| | Social Determinants of Discharge Destination for Patients After Stroke With Low Admission FIM Instrument ScoresAbstract Nguyen TA, Page A, Aggarwal A, Henke P. Social determinants of discharge destination for patients after stroke with low admission FIM instrument scores. ObjectiveTo investigate the effects of immigrant status (via country of birth), marital status, and area-based socioeconomic status (SES) on discharge destination after stroke for those with low admission scores on the FIM instrument. DesignCross-sectional study. SettingInpatient rehabilitation ward at an urban community hospital in Australia. ParticipantsA total of 326 inpatients admitted for rehabilitation poststroke. InterventionMultidisciplinary rehabilitation. Main Outcome MeasureDischarge home versus nursing home. ResultsA total admission FIM score of 75 or lower was associated with a higher probability of nursing home discharge. Married patients with a total FIM admission score of 75 or lower were significantly more likely to be discharged home, after adjusting for immigrant status, type and side of stroke, sex, and age (odds ratio, 6.07; 95% confidence interval, 1.65−22.40; P<.01). This effect was also observed for low motor and cognition components of FIM admission score. The effect of immigrant status did not remain significant after adjusting for marital status. Area-based SES and stroke characteristics did not substantially attenuate the relationship between immigrant status, marital status, and discharge location. ConclusionsMarital status is a significant determinant of discharge destination. Immigrant status and area-based SES were not significant predictors of discharge disposition. STROKE IS A LEADING CAUSE of long-term disability in adults, representing 25% of all chronic disability in Australia.1 It is estimated that about 217,500 Australians have been affected by a stroke some time in their lives.2 In Australia, individualized inpatient rehabilitation programs are offered to selected patients in rehabilitation hospitals after a stroke. Selection is often guided by factors associated with both positive and negative long-term functional outcomes. Patients with more negative long-term functional predictors and fewer positive predictors are often deemed to have a higher chance of nursing home discharge and hence may not be accepted for inpatient rehabilitation. Some positive predictors in stroke include young age,3, 4 gait status,5 and presence of committed caregivers.3, 6, 7, 8, 9 Negative predictors include urinary incontinence3, 10 and presence of medical comorbidities.5 Early potential predictors of outcome are not used to make final discharge decisions, although they may be useful for estimating likely discharge disposition early on. Discharge planning is still undertaken with consideration of each patient’s circumstances. It is likely, however, that sociodemographic variables may be important in influencing the availability of care after discharge in Australia and in other countries with culturally diverse populations. Social factors seem to play an important role in influencing discharge destination, although there are limited studies looking at this relationship. The availability of caregiver support to provide care poststroke in a home environment is in many cases a crucial prerequisite for home discharge. The caregiver role may be taken up by the spouse of the affected patient. Being married has been shown to be an important predictor in discharge location after stroke in some studies,6, 7, 8 but this was not shown in 1 other study.9 To our knowledge, no previous studies have looked at the effect of marital status in severe strokes or the potential confounding of immigrant status on marital status in discharge destination. Cultural variables can affect attitudes toward and interactions with people who have major disabilities, and they can also influence family and community support structures. Such cultural variables may include religion, education, employment, and family unit structure and size, as well as culture-specific ideologies concerning health and illness, caring for the disabled, and costs of care and institutional care. It is difficult to measure all the dynamic cultural variables that may be of relevance, although an indicator of cultural influence such as country of birth may be used to assess the effect of culture in discharge location after a severe stroke. Although country of birth cannot fully address all the cultural variables involved, it can help encompass multiple cultural facets into particular groups that share similar ideologies, and it has been used in several other studies11, 12, 13 as an indicator of cultural influences. Shen et al11 did not find any significant effect of