Advertisement

Efficacy of 7 Days per Week Inpatient Admissions and Rehabilitation Therapy

      Abstract

      DiSotto-Monastero M, Chen X, Fisch S, Donaghy S, Gomez M. Efficacy of 7 days per week inpatient admissions and rehabilitation therapy.

      Objective

      To evaluate the efficacy of 7d/wk of inpatient admissions and rehabilitation therapy (7DART) in a rehabilitation hospital.

      Design

      Cross-sectional, retrospective electronic data review.

      Setting

      Rehabilitation hospital.

      Participants

      Adult patients who participated in the 7DART program and were admitted and discharged between February 2009 and January 2010 (n=1808), and adult patients who received 5d/wk of inpatient admissions and rehabilitation therapy (5DART), and were admitted and discharged between February 2008 and January 2009 (n=1692).

      Interventions

      Occupational therapy and physiotherapy during the weekends (7DART only).

      Main Outcome Measures

      FIM rating change from admission to discharge, length of hospital stay, rehabilitation workload per patient, and discharge destination.

      Results

      There were 3500 patients admitted with a mean age ± SD of 72.1±13.3 years and a male-to-female ratio of 1:1.9. Under 7DART conditions, there was a 6.9% increase in admissions (7DART=1808 vs 5DART=1692, P=.006), an 86% increase in weekend admissions (255 vs 137, P<.001), a 13.2% increase in rehabilitation workload per patient (40.7h vs 36h, P<.001), and a 5.4% decrease in rehabilitation hospital stay (19.3d vs 20.3d, P=.043). Similar FIM rating changes were obtained from admission to discharge under both conditions (18.2 for 7DART vs 18.7 for 5DART, P=.099). Both groups resulted in 94% of patients achieving their rehabilitation goals (7DART=94.1%, 5DART=94.5%; P=.967), and 88.6% of patients returning to their homes (7DART=88.1%, 5DART=89.2%; P=.334).

      Conclusions

      Despite the fact that patients in both groups had similar functional outcomes and discharge destination, the 7DART rehabilitation model reduced length of hospital stay and increased rehabilitation workload, demonstrating increased efficiency and access to care by admitting more patients from acute care, rehabilitating them, and discharging them to the community in less time than the 5DART model.

      Key Words

      List of Abbreviations:

      THA (total hip arthroplasty), TKA (total knee arthroplasty)
      REHABILITATION THERAPY IS of paramount importance to help individuals recovering from life-changing illnesses, injuries, or complex medical conditions and procedures to rebuild their lives and return to their community and work activities. Increased rehabilitation intensity (including weekend therapy) has produced improved outcomes in different patient populations.
      • Blackerby W.F.
      Intensity of rehabilitation and length of stay.
      • Brusco N.K.
      • Shields N.
      • Taylor N.F.
      • Paratz J.
      A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial.
      • Cifu D.X.
      • Kreutzer J.S.
      • Kolakowsky-Hayner S.A.
      • Marwitz J.H.
      • Englander J.
      The relationship between therapy intensity and rehabilitation outcomes after traumatic brain injury: a multicenter analysis.
      • Hughes K.
      • Kuffner L.
      • Dean B.
      Effect of weekend physical therapy treatment on postoperative length of stay following total hip and total knee arthroplasty.
      • Killey B.
      • Watt E.
      The effect of extra walking on the mobility, independence and exercise self-efficacy of elderly hospital in-patients: a pilot study.
      • Aronow H.U.
      Rehabilitation effectiveness with severe brain injury: translating research into policy.
      • Sonoda S.
      • Saitoh E.
      • Nagai S.
      • Kawakita M.
      • Kanada Y.
      Full-time integrated treatment program, a new system for stroke rehabilitation in Japan: comparison with conventional rehabilitation.
      However, some studies
      • Johnston M.V.
      • Miller L.S.
      Cost-effectiveness of the Medicare three-hour regulation.
      • Ruff R.M.
      • Yarnell S.
      • Marinos J.
      Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week?.
      • Lang C.E.
      Comparison of 6- and 7-day physical therapy coverage on length of stay and discharge outcome for individuals with total hip and knee arthroplasty.
      present different results. Johnston and Miller
      • Johnston M.V.
      • Miller L.S.
      Cost-effectiveness of the Medicare three-hour regulation.
      studied 934 patients in acute medical rehabilitation units who received a minimum of 3h/d of physical and occupational therapy combined, and despite the average intensity of physical and occupational therapy having increased to .55 hours per patient per day, they could not find detectable benefit to patients in functional status, living arrangement, or other outcomes. Ruff et al
      • Ruff R.M.
      • Yarnell S.
      • Marinos J.
      Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week?.
      studied 113 patients who sustained a cerebrovascular accident and were hospitalized at a rehabilitation inpatient unit. They did not find a difference in length of stay or functional outcomes between those patients who received 6d/wk of inpatient rehabilitation compared with those who received 7d/wk of rehabilitation. Lang
      • Lang C.E.
      Comparison of 6- and 7-day physical therapy coverage on length of stay and discharge outcome for individuals with total hip and knee arthroplasty.
      studied 140 subjects with hip or knee arthroplasty and found no significant difference in postoperative length of stay, discharge destination, or discharge disposition between those individuals who received 6-day or 7-day physical therapy.
      The purpose of this study was to evaluate the efficacy of 7d/wk of inpatient admissions and rehabilitation therapy (7DART) in a rehabilitation hospital.

