PHYS THER-1989-Rapoport-32-7 by liwenting


									                                   Impact of Physical Therapy Weekend Coverage on
                                   Length of Stay in an Acute Care Community Hospital
                                   John Rapoport and Maureen Judd-Van Eerd
                                   PHYS THER. 1989; 69:32-37.

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Impact of Physical Therapy Weekend Coverage on Length
of Stay in an Acute Care Community Hospital

This study compares the length of hospital stay of a group ofpatients treated in a                           John Rapoport
community hospital during a period offive-day-a-weekphysical therapy coverage                                Maureen Judd-Van Eerd
with the length of stay of a similar patient group treated during a period of
seven-day-a-week physical therapy coverage. Comparisons of length of stay were
made between the two groups and between subgroups based on diagnosis (stroke
or orthopedic disorder) and surgical versus nonsurgical status. Multiple regression
analysis was used to control for other factors influencing length of hospital stay.
The mean length of stay was shorter for the seven-day-a-week group, and in a few
subgroups the difference in length of stay was statistically significant. The results of
this study suggest that weekend physical therapy may help reduce length of hospital
stay. Thisfindingshould interest individuals concerned with the cost-effective use
ofphysical therapy, especially under hospital reimbursement systems such as the
Medicare diagnosis-related group. [RapoportJ,Judd-VanEerd M: Impact of
physical therapy weekend coverage on .length of stay in an acute care community
hospital. Phys Ther 6932-37, 1989]

Key Words: Hospitalization; Length of stay; Physical therapy profession, patient
services; Quality of health care; Rehabilitation.

The introduction of the prospective                   the DRG system, a hospital receives a             department contributes to a shorter
payment system (PPS) in 1983 by the                   predetermined dollar amount per                   LOS or reduces overall costs in other
federal government changed the                        patient based on the patient's diagnosis.         ways, the hospital'sfinancialgoals will
Medicare reimbursement system for                     If the hospital can care for the patient          be positively affected.
treatment in an acute care setting.                   at a cost lower than the amount of the
Previously, a retrospective payment                   DRG reimbursement, afinancialbenefit              Review off the Literature
system based on the actual cost of                    results for the hospital. Reducing the
treatment had been used. After October                LOS while maintaining the quality of              The results of the limited amount of
1983, however, a patient's diagnosis-                 patient care is, therefore, a high                research on the effects of the Medicare
related group (DRG) became the                        priority for hospital management. The             PPS on physical therapy in hospitals are
guideline for reimbursement. The PPS                  role of physical therapy in this new              contradictory. One study suggested that
has changed incentives for hospital                   health care environment will be                   increased use of physical therapy
management and has resulted in                        determined in part by the ability of              results from the Medicare PPS.2 Other
increased attention to reducing length                physical therapists to help the hospital          publications have suggested that the
of stay (LOS) as a method of                          operate efficiently within the constraints        pressure for cost control can lead to
controlling costs and improving                       of the reimbursement system. If                   reduced use of physical therapy and
hospital financial performance.1 Under                operation of the physical therapy                 possibly reduced quality of care.3

                                                                                                        Hospital management increasingly must
                                                                                                        decide whether to provide physical
J Rapoport, PhD, is Professor of Economics, Mount Holyoke College, South Hadley, MA 01075-1461 (USA).   therapy coverage on a five-day-a-week
M Judd-Van ECed, MCed, was Manager, Physical Therapy Department, Holyoke Hospital, 575 Beech St,        or a seven-day-a-week basis. Some
Holyoke, MA 01040, when this study was completed. Her current address is 566 S Catalina Blvd,           evidence exists that hospitals are
Pasadena, CA 91106.                                                                                     moving toward seven-day-a-week
This article was submitted April 8, 1988; was with the authors for revision for two weeks; and was      coverage.4 If seven-day-a-week coverage
accepted August 15, 1988.