country of birth (non–English-speaking vs English-speaking background) on discharge destination in a cohort of older stroke patients (>65y). However, that study did not adjust for initial stroke severity and stroke characteristics. Socioeconomic status (SES) may be another important factor in determining the availability of resources and facilities to care for these patients after discharge, although there is a lack of studies addressing this. Identifying predictors of discharge destination may also have financial implications for health care. The costs of rehabilitation in the first year after first-ever-in-a-lifetime stroke are substantial, with inpatient and outpatient rehabilitation forming the largest component of first-year costs after a stroke in Australia.14 Funding and allocation of resources to provide inpatient rehabilitation are limited. Adequate access to rehabilitation services needs to be maintained to ensure long-term sustainability and appropriate resource allocation, and selecting suitable patients based on clinical and other sociodemographic factors is important to use these limited resources appropriately. The FIM instrument is a widely used and accepted functional scale used to measure the functional status of patients with stroke and other impairments. There have been numerous studies15, 16, 17 using the FIM to measure and determine functional outcomes in stroke. Low admission FIM scores have been associated with a higher probability of nursing home discharge,3, 15, 17, 18, 19 although some patients with low admission FIM scores do go home from our experience. Therefore, the purpose of this study was to investigate how the association between admission FIM scores (particularly low admission FIM scores) and discharge destination in patients with stroke was modified by sociodemographic factors such as immigrant status (measured by country of birth), marital status, and SES. Methods  Data Hospital admission data were obtained from 326 consecutive patients admitted to the rehabilitation ward at a central urban Sydney hospital between August 1999 and December 2004 after a primary diagnosis of stroke. Inclusion criteria included a primary diagnosis of stroke as defined by International Statistical Classification of Diseases and Other Health Related Problems, Tenth Revision20 codes for cerebrovascular accident (thrombotic, embolic, lacunar, intracerebral hemorrhage [primary], subarachnoid hemorrhage, stroke not specified as hemorrhage or infarction), admission for inpatient rehabilitation, and discharge to a nursing home or home. Patients with primary diagnoses of subdural hemorrhage (n=14) or closed head injuries (n=14), those missing country-of-birth information (n=8) or area SES information (n=9), and those discharged to other settings, including hostel or boarding house (n=33), acute hospital (n=43), and deceased (n=4), were excluded from the study. Demographic data including sex, age, country of birth, marital status, and postal code of residence (for SES analysis) were collected. Some of these factors have been associated with functional outcome in stroke.6, 21 Impairment group codes were recorded, based on clinical signs with radiologic confirmation (grouped as left brain, right brain, or undefined—which included bilateral, midline, or location not able to be confirmed radiologically). Admission FIM scores were obtained by FIM-credentialed ward staff (mean duration between admission and administration of admission FIM ± standard deviation, 3.4±4.8d). The average length of stay was 30.2±21.5 days. The time interval between stroke onset and admission to rehabilitation was not available from the collected data. Age was aggregated into 3 groups: younger than 50 years, 50 to 69 years, and 70 years or older to reflect young, middle, and older age groups. Country of birth was divided into 2 groups: non–English-speaking background (NESB) and English-speaking background (ESB). Country of birth was used as an indicator of cultural influences as in previous studies.11, 12, 13 The ESB group (53%) comprised people from Australia, United Kingdom, Ireland, and New Zealand. The NESB group (47%) comprised people from Greece (8%), Italy (7%), China (6%), Vietnam (4%), Lebanon (2%), and Southern Europe, Eastern Europe, Scandinavia, Southeast Asia, the Pacific, South America, and Africa (all <2%). Marital status was defined as married, de facto, or not married, which included those divorced, separated, or widowed. Postal code of residence was used to derive an estimate of area-based SES of the locality in which patients resided. This study used the Index of Economic Resources (IER), a measure of the income and economic wealth of an area derived by the Australian Bureau of Statistics using principal