      Methods

      After approval by our institution's Research Ethics Board, we conducted a cross-sectional retrospective review of electronic data collected at our institution for the National Rehabilitation Reporting System from consecutive patients who met the inclusion criteria: adult patients who received 7d/wk of inpatient admissions and rehabilitation therapy (7DART) and were admitted and discharged between February 2009 and January 2010, and adult patients who received 5d/wk of inpatient admissions and rehabilitation therapy (5DART) and were admitted and discharged between February 2008 and January 2009. Patients who did not meet these criteria were excluded from the study. Patient demographics (age, sex) and the preadmission status are presented in table 1.
      Table 1Demographics
      Variable7DART5DARTAll PatientsP
      χ2 test or Student t test between 7DART and 5DART values.
      Patients1808 (51.7)1692 (48.3)3500 (100.0).006
      Sex
       Men642 (35.5)572 (33.8)1214 (34.7).290
       Women1166 (64.5)1120 (66.2)2286 (65.3).290
      Age (y)72.2±13.671.9±13.072.1±13.3.505
      Pre-adm home1724 (95.5)1625 (96.0)3349 (95.7).318
       Private house/apartment
        without paid health services1472 (85.4)1384 (85.2)2856 (85.3).862
       Private house/apartment
        with paid health services252 (14.6)241 (14.8)493 (14.1).862
      Pre-adm assistive living setting68 (3.8)51 (3.0)119 (3.4).223
      Pre-adm residential care8 (0.4)8 (0.5)16 (0.5).894
      Other or unknown
      Other or unknown refers to patient records without documented preadmission living conditions.
      8 (0.4)8 (0.5)16 (0.5).894
      NOTE. Values are n (%), mean ± SD, or as otherwise indicated.
      Abbreviation: Pre-adm, preadmission.
      low asterisk χ2 test or Student t test between 7DART and 5DART values.
      Other or unknown refers to patient records without documented preadmission living conditions.

      Functional Outcomes

      The FIM rating on admission, FIM rating at discharge, and percent FIM rating change (100% × [FIM discharge − FIM admission/FIM admission]) were compared between 7DART and 5DART patients.

      Resource Utilization

      The total number of admissions and discharges (specifically those that happened during the weekend), rehabilitation length of stay, and rehabilitation workload per patient provided by physiotherapy and occupational therapy staff were compared between 7DART and 5DART patients.

      Results

      Functional and resource utilization outcomes were compared between 7DART and 5DART groups using the Student t test and chi-square analysis, with P<.05 considered significant.

