title: Initial physical grades and cognitive stages after acute stroke: who receives comprehensive rehabilitation services?
abstract: OBJECTIVE
  To study the degree to which initial physical grades and cognitive stages of independence assessed by physical medicine and rehabilitation (PM&R) staff early after hospitalization for acute stroke relate to the decision to either provide rehabilitation in consultation or admission to a specialized rehabilitation unit (SRU) for comprehensive, high-intensity, multidisciplinary rehabilitation.
  
  
  METHODS
  An observational study.
  
  
  METHODS
  Early rehabilitation assessment by PM&R staff during patients' acute hospitalization for stroke in 112 Veterans Affairs facilities.
  
  
  METHODS
  The sample included 8,783 veterans who were assessed by PM&R staff.
  
  
  METHODS
  Shortly after hospital admission, functional status was determined according to 7 physical grades and 7 cognitive stages of increasing independence. Patients' physical grades and cognitive stages ranged at initial PM&R assessment from the lowest and most dependent "I" through intermediate "II, III, IV, V, or VI," and ended with the highest at total independence "VII." To assess the statistically independent effects of physical grade and cognitive stage, a multivariable generalized estimating equation was applied to account for within Veterans Affairs facilities correlation and to adjust for demographics, stroke type, comorbidities, clinical events before PM&R assessment, and facility-related factors.
  
  
  METHODS
  The decision to admit patients to an SRU for comprehensive rehabilitation.
  
  
  RESULTS
  Only 11.2% of those patients assessed after stroke were admitted to an SRU after the acute management phase. After statistical adjustment, patients at the lowest physical grade (I) of independence had a 9-fold increased odds of admission to an SRU compared with those at the highest combined physical grades VI/VII (adjusted odds ratio 9.15, 95% confidence interval 4.31-19.39). In contrast, patients at intermediate cognitive stages of independence were the most likely to be admitted to an SRU. The presence of an SRU within the treating Veterans Affairs facility was strongly related to admission.
  
  
  CONCLUSIONS
  Patients' physical grades and cognitive stages assessed early after stroke are strong determinants of referral for comprehensive rehabilitation.
authors: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 423 Guardian Drive, 904 Blockley Hall, Philadelphia, PA 19104-6021(∗). Electronic address: mstinema@exchange.upenn.edu.
authors: Margaret G
authors: MG
authors: Stineman
authors: Physical Medicine and Rehabilitation, Veterans Affairs Medical Center, Albany, NY; Physical Medicine and Rehabilitation, Albany Medical College, Albany, NY(†).
authors: Barbara E
authors: BE
authors: Bates
authors: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA(‡).
authors: Jibby E
authors: JE
authors: Kurichi
authors: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA(§).
authors: Pui L
authors: PL
authors: Kwong
authors: Veterans Affairs Health Services Research & Development/Rehabilitation Research and Development Rehabilitation Outcomes Research Center Research Enhancement Award Program North Florida/South Georgia Veterans Health System, Gainesville, FL; Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL(¶).
authors: Diane Cowper
authors: DC
authors: Ripley
authors: Veterans Affairs Medical Center Gainesville, FL; Division of Health Policy and Outcomes Research, Department of Epidemiology and Health Policy Research(‖).
authors: W Bruce
authors: WB
authors: Vogel
authors: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA(∗∗).
authors: Dawei
authors: D
authors: Xie
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000175:diagnosis* / Q000209:etiology / Q000534:rehabilitation; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D062072:Patient Acuity; D018579:Patient Selection; D020127:Recovery of Function; D012017:Referral and Consultation; D020521:Stroke / Q000503:physiopathology / Q000523:psychology; D000071939:Stroke Rehabilitation