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Mandated Quality of Care Metrics for Medicare Patients: Examining New or Worsened Pressure Ulcers and Rehabilitation Outcomes in United States Inpatient Rehabilitation Facilities

Published:April 09, 2018DOI:https://doi.org/10.1016/j.apmr.2018.03.007

      Abstract

      Objective

      To examine the association between the Medicare pressure ulcer quality indicator (the development of new or worsened pressure ulcers) and rehabilitation outcomes among Medicare patients seen in an inpatient rehabilitation facility (IRF).

      Design

      Retrospective descriptive study.

      Setting

      IRFs subscribed to the Uniform Data System for Medical Rehabilitation.

      Participants

      Nearly 500,000 IRF Medicare patients who were discharged between January 2013 and September 2014 were examined.

      Interventions

      Not applicable.

      Main Outcome Measures

      Functional independence, functional change (gain), and discharge destination.

      Results

      The pressure ulcer quality indicator was associated with poorer rehabilitation outcomes; patients were less likely to achieve functional independence (odds ratio [OR], .47; 95% confidence interval [CI], .44–.51), were less likely to be discharged to a community setting (OR, .88; 95% CI, .82–.95), and made less functional gain during their IRF stay (a difference of 6 FIM points).

      Conclusions

      These results support that the pressure ulcer quality indicator is associated with lower quality of rehabilitation outcomes; however, given that those patients with a new or worsened pressure injury still made functional gains and most were discharged to the community, the risk of pressure injury development should not preclude the admission of these cases to an IRF.

      Keywords

      List of abbreviations:

      CI (confidence interval), CMS (Centers for Medicare and Medicaid Services), IRF (inpatient rehabilitation facility), IRF-PAI (Inpatient Rehabilitation Facility Patient Assessment Instrument), NQF (National Quality Forum), UDSMR (Uniform Data System for Medical Rehabilitation)
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      References

        • Hoff T.J.
        • Soerensen C.
        No payment for preventable complications: reviewing the early literature for content, guidance, and impressions.
        Qual Manag Health Care. 2011; 20: 62-75
      1. The Patient Protection and Affordable Care Act, 111th Congress Public Law 148 (2010).

        • Alterescu V.
        The financial costs of inpatient pressure ulcers to an acute care facility.
        Decubitus. 1989; 2: 14-23
        • Lyder C.H.
        Pressure ulcer prevention and management.
        Annu Rev Nurs Res. 2002; 20: 35-61
        • VanGilder C.
        • Lachenbruch C.
        • Harrison P.
        • Davis D.
        Overall Results from the 2011 International Pressure Ulcer Prevalence™ Survey.
        (Available at:)
      2. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. 2016. Available at: http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/. Accessed 12 December 2017.