      Patient Demographics, Living Situation, and Waiting Time to Treatment

      There were 3500 patients (7DART, 1808; 5DART, 1692) admitted during the study period, with a mean age ± SD of 72.1±13.3 years and a male-to-female ratio of 1:1.9 (see table 1); most (60%) were admitted for rehabilitation after musculoskeletal conditions (table 2). A group of subspecialty patients had a significant increase in admissions after the implementation of the 7DART program (ie, cardiac, neurologic, complex care, trauma, and oncology), but other groups of subspecialty patients had a significant decrease in admissions after the implementation of the 7DART program (ie, musculoskeletal, amputees, transplants, and burn) (see table 2). More patients in the group with increased admissions were men (45.2% vs 29.4%, P<.001), younger (71.0±16.1y vs 73.0±11.7y, P=.002), living at home preadmission (96.7% vs 94.5%, P=.027), fewer were living at an assistive living setting (2.6% vs 4.5%, P.033), more waited longer before rehabilitation admission (2.2±2.2d vs 1.5±2.1d, P<.001), had a greater admission total FIM rating (92.9±11.1 vs 91.6±11.3, P=.016), had a greater admission motor FIM rating (60.5±9.9 vs 58.3±10.0, P<.001), and more were discharged home without paid health services (47.8% vs 37.2%, P<.001) (table 3).
      Table 2Rehabilitation Specialties
      Specialty7DART5DARTAll PatientsP
      χ2 test between 7DART and 5DART values.
      (n=1808)(n=1692)(n=3500)
      Musculoskeletal1014 (56.1)1087 (64.2)2101 (60.0)<.001
      Cardiac243 (13.4)175 (10.3)418 (11.9).005
      Neurology148 (8.2)121 (7.2)269 (7.7).251
      Complex care138 (7.6)73 (4.3)211 (6.0)<.001
      Trauma99 (5.5)74 (4.4)173 (4.9).133
      Oncology74 (4.1)36 (2.1)110 (3.1)<.001
      Amputees50 (2.8)58 (3.4)108 (3.1).257
      Transplants23 (1.3)44 (2.6)67 (1.9).004
      Burns19 (1.1)24 (1.4)43 (1.2).324
      NOTE. Values are n (%) or as otherwise indicated.
      low asterisk χ2 test between 7DART and 5DART values.
      Table 3Subspecialty Patient Groups With Increased or Reduced Admissions After 7DART
      VariableIncreasedReducedP
      χ2 test or Student t test between increased and reduced values.
      (n=702)(n=1106)
      Sex
       Men317 (45.2)325 (29.4)<.001
       Women385 (54.8)781 (70.6)<.001
      Age (y)71.0±16.173.0±11.7.002
      Living arrangements
       Pre-adm home679 (96.7)1045 (94.5).027
       Pre-adm assistive living setting18 (2.6)50 (4.5).033
       Pre-adm residential care3 (0.4)5 (0.4).938
       Pre-adm other or unknown
      Other or unknown refers to patient records without documented preadmission living conditions.
      2 (0.3)6 (0.5).421
      Waiting time for rehab (d)2.2±2.21.5±2.1<.001
      Admission total FIM (rating)92.9±11.191.6±11.3.016
      Admission motor FIM (rating)60.5±9.958.3±10.0<.001
      Admission cognitive FIM (rating)32.4±4.233.3±2.9<.001
      Rehab LOS (d)19.4±11.819.2±14.9.764
      Rehab workload (d)44.2838.56<.001
      Discharge total FIM (rating)110.2±8.0110.3±8.2.799
      Discharge motor FIM (rating)77.3±6.476.9±6.7.208
      Discharge cognitive FIM rating32.8±3.633.4±2.6<.001
      Percentage FIM rating change
      Percentage FIM rating change: 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).
      19.9±13.921.7±13.0.005
      Percentage rehab goals met88.697.5<.001
      Total discharges634 (90.3)1034 (93.5).013
      Weekend discharges81 (12.8)222 (21.5)<.001
      Discharge destination
       Discharged home total529 (83.4)940 (90.9)<.001
       Discharged home without paid health services253 (47.8)350 (37.2)<.001
       Discharged home with paid health services276 (52.2)590 (62.8)<.001
       Discharged to an assistive living setting27 (4.3)59 (5.7).147
       Discharged to a residential care2 (0.3)8 (0.8).221
       Discharged to other or unknown9 (1.4)3 (0.3).010
       Transfer to acute care67 (10.6)24 (2.3)<.001
      NOTE. Values are n (%), mean ± SD, or as otherwise indicated.
      Abbreviations: Pre-adm, preadmission; Rehab, rehabilitation; Rehab LOS, rehabilitation length of stay.
      low asterisk χ2 test or Student t test between increased and reduced values.
      Other or unknown refers to patient records without documented preadmission living conditions.
      Percentage FIM rating change: 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).