46/32                                                                                    Physical Therapy/Volume 69, Number 1/January 1989
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in physical therapy results in shorter       community of over 43,000 inhabitants.             and might give a misleading picture of
hospital stays and if the hospital is        Holyoke Hospital is an acute care                 the experience of a "typical" patient.
reimbursed for these stays on a              community hospital with a capacity of             The following patients were omitted: 1)
prospective payment basis, weekend           243 licensed beds.                                patients whose hospital stay included
physical therapy service could produce                                                         one or more days designated as
a financial benefit to the hospital. A       The physical therapy department                   administratively necessary, 2) patients
financial benefit would result if the cost   employs six physical therapists                   whose first and last physical therapy
savings from the reduced LOS were            (including a manager) and two physical            visits did not take place in one of the
greater than the additional costs of         therapist assistants. The caseload in the         designated time periods (ie, patients
operating the physical therapy               department consists mainly of                     whose first visit was before April 1,
department on the weekend. If                outpatients. Inpatients comprise only             1986, and whose last visit was after
weekend physical therapy does not            about 20% of the total patient                    September 30, 1986, and patients
reduce LOS, however, the additional          population.                                       whose first visit was before October 1,
operating costs would have no                                                                  1986, and whose last visit was after
offsetting financial benefits and might      Before October 1, 1986, the hospital              March 31, 1987), and 3) patients who
reduce hospital financial performance.       provided physical therapy services on a           had several periods of physical therapy
                                             five-day-a-week basis. Beginning on               during their stay (ie, patients who were
Little specific evidence exists on           October 1,1986, services were                     treated a few times and then were
whether seven-day-a-week physical            expanded to seven-day-a-week coverage             treated again, perhaps after further
therapy coverage results in a shorter        for all inpatients with certain diagnoses         surgery). The total number of patients
LOS thanfive-day-a-weekservice. One          for a six-month duration. All inpatients          excluded for these reasons was about
study of patients with orthopedic            with one of the following diagnoses               17% of the initial study sample. The
disorders in a major teaching hospital       were included in this study: 1) stroke,           data analysis was based on a sample of
compared LOS and number of                   2) osteoarthrosis or other arthropathy,           137 patients in Group 1 and 136
treatments for two groups of patients,       3) fracture of the lower limb, or 4)              patients in Group 2.
one group treated in a unit with             total hip or total knee replacement.
seven-day-a-week physical therapy                                                              Variables
coverage and a second group treated          No additional physical therapists were
withfive-day-a-weekcoverage in               added to the current staff to cover               We obtained data from patient records
another unit of the same hospital. The       Saturdays and Sundays. Each weekend               on the following variables: 1) "total
results showed few differences between       day, two employees were available to              LOS," or the number of days from
groups in the number of treatments or        treat patients from 8 AM to 12 Noon.              hospital admission to hospital
LOS. The researchers did not control         These employees earned a free day                 discharge; 2) "time from admission to
for patient age or sex.5                     during the week.                                  initial physical therapy visit," or the
                                                                                               number of days from hospital
This study involved patients with            Subjects                                          admission until the patient first visited
orthopedic disorders or stroke in an                                                           the physical therapy department; 3)
acute care community hospital in which       The initial study sample included all             "time from first to last physical therapy
the physical therapy department              inpatients with one of the                        visit," or the number of calendar days
changed fromfive-day-a-weekto                above-mentioned diagnoses treated by              during which the patient was under the
seven-day-a-week coverage. In addition       a physical therapist and discharged               care of the physical therapy
to comparing patients' mean LOS before       from the hospital from April 1, 1986, to          department; and 4) "number of
and after the change in coverage, we         September 30,1986 (Group 1) or from               physical therapy visits," or the number
controlled for patient age and sex and       October 1,1986, to March 31, 1987                 of different sessions the patient had
examined the effects of weekend              (Group 2). Data were obtained                     with a therapist. Information on
coverage on LOS components,                  retrospectively from the hospital's               patients' age, sex, diagnosis, and
specifically the time interval between       computerized records and from the                 surgical status was also recorded.
hopsital admission and start of physical     physical therapy department's files.
therapy and the time interval between        Patients in the four diagnostic                   Data Analysis
the patient's first and last physical        categories represented the great
therapy visits. Our main hypothesis was      majority of inpatients treated by the             Two types of analyses were conducted.
that the change to seven-day-a-week          department. Patients with                         We first compared the two patient
coverage would reduce LOS.                   osteoarthrosis, lower limb fractures, or          groups with respect to 1) total LOS, 2)
                                             hip or knee replacement were grouped              time from admission to initial physical
Method                                       together and referred to as patients              therapy visit, 3) time from first to last
                                             with orthopedic disorders.                        physical therapy visit, and 4) number of
Study Site                                                                                     physical therapy visits. We divided the
                                             For analytical purposes, patients were            two groups into subgroups according
The study was conducted at Holyoke           omitted from the study sample whose               to diagnosis and surgical status.
Hospital in Holyoke, Mass, a                 particular circumstances were unusual             Although this method created very

