PRESSURE ULCERS ON OUTCOMES IN INPATIENT REHABILITATION FACILITIES
2. Mas MA`, Santaeuge`nia S, Garcı´a La´zaro M, et al: Clinical impact of pressure ulcers in patients admitted in a rehabilitation unit of an intermediate care hospital. EWMA J Supplement 2013;13:65
To the Editor: In an article published in the American Journal of Physical Medicine and Rehabilitation, Wang et al.1 reported results of negative impact of pressure ulcers (PUs) on outcomes in patients admitted to rehabilitation facilities in the United States. The authors would like to support this article on the basis of the results of a recently presented local study in Europe.2 In some European countries, inpatient rehabilitation of older patients with complex conditions is based on intermediate care hospitalization.3Y6 The authors of this article have data from a retrospective study performed during the period from January 2010 to December 2011 in several geriatric rehabilitation units of El Carme Intermediate Care Hospital in Badalona, north of Barcelona urban area, Catalonia (Spain). Rehabilitation intervention was provided by a multidisciplinary care team (medical, nursing, physiotherapy, occupational therapy, social work) and was based on Comprehensive Geriatric Assessment.7Y9 A total of 668 patients were included (mean age, 83 yrs; Charlson Comorbidity Index, 2; referred from acute care unit, 87%; main diagnostic group orthopedic, 46%; medical, 30%; stroke, 18%; and surgical, 6%).The sample of older patients in this study had a high prevalence of geriatric syndromes at admission, including immobility (32%), cognitive impairment (24%), mood disorder (22%), and malnutrition (17%). It conditioned higher prevalence of PUs at admission (16%) and longer length of stay than did the sample of the Wang et al.1 Age (82.1 T 9.9 vs. 80.1 T 9.6 yrs), Barthel Index at admission (32.9 T 25.3 vs. 44.3 T 25), and number of geriatric conditions (5.4 T 1.7 vs. 4.2 T 1.8) were significantly found as characteristics related with PU at admission. Negative impact of PU presence at admission to the rehabilitation unit (compared with PU free) was measured using Barthel Index at discharge (53.1 T 34.1 vs. 68.6 T 33.6; P G 0.001), length of stay in days (70.4 T 42 vs. 59.2 T 37.1; P G 0.001), and percentage of discharge destination (community, 69.2% vs. 82.5%; long-term care unit, 14% vs. 6.4%; acute care unit, 8.4% vs. 6.2%; death, 8.4% vs. 4,8%, P G 0.001). In our experience, from a geriatric rehabilitation facility in Europe, we support the following information in the study of Wang et al.1: the results of negative effect of PUs among functional outcomes, length of stay in the facility, and odds of being discharged to the community.
3. Melis RJ, Olde Rikkert MG, Parker SG, et al: What is intermediate care? BMJ 2004;329:360Y1
REFERENCES 1. Wang H, Niewczyk P, DiVita M, et al: Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities. Am J Phys Med Rehabil 2014;93:207Y16
638
4. Miralles R, Sabarte´s O, Ferrer M, et al: Development and validation of an instrument to predict probability of home discharge from a geriatric convalescence unit in Spain. J Am Geriatr Soc 2003;51:252Y7 5. Mas MA`, Renom A, Va´zquez-Ibar O, et al: Interruptions to rehabilitation in a geriatric rehabilitation unit: associated factors and consequences. Age Ageing 2009;38:346Y9 6. Esperanza A, Miralles R, Rius I, et al: Evaluation of functional improvement in older patients with cognitive impairment, depression and/or delirium admitted to a geriatric convalescence hospitalization unit. Arch Gerontol Geriatr 2004;38(suppl 9): 149Y53 7. Stuck AE, Siu AL, Wieland GD, et al: Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993; 342:1032Y6 8. Granger CV, Albrecht GL, Hamilton BB: Outcome of comprehensive medical rehabilitation: measurement by PULSES Profile and the Barthel Index. Arch Phys Med Rehabil 1979;60:145Y54 9. Bachmann S, Finger C, Huss A, et al: Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010; 340:c1718
Sebastia` Santaeuge`nia, MD Miquel A`ngel Mas, MD Ana Maria Alventosa, RN Manoli Garcı´a, RN Albert Monterde, RN Alicia Gutie´rrez, RN Department of Geriatric Medicine and Palliative Care Badalona Serveis Assistencials, Badalona Catalonia, Spain DOI: 10.1097/PHM.0000000000000124