components analysis of census information reported by people.22 The IER includes variables that are associated with economic resources within a certain locality. People living in areas with higher scores on the IER have a higher proportion of families with high income, a lower proportion of low-income families, and more households living in larger houses. A low score indicates the area has a relatively high proportion of households with low incomes and living in small dwellings.22 The primary outcome for this study was the discharge destination, defined as home or nursing home. The admission FIM scores were not used in goal setting or discharge planning. Analysis Definition of subgroups of low admission FIM scores for sociodemographic study factors Differences between immigrant status groups, marital status groups, and SES were investigated with a series of logistic regression models. Logistic regression is the most appropriate and parsimonious method for binary outcome data (ie, home or nursing home) and for considering confounding, modifying, or mediating effects of multiple variables, either sequentially or simultaneously.23 Immigrant status and marital status were considered as effect modifiers of the association between admission FIM scores and stroke outcome by investigating the interaction between admission FIM score and immigrant status and between admission FIM score and marital status, adjusting for sex, age (as a categoric variable), type of stroke, and side of stroke. These analyses investigated whether the probability of being discharged home differed by immigrant status and marital status across the range of admission FIM scores. The predicted probabilities of going home at discharge from hospital for a range of total admission FIM scores from 30 to 120 (modeled as a continuous variable) were calculated by rearranging the logistic regression models into the form of the logistic risk model: R(x1)=exp(α+β1x1)/(1+exp[α+β1x1]).24 From these analyses, the probability of being discharged home began to diverge for both immigrant and marital status groups at a total admission FIM score of approximately 75. Below this point, differences emerged between NESB and ESB immigrant groups and between married and not married groups. Above this cutpoint of 75, the probability of going home was similar for immigrant and marital status groups. This empirically derived subgroup was also considered in conjunction with a subgroup based on a standard clinical cutpoint of total admission FIM score of 40 or lower (derived from previous studies3, 15). A similar method was used to derive appropriate empirical cutpoints to motor and cognitive components of the total admission FIM score to investigate the effects of immigrant and marital status on discharge destination within these subdomains. Separate analyses were performed using these component scores to further distinguish any important relationships possibly obscured by using the total admission FIM score alone. Differences in the probability of being discharged home emerged at a motor component admission FIM score of 70 or lower and for a cognitive component admission FIM score of 25 or lower when the logistic risk model was applied. The effect of sociodemographic factors on discharge destination Sociodemographic variables and stroke characteristics were also considered as confounders of the association between admission FIM score and stroke outcome in a series of multivariate logistic regression models. The likelihood of going home variously accounting for the effects of immigrant status, marital status, and characteristics of stroke after discharge from hospital were calculated from these models. The effect of the ecologic measure of area-based SES was also investigated. No significant area-based SES differences in discharge destination were evident, and area-based SES was therefore excluded from the final regression models. Results Low total admission FIM scores based on an empirically derived cutpoint (≤75) and a standard clinical cutpoint (≤40) were associated with an increased probability of being discharged to a nursing home. Significant effect modification of this association (P<.01) was evident for immigrant status group, with those in the NESB immigrant groups more likely to be discharged home with low total admission FIM scores than those in the ESB immigrant groups (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.17−4.57; P<.05), after adjusting for the effects of type and side of stroke, sex, and age (table 1). Immigrant status differentials no longer differed significantly after adjustment for marital status in low total admission FIM score groups (≤75 and ≤40) (see table 1). The nonsignificance of immigrant status was also observed in separate analyses for low motor component admission FIM score (≤70) and low cognitive component admission FIM score (≤40). | | |  | Predictors | n | Adjusted for Sex and Age OR (95% CI) | Adjusted for Sex, Age, and Stroke⁎ | Adjusted for All Variables† OR (95% CI) | |
