Satisfaction Agreement by ukg16043

VIEWS: 19 PAGES: 92

More Info
									             Patient Satisfaction and
        Functional Status in Patients
      Who Received Inpatient Medical
              Rehabilitation Services




       Pei-Fen J. Chang, MSG, OTR/L
          University of Texas Medical Branch
Department of Preventive Medicine and Community Health
           Division of Rehabilitation Sciences
                              Outline

Introduction
Background and Significance
Research Design and Methods
Results
Discussion and Conclusion
                       Introduction

Concept of Satisfaction
Satisfaction in the Healthcare System
Quality of Care Model
Rehabilitation and Functional Outcome
Satisfaction and Functional Outcome
                                 Background

Theoretical Models – Lawler (1973)
  Discrepancy Theory
    Satisfaction is the perceived difference between
    what an individual desires and what the
    individual experiences.
  Fulfillment Theory
    Satisfaction is simply the difference between
    what happened and what was expected.
  Equity Theory
    Satisfaction is the perceived balance between
    inputs and outputs.
                                     Background

Theoretical Models
  Cognitive Model by Hunt (Pascoe, 1983, p.187)
    Satisfaction is “an evaluative reaction resulting from
    the interaction of the product/situation with the
    individual’s expectation; it is a cognitive response.”
  Affective Model by Linder-Pelz (1982)
    Satisfaction is a positive attitude resulting from the
    favorable comparison of beliefs about care to actual
    care received.
                                 Background

Theoretical Models
  Normative Decision Theory by Brennan
  (1995)
    Satisfaction is an appraisal whether the care
    provided met the individual’s expectations
    and/or preference.
  Pragmatic Model by Baker (1997)
    Satisfaction is an evaluative judgment to the
    care received. It is a continuous and multi-
    dimensional variable.
                                Background

Theoretical Models
  Primary Provider Theory (PPT) by Argon
  (2003)
    Healthcare providers hold the power to meet
    patient’s expectations for treatment and/or
    medications. Satisfaction happens through the
    interaction of patient expectation and provider
    power.
                                  Background

Theoretical Models
  Keith (1998, p.1122)
    Satisfaction is defined as “an attitude about
    service, service providers or patient’s health
    status.” There are both affective and
    cognitive components; the affective reflects
    positive or negative feelings and the cognitive is
    concerned with what is important and how it is
    evaluated.
                                          Background

Patient Satisfaction and Patient’s Characteristics
  Loker & Dunt (1978)
     Older, white, male, married, and patients with higher social
     class tended to be more satisfied
  Fox & Storms (1981)
     Older and female more satisfied
  Hall & Dornan (1990)
     Female and less educated patients more satisfied
  Stein, Fleishman, Mor & Dresser (1993)
     More educated, less satisfied; other patients’ demographic
     variables not related to satisfaction
                                       Background
Satisfaction Studies in Medical Specialties
  Satisfaction studies in ER, nursing care, internal
  medicine, surgical procedures, and other medical
  interventions.
  Providers’ characteristics
     Type of physician (Roblin et al., 2004)
     Language one speaks (Bischoff et al., 2003)
     Personal choice of physician (Kalda, Polluste, & Lember,
     2003)
  Care provided for patients
     Relationship between care providers and patients
     Whether services are organized
     Teaching materials, time spent, how fast the care
     providers respond to a patient’s request
                              Background

Inconsistent results of patient
satisfaction studies are due to:
  Different definitions of patient
  satisfaction – structure, process, or
  outcome
  Difference between satisfaction
  measurements
  Variation of study samples
                              Background

Model for Quality of Care by Donabedian
(1988)
  Structure – Attributes of the facilities where
  care is provided
  Process – Activities happen between care
  providers and the patients who received care
  Outcome – Ultimate health conditions resulting
  from services provided
                                           Background

Components of Model for Quality of Care


                  Structure / Facilities




 Process / Providers                Outcome / Patients
                                 Background

Satisfaction and Model for Quality of Care
  Satisfaction is thought to reflect the
  quality of care
  Structure and process of care have been
  studied extensively in the past
  Very little attention has been devoted to
  health status or outcome
     In a meta-analysis by Hall (1988), only 6% of
     221 articles measured outcome
                             Background

Measurement of Patient Satisfaction
  Two major aspects of patient satisfaction
  measurement (Hudak and Wright, 2000)
    Content: Areas of measurement
    Method: How the measurement is administered
                                             Background

          Measurement of Patient Satisfaction
              Content                           Method
•   Global – Multi-dimensional   •   Factual – Affective

•   Care – Treatment outcome     •   Open – Closed-ended questions

                                 •   Self-administered –
•   Generic – Disease-specific
                                     Interviewer-administered