      Subspecialty Patient Groups

      Even though fewer patients with musculoskeletal disorders were admitted under the 7DART rehabilitation model (48.3% vs 51.7%, P<.001), a greater number of them were admitted during the weekend (20.9% vs 12.6%, P<.001), and more of them were discharged during the weekend (22.3% vs 10.5%, P<.001), than patients with musculoskeletal disorders admitted under the 5DART rehabilitation model (table 4).
      Table 4Subspecialty Patient Groups
      Subspecialty7DART5DARTP
      χ2 test or Student t test between 7DART and 5DART values.
      Musculoskeletal
       Total admissions1014 (48.3)1087 (51.7)<.001
       Weekend admissions212 (20.9)137 (12.6)<.001
       Rehab LOS (d)18.4±14.418.9±14.8.471
       FIM rating change (%)
      FIM rating change (%) = 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).
      21.4±12.421.8±13.7.451
       Rehab goals met (%)98.497.1.888
       Total discharges959 (94.6)1017 (93.6).325
       Weekend discharges214 (22.3)107 (10.5)<.001
       Discharged home885 (92.3)934 (91.8).715
      TKA
       Total admissions455 (44.5)523 (53.5)<.001
       Weekend admissions126 (27.7)97 (18.5)<.001
       Rehab LOS (d)13.3±7.813.5±7.2.707
       FIM rating change (%)
      FIM rating change (%) = 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).
      19.3±11.819.9±10.9.378
       Rehab goals met (%)99.598.8.942
       Total discharges435 (95.6)503 (96.2).653
       Weekend discharges109 (25.1)51 (10.1)<.001
       Discharged home423 (97.2)480 (95.4).144
      THA
       Total admissions298 (51.0)286 (49.0).739
       Weekend admissions72 (24.2)40 (14.0).002
       Rehab LOS (d)15.3±11.016.8±12.8.126
       FIM rating change (%)
      FIM rating change (%) = 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).
      21.7±11.221.5±10.6.868
       Rehab goals met (%)98.698.5.995
       Total discharges285 (95.6)274 (95.8).921
       Weekend discharges63 (22.1)27 (9.9)<.001
       Discharged home265 (93.0)262 (95.6).180
      Cardiac
       Total admissions243 (58.1)175 (41.9).005
       Weekend admissions19 (7.8)0 (0.0)<.001
       Rehab LOS (d)12.5±4.913.5±4.3.028
       FIM rating change (%)
      FIM rating change (%) = 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).
      16.5±7.916.9±6.9.585
       Rehab goals met (%)90.795.7.600
       Total discharges225 (95.6)164 (93.7).656
       Weekend discharges34 (15.1)8 (4.9).001
       Discharged home195 (86.7)151 (92.1).093
      NOTE. Values are n (%), mean ± SD, or as otherwise indicated.
      Abbreviations: Rehab, rehabilitation; Rehab LOS, rehabilitation length of stay.
      low asterisk χ2 test or Student t test between 7DART and 5DART values.
      FIM rating change (%) = 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).
      Similar improved outcomes were obtained among patients admitted under the 7DART rehabilitation model for rehabilitation after total knee arthroplasty (TKA), total hip arthroplasty (THA), or after cardiac interventions (eg, myocardial infarct, coronary artery bypass, or angioplasty) (see table 4).