Physical Therapy/Volume 69, Number 1/January 1989                                                                               33/47
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small subgroups, we believed that it         variable would provide evidence that,               visits, total LOS, and the two segments
would create more homogeneous                when other factors were controlled for,             of the total LOS) represented
groups of patients and thus more             LOS was shorter under weekend                       dependent variables in the study. The
meaningful comparisons. The statistical      physical therapy service.                           means of these variables were lower
significance of the difference between                                                           for Group 2 than for Group 1, although
the two main groups was evaluated in          Results                                            the medians were not. There was great
two ways. A t statistic was computed to                                                          variability in these data as indicated by
test the null hypothesis that no             The basic characteristics of the two                the wide ranges and standard
difference existed in the mean values        groups of patients are listed in Table 1.           deviations, which were often larger
of LOS. In addition, because most of         The differences between the two                     than the medians and means,
the distributions were non-normal, we        groups were not pronounced, but                     respectively.
performed a nonparametric Wilcoxon           patients in Group 2 were somewhat
test for differences between the two         more likely to be men, to have an                   Table 2 presents the results of the
groups. A 5% significance level was          orthopedic disorder, and to have                    two-group comparison of mean total
used for hypothesis testing.                 undergone surgery. The last four                    LOS. For every subgroup except
                                             variables (number of physical therapy               patients with a nonsurgical orthopedic
We also performed a multivariate
analysis of variance (MANOVA) of the
determinants of LOS using multiple
regression for two reasons. First, the
multiple regression allowed us to            Table 1. Characteristics of Subjects (N = 273)
control statistically for patient
characteristics that may have affected                                                             Group 1                     Group 2
LOS (eg, age, sex). Second, in a study       Characteristic                                        (n = 137)                   (n = 136)
such as this where the two groups
represented different time periods, LOS
differences may be related to various          Male                                                54 (39.4%)                  57 (41.9%)
factors that change over time. For             Female                                              83 (60.6%)                  79 (58.1%)
example, a national trend exists toward      Age (yr)
shorter hospital stays and substitution                                                            65.2                        64.5
of outpatient for inpatient care.                 s                                                20.8                        21.4
Hospitals are also focusing more on               Median                                           71                          70
                                                  Range                                            (11-94)                     (7-97)
discharge planning and other
management techniques to shorten
                                                Stroke                                             55 (40%)                    47 (35%)
patients' LOS. The inclusion of a trend         Orthopedic disorder                                87 (64%)                    90 (66%)
variable in the regression equation was       Surgical statusa
one way to control for such effects and         Surgery                                            80 (58%)                    87 (64%)
to more accurately discern the effect of        No surgery                                         57 (42%)                    49 (36%)
the main independent variable,                Number of physical therapy visits
weekend service.                                                                                    7.6                         7.2
                                               s                                                    7.4                         5.5
                                               Median                                               5                           6
Multiple regressions were performed            Range                                               (1-41)                      (1-31)
for three dependent variables: 1) total      Tntai length of stay (d)
LOS, 2) time from admission to initial                                                             17.5                        14.6
physical therapy visit, and 3) time from       s                                                   23.0                        13.9
first to last physical therapy visit. The      Median                                              12                          12
                                               Range                                               (1-206)                     (1-120)
independent variables were 1) age, 2)
                                             Time from admission to initial
sex (1 if patient was male, 0 if female),
                                             physical therapy visit (d)
3) surgery (1 if patient had an                                                                     7.4                         6.2
operation, 0 otherwise), 4) number of           s                                                  17.6                        10.3
physical therapy visits, 5) a trend             Median                                              4                           4
                                                Range                                              (1-174)                     (1-103)
variable (1 if patient was discharged in
April 1986, with months numbered              Time from first to last physical
                                              therapy visit (d)
consecutively up to 12 for patients                                                                 8.5                         7.3
discharged in March 1987), and 6) a               s                                                 9.8                         6.8
weekend-service variable (1 for patients          Median                                            6                           6
in Group 2, 0 for Group 1). The                   Range                                            (0-69)                      (0-37)
weekend-service variable was the
variable of major interest. A negative        Percentage of total in parentheses.
estimated regression coefficient for this     Some patients were diagnosed with both stroke and orthopedic disorder.