RESPONSE TO LETTER BY DR SANTAEUGE` NIA AND COLLEAGUES To the Editor: The authors thank Dr Santaeuge`nia and colleagues for their interest and comments on our study of the impact of pressure ulcers on functional outcomes in the inpatient rehabilitation facility (IRF) setting.1 Santaeuge`nia et al. shared their recent study of 668 patients treated in geriatric rehabilitation units of an intermediate care hospital in Spain. The reviewers found that the presence of pressure ulcers had a negative association with patient outcomes Am. J. Phys. Med. Rehabil. & Vol. 93, No. 7, July 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
including functional gain, length of stay, discharge destination, and mortality. In the authors’ study of 2902 matched pairs of pressure ulcer and pressure ulcerYfree patients treated at IRFs in the United States, the presence of a pressure ulcer was associated with a lower motor functional gain, a longer length of stay, and a lower likelihood of being discharged to the community. Although the study by Santaeuge`nia et al. supports the authors’ findings, there are several differences in study design and population that the authors would like to note. In comparison with the Wang et al. study sample,1 the Santaeuge`nia et al. study sample had a higher pressure ulcer prevalence (16% vs. 5%), was older (mean age of 83 vs. 75 yrs), and had a longer length of stay (mean [SD], 59.2 [3.7] days or longer vs. 14.5 [9.3]). These variations in characteristics may be attributed to the differences in healthcare systems, governmental policies, and how inpatient rehabilitation is defined between the two countries. In the United States, financial factors result in patients spending less time in both the acute care setting and the inpatient rehabilitation setting, a reflection of the prospective payment system for all Medicare beneficiaries (who make up the largest percentage of patients seen at IRFs in the United States). For patients who need additional services, IRFs are one of several options for postacute care. To be considered an appropriate admission for an IRF, a patient must be medically stable, must be able to fully participate in at least 3 hrs of physical therapy per day, and must also be expected to benefit from the therapies that are provided in the IRF setting.2 Government policies and regulations have an impact on the types of patients who are admitted to IRFs and other postacute facilities in the United States, which may account for some of the sociodemographic differences between the study populations. In addition, Medicare patients have an expected length of stay in the IRF through the prospective payment system, based in part upon the severity of their disability upon admission and comorbidities. Although the expected length of stay may not coincide with the clinical needs of the patient, there is financial motivation to discharge the patient as close to the expected date as possible. Despite the differences in healthcare systems and policies, it was reported by both authors
www.ajpmr.com
that pressure ulcers had a negative impact on rehabilitation outcomes. The consistency in this finding speaks to the validity of the observed association. It is also worth noting that the patients in both study samples (with or without pressure ulcers) benefited from their respective rehabilitation programs and demonstrated significant functional improvements, which are a demonstration of the positive impact of postacute rehabilitation. REFERENCES 1. Wang H, Niewczyk P, Divita M, et al Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities. Am J Phys Med Rehabil 2014;93:207Y16 2. Centers for Medicare and Medicaid Services: CMS Manual System Pub 100-04 Medicare Claims Processing Transmittal 938: The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). May 5, 2006. Available at: https:// www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ downloads/R938CP.pdf. Accessed March 26, 2014 Hua Wang, PhD Kaiser Foundation Rehabilitation Center Vallejo, California Michelle Camicia, MSN, CRRN Kaiser Foundation Rehabilitation Center Vallejo, California Jacqueline Mix, MPH Uniform Data System for Medical Rehabilitation Amherst, New York Margaret DiVita, PhD Uniform Data System for Medical Rehabilitation Amherst, New York and State University of New York at Cortland Paulette Niewczyk, MPH, PhD Uniform Data System for Medical Rehabilitation Amherst, New York
DOI: 10.1097/PHM.0000000000000095
Letters to the Editor Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
639