      Resource Utilization

      There was a 6.9% increase in total admissions (1808 vs 1692, P=.006), an 86% increase in weekend admissions (255 vs 137, P<.001), and an 8.3% increase in total discharges (1668 vs 1540, P=.185), including especially a 111.9% increase in discharges during the weekends (303 vs 143, P<.001), in the 7DART group compared with the 5DART group (table 5). The total number of admissions to the rehabilitation hospital has increased during the last 4 years, specifically after the introduction of the 7DART rehabilitation model in February 2009 (Feb 2007 through Jan 2008=2438 admissions; Feb 2008 through Jan 2009=2335 admissions; Feb 2009 through Jan 2010=2470 admissions; Feb 2010 through Jan 2011=2596 admissions).
      Table 5Resource Utilization
      Resource7DART5DARTTotalP
      χ2 test or Student t test between 7DART and 5DART values.
      Total admissions1808 (51.7)1692 (48.3)3500 (100.0).006
      Weekend admissions255 (14.1)137 (8.1)392 (11.2)<.001
      Total discharges1668 (52.0)1540 (48.0)3208 (100.0).185
      Weekend discharges303 (18.2)143 (9.3)446 (13.9)<.001
      Rehab LOS (d)19.3±13.820.3±15.419.8±14.6.043
      Rehab workload (h)40.736.076.7<.001
      Waiting time for rehab (d)1.8±2.11.6±2.21.7±2.2.007
      NOTE. Values are n (%), mean ± SD, or as otherwise indicated.
      Abbreviations: Rehab, rehabilitation; Rehab LOS, rehabilitation length of stay.
      low asterisk χ2 test or Student t test between 7DART and 5DART values.
      Also, there was a 13.2% increase in rehabilitation workload per patient (40.7h vs 36h, P<.001) and a 5.4% decrease in rehabilitation hospital length of stay (19.3d vs 20.3d, P=.43) among 7DART patients compared with 5DART patients. The waiting time for rehabilitation admission was similar in both groups (see table 5).

      Functional Outcomes

      The mean total FIM rating and the mean motor FIM and cognitive FIM ratings were similar in both rehabilitation groups on admission and at discharge. The percentage FIM rating change from admission to discharge, as well as the percentage of rehabilitation goals met, were similar between 7DART and 5DART patients (table 6).
      Table 6Functional Outcomes
      Outcome7DART5DARTTotalP
      χ2 test or Student t test between 7DART and 5DART values.
      Admission total FIM92.0±11.291.7±11.591.9±11.4.434
      Admission motor FIM59.1±10.058.7±10.258.9±10.1.242
      Admission cognitive FIM33.0±3.433.0±3.433.0±3.41.000
      Discharge total FIM110.2±8.2110.4±8.5110.3±8.3.479
      Discharge FIM motor77.0±6.677.2±7.277.1±6.9.391
      Discharge FIM cognitive33.2±3.033.2±3.033.2±3.01.000
      FIM rating change
      FIM rating change: (Discharge total FIM rating − Admission total FIM rating)/Admission total FIM rating.
      (points)
      18.2±8.918.7±9.018.4±9.0.099
      Percentage FIM rating change
      Percentage FIM rating change: 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).
      21.1±13.421.9±15.721.5±14.5.104
      Rehabilitation goals met (%)94.194.594.3.967
      NOTE. Values are mean ± SD or as otherwise indicated.
      low asterisk χ2 test or Student t test between 7DART and 5DART values.
      FIM rating change: (Discharge total FIM rating − Admission total FIM rating)/Admission total FIM rating.
      Percentage FIM rating change: 100% × ([Discharge total FIM rating − Admission total FIM rating]/Admission total FIM rating).

      Discharge Destination

      Even though percentage-wise more patients were discharged home in the 5DART group than in the 7DART group (89.2% vs 88.1%, P=.334), there were percentage-wise more patients discharged home without paid health services in the 7DART group than in the 5DART group (59% vs 57.8%, P=.544) (table 7).
      Table 7Discharge Destination
      Destination7DART5DARTTotalP
      χ2 test between 7DART and 5DART values.
      (n=1668)(n=1540)(n=3208)
      Home1469 (88.1)1373 (89.2)2842 (88.6).334
       Private house/apartment without paid health services866 (59.0)794 (57.8)1660 (58.4).544
       Private house/apartment with paid health services603 (41.0)579 (42.2)1182 (41.6).544
      Assistive living setting86 (5.2)70 (4.5)156 (4.9).422
      Residential care10 (0.6)12 (0.8)22 (0.7).538
      Other or unknown12 (0.7)11 (0.7)23 (0.7).986
      Transfer to acute care91 (5.5)74 (4.8)165 (5.1).405
      NOTE. Values are n (%) or as otherwise indicated.
      low asterisk χ2 test between 7DART and 5DART values.