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| OR (95% CI) for Immigrant Status | OR (95% CI) for Marital Status | |
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| Clinical cutpoint for total admission FIM score (≤40) (n=70)‡ | | | Country of birth | | | | | | | |  ESB§ | 32 | 1.00 | 1.00 | | 1.00 | | | NESB | 38 | 3.47(1.14−10.56)¶ | 2.77(0.82−9.32) | | 1.60(0.41−6.23) | | | Marital status | | | | | | | | Not married§ | 37 | 1.00 | | 1.00 | 1.00 | | | Married | 33 | 5.64(1.86−17.06)# | | 6.93(1.98−24.32)# | 6.07(1.65−22.40)# | | | Side of stroke | | | | | | | | Left brain§ | 38 | 1.00 | 1.00 | 1.00 | 1.00 | | | Right brain | 22 | 0.22(0.06−0.79)¶ | 0.23(0.06−0.89)¶ | 0.17(0.04−0.72)¶ | 0.18(0.04−0.77)¶ | | | Other | 10 | 0.18(0.03−1.10) | 0.21(0.03−1.38) | 0.15(0.02−1.20) | 0.16(0.02−1.27) | | | Type of stroke | | | | | | | | Hemorrhagic§ | 20 | 1.00 | 1.00 | 1.00 | 1.00 | | | Nonhemorrhagic | 41 | 0.57(0.18−1.77) | 0.63(0.16−2.45) | 0.60(0.14−2.60) | 0.64(0.14−2.81) | | | Undefined | 9 | 0.12(0.01−1.21) | 0.12(0.01−1.33) | 0.09(0.01−1.32) | 0.09(0.01−1.39) | | | Empirical cutpoint for total admission FIM score (≤75) (n=158)∥ | | | Country of birth | | | | | | | | ESB§ | 81 | 1.00 | 1.00 | | 1.00 | | | NESB | 77 | 2.51(1.29−4.89)# | 2.31(1.17−4.57)¶ | | 1.65(0.80−3.41) | | | Marital status | | | | | | | | Not married§ | 78 | 1.00 | | 1.00 | 1.00 | | | Married | 80 | 4.47(2.22−9.00)⁎⁎ | | 5.02(2.41−10.47)⁎⁎ | 4.48(2.11−9.53)⁎⁎ | | | Side of stroke | | | | | | | | Left brain§ | 69 | 1.00 | 1.00 | 1.00 | 1.00 | | | Right brain | 65 | 0.57(0.28−1.15) | 0.61(0.29−1.26) | 0.55(0.25−1.18) | 0.56(0.26−1.23) | | | Other | 24 | 0.44(0.17−1.16) | 0.50(0.18−1.35) | 0.31(0.11−0.90)¶ | 0.35(0.12−1.03) | | | Type of stroke | | | | | | | | Hemorrhagic§ | 36 | 1.00 | 1.00 | 1.00 | 1.00 | | | Nonhemorrhagic | 93 | 0.83(0.37−1.88) | 0.86(0.36−2.02) | 0.69(0.28−1.70) | 0.74(0.30−1.85) | | | Undefined | 29 | 0.81(0.29−2.28) | 0.80(0.28−2.31) | 0.61(0.20−1.90) | 0.64(0.20−2.02) | | | | |
| ⁎ Models adjusted separately for immigrant status and marital status to show the effect of marital status on immigrant status and vice versa. †Models adjusted for sex, age, type of stroke, side of stroke, immigrant status, and marital status. ‡Clinical cutpoint based on that used in previous studies3, 15 (home discharge, n=25; nursing home discharge, n=45). §Referent group. ∥Cutpoint empirically derived from study data, based on the total admission FIM score above which no differences in probabilities of being discharged home were evident for marital status and country of birth groups (home discharge, n= 91; nursing home discharge, n=67). ¶P<.05. #P<.01. ⁎⁎P<.001. |
Those married were significantly more likely to be discharged home than the unmarried group both for total admission FIM scores of 40 or lower (OR=6.93; 95% CI, 1.98−24.32; P<.01) and for total admission FIM scores of 75 or lower (OR=5.02; 95% CI, 2.41−10.47; P<.001). The magnitude of this difference was reduced after adjustment for immigrant status. The difference between married and unmarried groups, however, remained statistically significant for both total admission FIM groups (see table 1). A similar pattern was evident for the component motor admission FIM score of 70 or lower and cognitive admission FIM score of 25 or lower. For all subgroups of total, motor, and cognitive admission FIM score, stroke type and side of stroke did not substantially attenuate the relationship between immigrant status, marital status, and discharge destination. Discussion The current study found that a total admission FIM score of 75 or lower was associated with a higher probability of nursing home discharge after inpatient rehabilitation. Other studies3, 15, 17, 18, 19 have also shown that low admission FIM scores are associated with a higher probability of nursing home discharge. This effect was also observed for motor admission FIM scores of 70 or lower and cognitive admission FIM scores of 25 or lower. Married patients were significantly more likely to be discharged home with total admission FIM scores of 75 or lower, although the magnitude of this difference was reduced after adjustment for immigrant status. The difference between married and unmarried groups, however, remained statistically significant for both total admission FIM groups (scores ≤40 and ≤75). NESB immigrant groups were more likely to be discharged home with low total admission FIM scores than ESB immigrant groups after adjusting for the