RE: IMPACT OF PRESSURE ULCERS ON OUTCOMES IN INPATIENT REHABILITATION FACILITIES
2. Mas MA`, Santaeuge`nia S, Garcı´a La´zaro M, et al: Clinical impact of pressure ulcers in patients admitted in a rehabilitation unit of an intermediate care hospital. EWMA J Supplement 2013;13:65
To the Editor: In an article published in the American Journal of Physical Medicine and Rehabilitation, Wang et al.1 reported results of negative impact of pressure ulcers (PUs) on outcomes in patients admitted to rehabilitation facilities in the United States. The authors would like to support this article on the basis of the results of a recently presented local study in Europe.2 In some European countries, inpatient rehabilitation of older patients with complex conditions is based on intermediate care hospitalization.3Y6 The authors of this article have data from a retrospective study performed during the period from January 2010 to December 2011 in several geriatric rehabilitation units of El Carme Intermediate Care Hospital in Badalona, north of Barcelona urban area, Catalonia (Spain). Rehabilitation intervention was provided by a multidisciplinary care team (medical, nursing, physiotherapy, occupational therapy, social work) and was based on Comprehensive Geriatric Assessment.7Y9 A total of 668 patients were included (mean age, 83 yrs; Charlson Comorbidity Index, 2; referred from acute care unit, 87%; main diagnostic group orthopedic, 46%; medical, 30%; stroke, 18%; and surgical, 6%).The sample of older patients in this study had a high prevalence of geriatric syndromes at admission, including immobility (32%), cognitive impairment (24%), mood disorder (22%), and malnutrition (17%). It conditioned higher prevalence of PUs at admission (16%) and longer length of stay than did the sample of the Wang et al.1 Age (82.1 T 9.9 vs. 80.1 T 9.6 yrs), Barthel Index at admission (32.9 T 25.3 vs. 44.3 T 25), and number of geriatric conditions (5.4 T 1.7 vs. 4.2 T 1.8) were significantly found as characteristics related with PU at admission. Negative impact of PU presence at admission to the rehabilitation unit (compared with PU free) was measured using Barthel Index at discharge (53.1 T 34.1 vs. 68.6 T 33.6; P G 0.001), length of stay in days (70.4 T 42 vs. 59.2 T 37.1; P G 0.001), and percentage of discharge destination (community, 69.2% vs. 82.5%; long-term care unit, 14% vs. 6.4%; acute care unit, 8.4% vs. 6.2%; death, 8.4% vs. 4,8%, P G 0.001). In our experience, from a geriatric rehabilitation facility in Europe, we support the following information in the study of Wang et al.1: the results of negative effect of PUs among functional outcomes, length of stay in the facility, and odds of being discharged to the community.
3. Melis RJ, Olde Rikkert MG, Parker SG, et al: What is intermediate care? BMJ 2004;329:360Y1
REFERENCES 1. Wang H, Niewczyk P, DiVita M, et al: Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities. Am J Phys Med Rehabil 2014;93:207Y16
638
4. Miralles R, Sabarte´s O, Ferrer M, et al: Development and validation of an instrument to predict probability of home discharge from a geriatric convalescence unit in Spain. J Am Geriatr Soc 2003;51:252Y7 5. Mas MA`, Renom A, Va´zquez-Ibar O, et al: Interruptions to rehabilitation in a geriatric rehabilitation unit: associated factors and consequences. Age Ageing 2009;38:346Y9 6. Esperanza A, Miralles R, Rius I, et al: Evaluation of functional improvement in older patients with cognitive impairment, depression and/or delirium admitted to a geriatric convalescence hospitalization unit. Arch Gerontol Geriatr 2004;38(suppl 9): 149Y53 7. Stuck AE, Siu AL, Wieland GD, et al: Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993; 342:1032Y6 8. Granger CV, Albrecht GL, Hamilton BB: Outcome of comprehensive medical rehabilitation: measurement by PULSES Profile and the Barthel Index. Arch Phys Med Rehabil 1979;60:145Y54 9. Bachmann S, Finger C, Huss A, et al: Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010; 340:c1718
Sebastia` Santaeuge`nia, MD Miquel A`ngel Mas, MD Ana Maria Alventosa, RN Manoli Garcı´a, RN Albert Monterde, RN Alicia Gutie´rrez, RN Department of Geriatric Medicine and Palliative Care Badalona Serveis Assistencials, Badalona Catalonia, Spain DOI: 10.1097/PHM.0000000000000124