      Discussion

      The main results in this study were a 1-day reduction in length of inpatient rehabilitation stay, better resource utilization, and more patients discharged home without paid health services in the 7DART group compared with the 5DART group. Similar results were reported by Hooper and Dijkers
      • Hooper P.J.
      • Dijkers M.
      Weekend therapy in rehab hospitals: a survey of costs and benefits.
      who surveyed 149 rehabilitation facilities that offered some weekend therapy (82%), and many of them for 5 or more years before the survey in the state of Michigan. These authors found that the benefits of offering weekend coverage outranked the costs by improved patient care and treatment consistency (26%), improved revenue and profitability (21%), higher patient and family satisfaction (16%), decreased length of stay (15%), and better integration of the family into the treatment program (11%).
      • Hooper P.J.
      • Dijkers M.
      Weekend therapy in rehab hospitals: a survey of costs and benefits.
      They identified the following challenges on initial implementation of the weekend therapy program: staffing (76%), interference with patient leaves of absence (21%), recruiting personnel (18%), and interference with visiting hours (16%). Nevertheless, 11% of the respondents reported “little or no problems.” The initial staffing challenges (76%) decreased after the weekend program was fully established (22% staff costs + 14% staff coverage).
      A similar reduction in length of rehabilitation hospital stay (5.1%) was reported in a randomized controlled trial
      • Brusco N.K.
      • Shields N.
      • Taylor N.F.
      • Paratz J.
      A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial.
      among patients who received physiotherapy intervention from Monday to Saturday compared with patients who received physiotherapy intervention only from Monday to Friday among 262 inpatients in an Austrian metropolitan hospital.
      Hughes et al
      • Hughes K.
      • Kuffner L.
      • Dean B.
      Effect of weekend physical therapy treatment on postoperative length of stay following total hip and total knee arthroplasty.
      also reported a reduction in length of postoperative length of stay (1.44±.12d) among 84 patients who received physical therapy over the weekend after a THA or a TKA, compared with a retrospective control group of 53 patients who received a THA or a TKA before the implementation of the weekend physical therapy program.
      • Hughes K.
      • Kuffner L.
      • Dean B.
      Effect of weekend physical therapy treatment on postoperative length of stay following total hip and total knee arthroplasty.
      The reduction in the postoperative length of stay was greater in the THA group than in the TKA group (1.91±.23d vs .93±.12d, P<.001). Their reduction in postoperative length of stay for the THA study group was slightly greater than the reduction obtained with the 7DART group in our present study (1.91±.23d vs 1.5±1.8d, P=.126). Their reduction in postoperative length of stay for the TKA study group was significantly greater than the reduction obtained with the 7DART group in the present study (.93±.12d vs 0.2±0.6d, P<.001). A possible explanation for the better results in their study is that those patients received rehabilitation therapy immediately after THA or TKA in the acute care hospital. In our study, patients were transferred from the acute care hospital to our rehabilitation hospital after THA or TKA, because their cases were complex (eg, diabetes, hypertension, obesity) and they could not be discharged home after surgery. Instead they required a specialized rehabilitation institution like ours.
      Other authors did not find improved rehabilitation outcomes with increased rehabilitation intensity,
      • Johnston M.V.
      • Miller L.S.
      Cost-effectiveness of the Medicare three-hour regulation.
      • Ruff R.M.
      • Yarnell S.
      • Marinos J.
      Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week?.
      • Lang C.E.
      Comparison of 6- and 7-day physical therapy coverage on length of stay and discharge outcome for individuals with total hip and knee arthroplasty.
      which differs with the results of our study. In 1 study
      • Johnston M.V.
      • Miller L.S.
      Cost-effectiveness of the Medicare three-hour regulation.
      of 934 patients who received a minimum of 3h/d of physical and occupational therapy combined, and despite an increase of physical and occupational therapy of .55 hours per patient per day, the authors could not find a detectable benefit to patients in functional status, living arrangement, or other outcomes, probably because the intensity of the physical and occupational therapy was not graded according to the varying needs of patients. In another study
      • Ruff R.M.
      • Yarnell S.
      • Marinos J.
      Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week?.
      of 113 patients who sustained a cerebrovascular accident, the study group received 7d/wk of rehabilitation therapy compared with the control group who received only 6d/wk of rehabilitation therapy. The authors found no significant differences in length of stay or in patients' functional recovery, but there was a treatment selection bias because the treatment selection was based on the funding source, and the study group was funded by Medi-Cal. Another study
      • Lang C.E.
      Comparison of 6- and 7-day physical therapy coverage on length of stay and discharge outcome for individuals with total hip and knee arthroplasty.
      did not find a significant difference in postoperative length of stay, discharge destination, or discharge disposition between those individuals who received 6-day or 7-day physical therapy, among 140 subjects with hip or knee arthroplasty. These results differ from those of our present study (see table 4), probably because this author only added 1 day of rehabilitation therapy in the 7-day physical therapy group and did not control for confounding factors that could affect length of stay (ie, age, living situation, comorbid conditions, type of institution, and physician feedback on resource utilization).