48/34                                                                               Physical Therapy/ Volume 69, Number 1/January 1989
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                                                                                                                     seven days (40%) shorter for patients
                                                                                                                     in Group 2 than in Group 1.
Table 2.            Comparison of Total Length of Stay (LOS) by Diagnosis and Surgical Status
(N = 273)                                                                                                            The results for LOS segments and
                                                                                                                     number of physical therapy visits
                                    LOS (d)                                                                          between groups are shown in Table 3.
                                    Group 1 (n = 137)                               Group 2 (n = 136)                Patients with stroke who did not have
Variable                            n                              s                n                      5
                                                                                                                     surgery in Group 2 showed
                                                                                                                     significantly less time from admission
                                                                                                                     to initial physical therapy visit and from
Stroke                                                                                                               first to last physical therapy visit than
  Surgery                           11            38.46            59.0             13         34.54       29.5
  No surgerya                       44            18.78            11.0             34         11.68        6.3
                                                                                                                     the same subgroup in Group 1. This
                                                                                                                     subgroup also had a lower mean
Orthopedic disorder
  Surgery                           72            15.76            20.0             75         13.32        9.5      number of visits in Group 2 than in
  No surgery                        15             8.67             6.4             15         10.53       11.7      Group 1. Mean time from first to last
                                                                                                                     physical therapy visit was slightly
 A statistically significant difference existed between groups at the 5% level on the Wilcoxon and t tests.          higher for the other three subgroups in
                                                                                                                     Group 2 than in Group 1. Mean time
                                                                                                                     from admission to initial physical
                                                                                                                     therapy visit was lower in Group 2 than
Table 3-            Comparison of Length of Stay (LOS) Components by Diagnosis and Surgical                          in Group 1 for two of these three
Status                                                                                                               subgroups.

                                             Group 1                                     Group 2                     Table 4 summarizes the results of the
LOS Component                                n                            s              n                 s         multiple regression analysis. For each
                                                                                                                     dependent variable, a regression
                                                                                                                     analysis was performed for age, sex,
Time from admission to initial physical                                                                              surgical status, trend variable, and
therapy visit (d)                                                                                                    weekend coverage variable (equations
     Stroke                                                                                                          1, 3, 5, 6, 7, and 9). In all but one of
       Surgery                               11           21.55           50.8           13        17.08   27.9
                                                                                                                     these equations, the weekend variable
       No surgerya                           44            5.43            3.8           34         4.12    2.5
                                                                                                                     was negative. The results were
     Orthopedic disorder
       Surgery                               72            6.90           13.7           75        5.28        5.4   statistically significant in the equations
        No surgery                           15            4.33            3.3           15        5.53        8.4   for total LOS andfirst-to-lastphysical
                                                                                                                     therapy visit for patients with stroke.
Time from first to last physical
therapy visit (d)                                                                                                    The other four equations controlled for
     Stroke                                                                                                          the effect of number of visits. The LOS
       Surgery                               11           12.18           11.4           13        14.38       7.7   may have been shorter for Group 2
       No surgeryb                           44           11.68            9.9           34         5.91       6.4
                                                                                                                     simply because those patients had
     Orthopedic disorder                                                                                             fewer physical therapy visits. Equations
       Surgery                               72            7.0                9.5        75         7.41       6.4
       No surgery                            15            4.0                4.6        15         4.27       5.1   2, 4, 8, and 10 add the number of visits
                                                                                                                     as an independent variable to the
                                                                                                                     regression analysis. The fact that the
Number of physical therapy visits
                                                                                                                     weekend coverage variable coefficient
     Stroke                                                                                                          remained negative and (in three of the
       Surgeryc                              11            9.18           10.0           13        12.0        6.0
        No surgeryb                          44           10.09            8.3           34         5.79       5.1   equations) statistically significant
     Orthopedic disorder
                                                                                                                     suggests that when the number of visits
      Surgeryc                               72            6.47               6.3        75         7.47       5.3   was held constant, LOS was shorter
       No surgery                            15            4.73               5.6        15         4.60       4.2   under weekend service.
    Statistically significant difference at the 5% level on t test only.                                             The other variables included in the
    Statistically significant difference at the 5% level on t and Wilcoxon tests.                                    regression analysis were not a major
    Statistically significant difference at the 5% level on Wilcoxon test only.                                      focus of this study. Increased age was
                                                                                                                     associated with a longer LOS. Patients
diagnosis, the mean LOS was shorter                              the difference in LOS large enough to               with stroke tended to stay longer than
for patients in Group 2 than in Group                            be statistically significant at the 5%              patients with orthopedic disorders, and
1. In only one subgroup, patients with                           level. In this subgroup, LOS was about              patients who had surgery stayed longer
stroke who did not have surgery, was                                                                                 than patients who did not have surgery.
                                                                                                                     Sex was not significant in most