        • Berlowitz D.R.
        • Brandeis G.H.
        • Anderson J.
        • Du W.
        • Brand H.
        Effect of pressure ulcers on the survival of long-term care residents.
        J Gerontol A Biol Sci Med Sci. 1997; 52: M106-M110
        • Lyder C.H.
        • Wang Y.
        • Metersky M.
        • et al.
        Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study.
        J Am Geriatr Soc. 2012; 60: 1603-1608
        • Neil J.A.
        • Munjas B.A.
        Living with a chronic wound: the voices of sufferers.
        Ostomy Wound Manage. 2000; 46 (36-8): 28-34
        • Smith D.M.
        Pressure ulcers in the nursing home.
        Ann Intern Med. 1995; 123: 433-442
        • Dunk A.M.
        • Carville K.
        The international clinical practice guideline for prevention and treatment of pressure ulcers/injuries.
        J Adv Nurs. 2016; 72: 243-244
        • Dealey C.
        • Posnett J.
        • Walker A.
        The cost of pressure ulcers in the United Kingdom.
        J Wound Care. 2012; 21 (264, 266): 261-262
        • Graves N.
        • Birrell F.
        • Whitby M.
        Effect of pressure ulcers on length of hospital stay.
        Infect Control Hosp Epidemiol. 2005; 26: 293-297
        • Centers for Medicare & Medicaid Services (CMS), DHHS
        Medicare program; prospective payment system for inpatient rehabilitation facilities. Final rule.
        Fed Regist. 2001; 66: 41315-41430
        • Centers for Medicare & Medicaid Services (CMS), HHS
        Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2012; changes in size and square footage of inpatient rehabilitation units and inpatient psychiatric units. Final rule.
        Fed Regist. 2011; 76: 47836-47915
        • Centers for Medicaid and Medicare Services
        IRF-PAI training manual.
        DHHS, Washington2012
        • Reistetter T.A.
        • Graham J.E.
        • Deutsch A.
        • Granger C.V.
        • Markello S.
        • Ottenbacher K.J.
        Utility of functional status for classifying community versus institutional discharges after inpatient rehabilitation for stroke.
        Arch Phys Med Rehabil. 2010; 91: 345-350
        • Keith R.A.
        • Granger C.V.
        • Hamilton B.B.
        • Sherwin F.S.
        The functional independence measure: a new tool for rehabilitation.
        Adv Clin Rehabil. 1987; 1: 6-18
        • Bluestein D.
        • Javaheri A.
        Pressure ulcers: prevention, evaluation, and management.
        Am Fam Physician. 2008; 78: 1186-1194
        • White-Chu E.F.
        • Flock P.
        • Struck B.
        • Aronson L.
        Pressure ulcers in long-term care.
        Clin Geriatr Med. 2011; 27: 241-258
        • Dillingham T.R.
        • Yacub J.N.
        • Pezzin L.E.
        Determinants of postacute care discharge destination after dysvascular lower limb amputation.
        PM R. 2011; 3: 336-344
        • Golden S.H.
        • Hill-Briggs F.
        • Williams K.
        • Stolka K.
        • Mayer R.S.
        Management of diabetes during acute stroke and inpatient stroke rehabilitation.
        Arch Phys Med Rehabil. 2005; 86: 2377-2384
        • Graham J.E.
        • Ripsin C.M.
        • Deutsch A.
        • et al.
        Relationship between diabetes codes that affect Medicare reimbursement (tier comorbidities) and outcomes in stroke rehabilitation.
        Arch Phys Med Rehabil. 2009; 90: 1110-1116
        • Reistetter T.A.
        • Graham J.E.
        • Deutsch A.
        • Markello S.J.
        • Granger C.V.
        • Ottenbacher K.J.
        Diabetes comorbidity and age influence rehabilitation outcomes after hip fracture.
        Diabetes Care. 2011; 34: 1375-1377
        • Semel J.
        • Gray J.M.
        • Ahn H.J.
        • Nasr H.
        • Chen J.J.
        Predictors of outcome following hip fracture rehabilitation.
        PM R. 2010; 2: 799-805
        • Zekry D.
        • Herrmann F.R.
        • Grandjean R.
        • et al.
        Does dementia predict adverse hospitalization outcomes? A prospective study in aged inpatients.
        Int J Geriatr Psychiatry. 2009; 24: 283-291
        • Hosmer D.W.
        • Lemeshow S.
        Applied logistic regression.
        2nd ed. Wiley, New York2000
        • Krishnan S.
        • Karg P.E.
        • Boninger M.L.
        • Brienza D.M.
        Association between presence of pneumonia and pressure ulcer formation following traumatic spinal cord injury.
        J Spinal Cord Med. 2017; 40: 415-422
        • Brienza D.
        • Krishnan S.
        • Karg P.
        • Sowa G.
        • Allegretti A.L.
        Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study.
        Spinal Cord. 2018; 56: 28-34
        • Schue R.M.
        • Langemo D.K.
        Pressure ulcer prevalence and incidence and a modification of the Braden Scale for a rehabilitation unit.
        J Wound Ostomy Continence Nurs. 1998; 25: 36-43
        • Girouard K.
        • Harrison M.B.
        • VanDenKerkof E.
        The symptom of pain with pressure ulcers: a review of the literature.
        Ostomy Wound Manage. 2008; 54 (42): 30-40
        • Gorecki C.
        • Brown J.M.
        • Nelson E.A.
        • et al.
        Impact of pressure ulcers on quality of life in older patients: a systematic review.
        J Am Geriatr Soc. 2009; 57: 1175-1183
        • Beninato M.
        • Gill-Body K.M.
        • Salles S.
        • Stark P.C.
        • Black-Schaffer R.M.
        • Stein J.
        Determination of the minimal clinically important difference in the FIM instrument in patients with stroke.
        Arch Phys Med Rehabil. 2006; 87: 32-39
        • 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: 207-216
        • DiVita M.A.
        • Granger C.V.
        • Goldstein R.
        • Niewczyk P.
        • Freudenheim J.L.
        Risk Factors for Development of New or Worsened Pressure Ulcers Among Patients in Inpatient Rehabilitation Facilities in the United States: Data From the Uniform Data System for Medical Rehabilitation.
        PM and R. 2015; 7: 599-612
        • New P.W.
        • Rawicki H.B.
        • Bailey M.J.
        Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact.
        Arch Phys Med Rehabil. 2004; 85: 87-93
        • Verschueren J.H.
        • Post M.W.
        • de Groot S.
        • van der Woude L.H.
        • van Asbeck F.W.
        • Rol M.
        Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehabilitation.
        Spinal Cord. 2011; 49: 106-112
        • Medicare Payment Advisory Commission
        Report to the Congress: Medicare Payment Policy: inpatient rehabilitation facility services.
        MEDPAC, Washington, D.C.2017
        • Gefen A.
        • Farid K.J.
        • Shaywitz I.
        A review of deep tissue injury development, detection, and prevention: shear savvy.
        Ostomy Wound Manage. 2013; 59: 26-35
        • Byrne D.W.
        • Salzberg C.A.
        Major risk factors for pressure ulcers in the spinal cord disabled: a literature review.
        Spinal Cord. 1996; 34: 255-263
        • Coleman S.
        • Nelson E.A.
        • Keen J.
        • et al.
        Developing a pressure ulcer risk factor minimum data set and risk assessment framework.
        J Adv Nurs. 2014; 70: 2339-2352