effects of type and side of stroke, sex, and age. Immigrant determinants were no longer significantly different, however, after adjustment for marital status. Area-based SES analyses did not show any differences in discharge outcomes between high and low area-based SES groups. In addition, 25 patients with very low total admission FIM scores (≤40) in our study were eventually discharged home. Two previous studies,3, 15 in contrast, observed that all stroke patients with very low total admission FIM scores (≤40) went to a nursing home. Although advances in acute stroke care and rehabilitation may have facilitated improvements in functional outcomes, it is unlikely that there were significant differences in discharge function compared with the current study population to account for the observed variation. Another reason may be differences in social and family supports, such as the greater availability of community services for personal care at home, respite care, access to appropriate accommodation and equipment, and greater availability of family caregivers in our study cohort. Our study was unique in several ways. First, it explored the relationship between immigrant status, marital status, and area-based SES status on discharge destination among patients after a severe stroke in all age groups (when adjusted for patient and stroke factors). To our knowledge, no other studies have looked at the effects of all of these factors together after severe stroke. Although previous studies6, 7, 8 have shown the positive outcomes associated with marital status, our study showed that the effect of marital status is not attenuated significantly by immigrant and area-based SES status, stroke characteristics, sex, and age. Hence, marital status is the most important social determinant in discharge destination in our study. Second, our study showed that a total admission FIM score of 75 or lower, motor component admission FIM score of 70 or lower, and cognitive component admission FIM score of 25 or lower were associated with a higher probability of nursing home discharge in our study population. Third, not all patients with very low total admission FIM scores (≤40) were discharged to a nursing home in our study, as opposed to findings from previous studies.3, 15 Study Limitations There were some limitations to our study. Individual FIM item scores were not recorded in the hospital inpatient database, and hence other analytic strategies such as Rasch modeling and conversion to interval scaling could not be performed.25, 26 This may have resulted in misclassification bias in the defined categories of low and high FIM score groups. That is, some patients classified as being of lower functional independence because of the absence of interval scaling with Rasch models may have had higher functional independence, and vice versa. This misclassification bias, however, would have reduced observed differences and underestimated true differences between marital status, immigrant status, and SES groups. Second, the results of the present study related to relative differentials between groups of patients with certain characteristics. The measurement of functional independence may be biased, but the relative differentials between groups using the same measure would not be biased. The use of NESB versus ESB country-of-birth groups reflected the multicultural characteristics of the study catchment population. The relatively small numbers of patients in specific subgroups of the NESB group precluded applying an analytic strategy similar to that applied to the broader country-of-birth grouping. The potential for further clinical improvement in the time period from stroke onset to rehabilitation unit admission was not addressed in the analysis and could be a further confounding factor. Also, specific care needs and functional ability of patients on discharge were not assessed, although the aim of this study was to identify factors influencing discharge destination rather than assessing actual discharge functional status. An additional consideration was that those with low admission FIM scores who had good social supports and modifiable home environments may have been more likely to be selected for rehabilitation, thereby increasing the chance of home discharge in this study population. Follow-up after discharge was not performed, because the data were analyzed retrospectively and discharge contact details were not collected as part of the study. Finally, the results of the present study relate to a developed metropolitan population with a high migrant presence. Although not applicable to all cultures and social contexts, the results of the present study may be of relevance to similarly developed metropolitan societies with