Physical Therapy/Volume 69, Number 1/January 1989                                                                                                        35/49
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Table 4.         Multiple Regression Results for Length of Stay (LOS) Determinants

                                Regression Coefficienta
Dependent               Equation                                                                      Surgical        Weekend           Number of
Variable          n     Number Constant            Age                  Sex            Trend          Status          Therapy           Visits           R2

Total LOS
  Stroke          102     1       -.28              .11        (0.51)   5.40 (1.16)    2.29b(1.68)    21.33b(3.94)    -19.74 b (2.16)                        .15
                  102     2     -15.49 (0.96)       .13        (0.67)   4.41 (1.07)    2.61b(2.15)         b
                                                                                                      17.31 (3.55)    -17.98 b (2.21)   1.39b(5.12)          .33
    Orthopedic    171     3      -1.08 (0.22)       .17b (3.55)          .76 (0.32)     .28 (0.42)     4.13 (1.44)     -2.86 (0.62)                          .07
    disorder      171     4      -1.67 (0.49)       .06b (1.66)         2.55 (1.58)     .16 (0.36)    -.97 (0.49)      -4.01 (1.28)     1.91b(14.11)         .57

Time from admission to initial physical therapy visit
  Stroke       102     5         -7.28 (0.48) .11              (0.54)   2.14 (0.54)     1.25 (1.08)   14.56b(3.17)     -9.36 (1.21)                          .07
    Orthopedic    171     6         3.07 (0.85)     .06        (1.64)    .49 (0.29)    -.21 (0.42)      .83 (0.40)        .04 (0.01)                     0

Time from first to last physical therapy visit
  Stroke         102      7         8.02 (1.14)     .0038 (0.04)         1.69 (0.93)    .52 (0.97)     4.59b(2.15)     -6.92 b (1.91)                        .06
                 102      8       -3.69 (1.22)      .02 (0.53)            .93 (1.20)    .77b (3.37)    1.50 (1.64)     -5.57 b (3.64)    1.07b (21.02)       .83
  Orthopedic 171          9       -3.94 (1.49)      .10b (3.86)         -.34 (0.27)     .55 (1.55)    2.95b(1.96)      -2.83 (1.16)                          .11
  disorder       171     10        -4.32 b (4.5)           b
                                                    .022 (2.28)           .84b(1.84)    .47b (3.66)   -.42 (0.76)      -3.59 b (4.06)    1.26b (32.99)       .88

Number in parentheses is t-test value.
Coefficient significantly different from zero at 5% level by one-sided t test.