•   Direct - Indirect            •   Type of response format
                                       Background

          Measurement of Patient Satisfaction

Global Approach                 Multi-dimensional Approach
  One or two questions for        Require additional time and
  overall satisfaction            effort
  Easy to administer and          Require to establish reliability
  analyze                         and validity of the questions
                                  Provide comprehensive
  Lack of variability             information on satisfaction
  Result in higher                Examine various components of
  satisfaction rating             patient satisfaction such as
  (Krowinski & Steiber, 1996)     structural, technical and
                                  interpersonal aspects of care
                           Background

Examples of Patient Satisfaction
Measurement Instruments
  Ware and Colleagues (1977)
  Larson, Attkisson, Hargreaves, & Nguyen
  (1979)
  Cherkin, Deyo, & Berg (1991)
             Examples of Patient Satisfaction
                 Measurement Instruments

Ware and colleagues (1977)
  Patient Satisfaction Questionnaire (PSQ)
  One of the first multi-dimensional instruments
  8 dimensions:
      Interpersonal manner      Physical environment
      Technical quality         Availability of providers and
                                  facilities
      Accessibility /
       convenience               Continuity of care
      Financial aspect          Efficacy and outcome
                                      Background

Measurement of Functional Status
  Functional Independence Measure (FIMTM)
  Instrument
    Developed by the Uniform Data System for Medical
    Rehabilitation (UDSMR) during 1980s
    Serve as interdisciplinary indicator of the severity of
    disability defined by the World Health Organization
    In 2002, FIMTM was incorporated in the inpatient
    rehabilitation perspective payment system by the
    Centers for Medicare and Medicaid Services (CMS)
                            Background

Previous Studies of Patient Satisfaction
  Most studies were in the primary care area
  with the association between patient
  characteristics and patient satisfaction
  Some studies included health-related
  patient behavior and patient-provider
  interaction but not related to outcome
  Did not include patients with physical
  disabilities in the studies
                                Background

Recent Satisfaction Studies Included
Patients with Disabilities
  Higher scores in transfer, social-cognition and
  locomotion associated with better overall
  satisfaction (Ottenbacher et al., 2001)
  Motor and cognition improvements were
  significantly associated with overall
  satisfaction at follow-up (Tooth et al., 2003)
  Higher motor function at discharge was
  associated with better overall satisfaction at
  follow-up (Mancuso et al., 2003)
                             Background

Limitations in Previous Studies of
Patient Satisfaction
  Limited by sample size in the primary care
  studies
  Most studies were retrospective, only used
  cross-sectional data
  Most studies only measured satisfaction
  once at follow-up
  Most studies used one question to assess
  global satisfaction
                              Significance

From This Study
  A prospective study
  Satisfaction is measured at discharge and
  at follow-up
  Using multiple questions
  Included patients with physical disabilities
                              Significance

Satisfaction as a component of quality of care
with focus on patient-centered care by the
Institute of Medicine (IOM)
Satisfaction as an outcome in healthcare by
the Joint Commission on Accreditation of
Healthcare Organization (JCAHO)
Satisfaction as a quality indicator of program
excellence by the Commission of
Accreditation of Rehabilitation Facilities
(CARF)
     Research Design and Methods

Research Questions
Specific Aims
Research Design
  Cross-lagged Panel Design
  Data Source
Measurements and Variable Definitions
  Measurement of Functional Status
  Measurement of Patient Satisfaction
Data Analysis
       Research Design and Methods

Research Questions
  Does functional status and satisfaction change
  over time in patients with disabilities?
  Are patterns of change over time in functional
  status and satisfaction different between
  patients with the neurological and orthopedic
  impairments?
  Does functional status predict satisfaction
  response at a later time?
  Does satisfaction predict functional status at a
  later time?
         Research Design and Methods
Specific Aim 1: Examine whether functional status
measured by the Functional Independence Measure (FIM)
changes from discharge to follow-up following medical
rehabilitation.
Specific Aim 2: Examine whether patient satisfaction
changes from discharge to follow-up following medical
rehabilitation.
Specific Aim 3: Examine the relationship between
functional status measured by the Functional
Independence Measure (FIM) at discharge and patient
satisfaction at follow-up from medical rehabilitation.
Specific Aim 4: Examine the relationship between
patient satisfaction at discharge and functional status
measured by the Functional Independence Measure (FIM)
at follow-up from medical rehabilitation.
                        Research Design

Cross-lagged Panel Design

    Functional Status       Functional Status
      at discharge            at follow-up




      Satisfaction             Satisfaction
      at discharge             at follow-up
                       Research Design