multicultural populations. The present study showed that the probability of home discharge was significantly higher if patients were married before stroke. This remained statistically significant when adjusted for immigrant status, age, sex, and stroke variables. Jorgensen et al6 found that patients with a spouse at home were 3 times more likely to have good outcome (Barthel Index score >50) and that 92% of patients with good outcomes were discharged home. DeJong and Branch7 observed that being married was the most important overall predictor of independent living poststroke, followed by functional status as reflected by Barthel Index scores. The impact of marital status in determining discharge destination highlights the importance of social supports and caregiver availability in facilitating independent living. Indeed, the availability of a nonworking family member to provide adequate care on discharge and discharge functional status have also been shown to be predictors of home discharge poststroke.8, 9, 27 It has also been suggested that patients with greater levels of social support physically improve the most over time compared with those with fewer social supports.28 The present study also found that patients from the NESB immigrant group had a higher probability of discharge home after a severe stroke compared with the ESB group. After accounting for marital status, the effect of immigrant status in our study did not remain significant. This is likely due to higher marriage rates among the NESB group (64%, predominantly Greek, Italian, and Chinese) compared with the ESB group (30%). This observation may suggest that different immigrant groups have differing values relating to marriage and divorce. Religious beliefs within the NESB group are likely to be important, although we were unable to incorporate this as a study variable using the available collected data. There would also be a large overlap of certain large religious denominations (eg, Catholic) between the NESB and ESB groups that would make studying this factor difficult. The present study, to our knowledge, is the first to explore the effect of immigrant status on discharge destination among patients after severe stroke in all age groups. SES based on prestroke locality of residence in our study did not have a significant effect on discharge destination. The area-based SES measure does have limitations. It is an aggregate measure of SES status of a population group within a particular area and not a measure of individual socioeconomic circumstances, which would vary among families in a particular locality. The difference between living at home with caregiver support and nursing home care after a severe stroke may have significant psychologic, emotional, and financial implications for the patient and families, even if only minimal functional recovery is regained. The results of this study may help in identifying early predictors of home discharge after a severe stroke, and patients who may benefit most from inpatient rehabilitation to provide caregiver training and facilitate home discharge. There are other sociodemographic determinants that also influence discharge outcome but cannot be addressed within the scope of this study, although we have attempted to identify some of these important factors in our study. Conclusions Our study showed that marital status is an important determinant in discharge destination, and the effect remained statistically significant when adjusted for immigrant status, age, sex, and stroke variables. Although the NESB immigrant group had a higher rate of home discharge, immigrant status was no longer significant when adjusted for marital status, which showed that marital status was a more important predictor and that marital rates may be higher in the NESB group. Area-based SES status did not have an influence on discharge destination. These findings reinforce the likely relevance of sociocultural influences in discharge location. Cultural factors and their roles in stroke outcome are an understudied area of stroke research, and this warrants further discussion. Acknowledgment We thank all the staff of the rehabilitation ward at Balmain Hospital for collecting the data. References 1. 1Australian Institute of Health and Welfare. Secondary prevention and rehabilitation after coronary events or stroke: a review of monitoring issues. Canberra: AIHW; 2003;. 2. 2Australian Institute of Health and Welfare. Heart, stroke and vascular diseases—Australian facts 2004. 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No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(07)00220-1 doi:10.1016/j.apmr.2007.03.011 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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