equations, but its positive coefficient                   One implication of five-day-a-week                   coverage. Even when the number of
indicated that men tended to have a                       physical therapy service is that patients            visits was controlled for, however,
slightly longer LOS than women. The                       who are ready to begin physical                      weekend coverage still affected the
trend variable usually was positive,                      therapy on Saturday or Sunday must                   number of calendar days from first to
suggesting that when other factors                        wait until Monday to start. With a                   last physical therapy visit.
were controlled for, LOS increased                        seven-day-a-week schedule, patients
slightly over the 12-month period.                        who are ready to begin physical                      The differences among the subgroups
                                                          therapy on a weekend may do so. This                 in mean values of variables as well as
Discussion                                                difference in scheduling is probably the             the effect of weekend coverage were
                                                          main reason for the observed                         large. Patient age and sex also had an
The results of this study, especially the                 reduction in time from hospital                      effect, and controlling for these
negative estimated regression                             admission to first physical therapy visit.           variables is important. Hospital
coefficient for weekend coverage,                                                                              management may want to consider
supported the hypothesis that weekend                     The reasons for the effect of weekend                such differences when deciding on a
coverage for physical therapy would                       service on the time period from first to             weekend-coverage policy. From a
reduce LOS. The results were very                         last physical therapy visit are less clear.          financial perspective, weekend
different for patients with stroke or                     If a certain number of visits is needed              coverage may be justified for some
orthopedic disorders, the two                             for a patient's recovery, weekend                    groups of patients but not for others.
diagnostic groups examined in the                         service may enable treatment to be
study. The effect of weekend coverage                     completed in a smaller number of                     The results of this study showed a
for patients with stroke was statistically                calendar days. If consecutive daily visits           greater effect of weekend service on
significant. The effect of weekend                        are more effective than five-day-a-week              LOS than the study of Holden and
coverage for patients with orthopedic                     coverage in aiding a patient's recovery,             Daniele.5 This difference may be
disorders was somewhat weaker                             weekend service may reduce the                       because our diagnostic categories were
statistically, and the reduction in LOS                   number of visits needed. Our findings                different or because we controlled for
was smaller than for patients with                        suggest that both of these effects could             certain factors not previously controlled
stroke.                                                   be present. Patients with stroke                     for. A possible limitation of our study is
                                                          required fewer visits under weekend                  that the comparison was between time

50/36                                                                                          Physical Therapy/ Volume 69, Number 1/January 1989
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periods and, thus, did not involve a          before and after the start of physical            helpful comments on a draft of this
control group of patients. A variety of       therapy.                                          article. We also thank the physical
time-dependent factors were only                                                                therapy staff at Holyoke Hospital for
partially revealed by our statistical         Conclusion                                        collecting the data.
methodology. We also could not
control for factors such as severity of       The results of this study suggest that
illness, type of insurance coverage, bed      providing physical therapy on a                   References
availability in the institutions to which     seven-day-a-week basis rather than five           1 Feder J, HadleyJ, Zuckerman S: How did
patients were discharged, and                 days a week may result in a decreased             Medicare's prospective payment system affect
differences in medical and physical           LOS for patients in a community                   hospitals? N Engl J Med 317:867-873, 1987
therapy practice patterns that may have       hospital. Considerable differences in             2 Dore D: Effect of the Medicare prospective
                                                                                                payment system on the utilization of physical
influenced LOS. Our results suggest           this effect are associated with patient           therapy. Phys Ther 67:964-966, 1987
that future studies should control for        age, sex, and diagnosis.                          3 PPS found reducing PT; costfightingmay
patient characteristics and that a                                                              backfire. PT Bulletin 2(31):2, 1987
multivariate analysis is necessary. In        Acknowledgments                                   4 Hooper PJ, Dijkers M: Weekend therapy in
addition, it may be useful to include as                                                        rehab hospitals: A survey of costs and benefits.
                                                                                                Clinical Management in Physical Therapy 7(1):
dependent variables not just the total        We thank Debbie Olene for research                16,17,21, 1987
LOS but also the time segments both           assistance and Irene Powell, Jane                 5 Holden MK, Daniele CA: Comparison of
                                              McCusker, and Stephen Judd for                    seven- andfive-dayphysical therapy coverage in
                                                                                                patients with acute orthopedic disorders. Phys
                                                                                                Ther 67:1240-1246, 1987

Physical Therapy/Volume 69, Number 1/January 1989                                                                                       37/51
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                                  Impact of Physical Therapy Weekend Coverage on
                                  Length of Stay in an Acute Care Community Hospital
                                  John Rapoport and Maureen Judd-Van Eerd
                                  PHYS THER. 1989; 69:32-37.

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