RESPONSE TO LETTER BY DR SANTAEUGE` NIA AND COLLEAGUES To the Editor: The authors thank Dr Santaeuge`nia and colleagues for their interest and comments on our study of the impact of pressure ulcers on functional outcomes in the inpatient rehabilitation facility (IRF) setting.1 Santaeuge`nia et al. shared their recent study of 668 patients treated in geriatric rehabilitation units of an intermediate care hospital in Spain. The reviewers found that the presence of pressure ulcers had a negative association with patient outcomes Am. J. Phys. Med. Rehabil. & Vol. 93, No. 7, July 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
including functional gain, length of stay, discharge destination, and mortality. In the authors’ study of 2902 matched pairs of pressure ulcer and pressure ulcerYfree patients treated at IRFs in the United States, the presence of a pressure ulcer was associated with a lower motor functional gain, a longer length of stay, and a lower likelihood of being discharged to the community. Although the study by Santaeuge`nia et al. supports the authors’ findings, there are several differences in study design and population that the authors would like to note. In comparison with the Wang et al. study sample,1 the Santaeuge`nia et al. study sample had a higher pressure ulcer prevalence (16% vs. 5%), was older (mean age of 83 vs. 75 yrs), and had a longer length of stay (mean [SD], 59.2 [3.7] days or longer vs. 14.5 [9.3]). These variations in characteristics may be attributed to the differences in healthcare systems, governmental policies, and how inpatient rehabilitation is defined between the two countries. In the United States, financial factors result in patients spending less time in both the acute care setting and the inpatient rehabilitation setting, a reflection of the prospective payment system for all Medicare beneficiaries (who make up the largest percentage of patients seen at IRFs in the United States). For patients who need additional services, IRFs are one of several options for postacute care. To be considered an appropriate admission for an IRF, a patient must be medically stable, must be able to fully participate in at least 3 hrs of physical therapy per day, and must also be expected to benefit from the therapies that are provided in the IRF setting.2 Government policies and regulations have an impact on the types of patients who are admitted to IRFs and other postacute facilities in the United States, which may account for some of the sociodemographic differences between the study populations. In addition, Medicare patients have an expected length of stay in the IRF through the prospective payment system, based in part upon the severity of their disability upon admission and comorbidities. Although the expected length of stay may not coincide with the clinical needs of the patient, there is financial motivation to discharge the patient as close to the expected date as possible. Despite the differences in healthcare systems and policies, it was reported by both authors
www.ajpmr.com
that pressure ulcers had a negative impact on rehabilitation outcomes. The consistency in this finding speaks to the validity of the observed association. It is also worth noting that the patients in both study samples (with or without pressure ulcers) benefited from their respective rehabilitation programs and demonstrated significant functional improvements, which are a demonstration of the positive impact of postacute rehabilitation. REFERENCES 1. Wang H, Niewczyk P, Divita M, et al Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities. Am J Phys Med Rehabil 2014;93:207Y16 2. Centers for Medicare and Medicaid Services: CMS Manual System Pub 100-04 Medicare Claims Processing Transmittal 938: The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). May 5, 2006. Available at: https:// www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ downloads/R938CP.pdf. Accessed March 26, 2014 Hua Wang, PhD Kaiser Foundation Rehabilitation Center Vallejo, California Michelle Camicia, MSN, CRRN Kaiser Foundation Rehabilitation Center Vallejo, California Jacqueline Mix, MPH Uniform Data System for Medical Rehabilitation Amherst, New York Margaret DiVita, PhD Uniform Data System for Medical Rehabilitation Amherst, New York and State University of New York at Cortland Paulette Niewczyk, MPH, PhD Uniform Data System for Medical Rehabilitation Amherst, New York
DOI: 10.1097/PHM.0000000000000095
Letters to the Editor Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
639