      Study Limitations

      The main limitation of this study is that it is a retrospective study based on electronic data collected at our institution for the National Rehabilitation Reporting System, and it could have errors in data entry or errors in the coding of clinical diagnoses, complications, or discharge destination. Another limitation is that this study did not evaluate the work-related quality of life and satisfaction of the affected clinical staff (ie, medical, nursing, physiotherapy, occupational therapy, and pharmacy), or the quality-of-life ratings and satisfaction of study participants and their families, after the implementation of the 7DART model of rehabilitation. It is too early to evaluate the cost-effectiveness of the 7DART model implementation. Another limitation might be that we only looked at the difference between 5DART and 7DART, and did not specifically look at 6-day rehabilitation therapy, which some other studies did. However, these limitations do not reduce the importance of the study findings in support of the 7DART model of rehabilitation, and they could be the purpose of future research studies.

      Conclusions

      Despite the fact that patients in both groups had similar functional outcomes and discharge destinations, the 7DART rehabilitation model reduced length of hospital stay and increased rehabilitation workload, demonstrating increased efficiency and access to care by admitting more patients from acute care, rehabilitating them, and discharging them to the community in less time than the 5DART model.

      Acknowledgments

      We thank all members of the Clinical Informatics Department at St. John's Rehab Hospital for providing the electronic data used in this study; the clinical, management, and professional practice staff at St. John's Rehab Hospital for planning and implementing the 7DART program; and Olesya Falenchuk, PhD, for her review of the statistical analysis.

      References

        • Blackerby W.F.
        Intensity of rehabilitation and length of stay.
        Brain Inj. 1990; 4: 167-173
        • Brusco N.K.
        • Shields N.
        • Taylor N.F.
        • Paratz J.
        A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial.
        Aust J Physiother. 2007; 53: 75-81
        • Cifu D.X.
        • Kreutzer J.S.
        • Kolakowsky-Hayner S.A.
        • Marwitz J.H.
        • Englander J.
        The relationship between therapy intensity and rehabilitation outcomes after traumatic brain injury: a multicenter analysis.
        Arch Phys Med Rehabil. 2003; 84: 1441-1448
        • Hughes K.
        • Kuffner L.
        • Dean B.
        Effect of weekend physical therapy treatment on postoperative length of stay following total hip and total knee arthroplasty.
        Physiother Can. 1993; 45: 245-249
        • Killey B.
        • Watt E.
        The effect of extra walking on the mobility, independence and exercise self-efficacy of elderly hospital in-patients: a pilot study.
        Contemp Nurse. 2006; 22: 120-133
        • Aronow H.U.
        Rehabilitation effectiveness with severe brain injury: translating research into policy.
        J Head Trauma Rehabil. 1987; 2: 24-36
        • Sonoda S.
        • Saitoh E.
        • Nagai S.
        • Kawakita M.
        • Kanada Y.
        Full-time integrated treatment program, a new system for stroke rehabilitation in Japan: comparison with conventional rehabilitation.
        Am J Phys Med Rehabil. 2004; 83: 88-93
        • Johnston M.V.
        • Miller L.S.
        Cost-effectiveness of the Medicare three-hour regulation.
        Arch Phys Med Rehabil. 1986; 67: 581-585
        • Ruff R.M.
        • Yarnell S.
        • Marinos J.
        Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week?.
        Am J Phys Med Rehabil. 1999; 78: 143-146
        • Lang C.E.
        Comparison of 6- and 7-day physical therapy coverage on length of stay and discharge outcome for individuals with total hip and knee arthroplasty.
        J Orthop Sports Phys Ther. 1998; 28: 15-22
        • Hooper P.J.
        • Dijkers M.
        Weekend therapy in rehab hospitals: a survey of costs and benefits.
        Clin Manage. 1987; 7: 16-21