Data Source
  Five hospitals provided comprehensive
  inpatient rehabilitation services located in
  Connecticut, Michigan, Georgia, and
  Tennessee
  Discharge data were collected between
  February and October, 2004, and follow-up
  data were collected between June 2004 and
  January 2005.
                           Research Design

Data Source
  All facilities that contribute information to
  the UDSMR have to follow a protocol:
    Information on functional status (FIM scores)
    is collected within 72 hours of admission to
    inpatient rehabilitation, and within 72 hours of
    discharge from the program
    All assessments are performed by professional
    staff such as rehabilitation nurses, physical
    therapists, occupational therapists and/or
    speech therapists
                       Research Design
Data Source
  Follow-up data were collected by IT
  HealthTrack
  Interviewers are nurses trained to
  administer and interpret the FIM
  instrument through phone interview with
  patient or proxy
  Patients are contacted at 80 to 180 days
  after discharge by telephone
  No proxy interviews were included in this
  study
     Research Design and Methods

Measurements and Variable Definitions
  Measurement of Functional Status
  Measurement of Patient Satisfaction
     Research Design and Methods

Measurement of Functional Status
  FIMTM Instrument
  18 items, six subscales, two domains
  Each item ranges from minimum score 1
  (total assistance) to maximum score 7
  (total independence)
  Total scores range from 18 to 126 with
  higher scores indicating better functional
  performance
Items Measured                               Score
Motor Domain Score                           No Helper
      Self-Care                                    7 Complete Independence
             Eating                                6 Modified Independence
             Grooming
             Bathing                         Modified Dependence
             Upper Body dressing                   5 Supervision
             Lower Body dressing                   4 Minimal Assistance
             Toileting                             3 Moderate Assistance
      Sphincter
             Bladder management              Complete Dependence
             Bowel management                      2 Maximal Assistance
      Mobility                                     1 Total Assistance
             Chair/wheelchair/bed transfer
             Toilet transfer
             Tub/shower transfer
      Locomotion
             Walking
             Stairs
Cognition Domain Score
      Communication
             Comprehension
             Expression
      Social-Cognition
             Social interaction
             Problem-solving
             Memory
         Research Design and Methods
Measurement of Functional Status
  Reliability of FIMTM Instrument
    Intra-class correlation coefficients (ICC) for rater
    agreement (Hamilton, Laughlin, Fiedler, & Granger,
    1994)
        .94 for self-care, .90 for sphincter, .92 for transfer, .90 for
         locomotion, .91 for communication, and .89 for social-
         cognition
    Inter-rater, test-retest and equivalence reliability
    (Ottenbacher, Hsu, Granger, & Fiedler, 1996)
        .95 for inter-rater reliability, .95 for test-retest reliability,
         and .92 for equivalence reliability
       Research Design and Methods
Measurement of Patient Satisfaction
  Five satisfaction questions were selected
  Questions were developed by the IT
  HealthTrack
    From a pool of questions submitted by more than
    300 facilities between 1996 to 2001
    Recurrent themes
    Consistency with Commission on Accreditation of
    Rehabilitation Facility (CARF) requirements for
    patient participation
    Ease of administration and understanding when
    administered by telephone interview
           Research Design and Methods

Patient Satisfaction Questions
1.   What is your level of satisfaction with improvement in
     your ability to care for yourself following rehabilitation?
2.   What is your level of satisfaction with involvement in
     decision making (or goal setting) during your
     rehabilitation program?
3.   What is your level of satisfaction with achieving your
     goals in rehabilitation?
4.   What is your level of satisfaction with your quality of life?
5.   What is your level of overall satisfaction with the
     rehabilitation program?
           Research Design and Methods
 Patient Satisfaction as Process (and overall) and
 Outcome:
1.   What is your level of satisfaction with improvement in
     your ability to care for yourself following rehabilitation?
2.   What is your level of satisfaction with involvement in
     decision making (or goal setting) during your
     rehabilitation program?
3.   What is your level of satisfaction with achieving your
     goals in rehabilitation?
4.   What is your level of satisfaction with your quality of
     life?
5.   What is your level of overall satisfaction with the
     rehabilitation program?
         Research Design and Methods

Measurement of Patient Satisfaction
  Reliability of Patient Satisfaction Measurement
    Satisfaction responses were collected twice within a
    period of five days from 17 patients (6 males, 11
    females; 7 with stroke, 10 with hip fracture) in an
    outpatient rehabilitation facility in Chicago.
    Test-retest reliability
        .76 for question 1
        .78 for question 2
        .81 for question 3
        .82 for question 4
        .81 for question 5
                         Research Methods

Data Analysis
  Two dependent variables
    Patient satisfaction from 5 questions
    Functional status (FIM scores)
        Motor Domain score
        Cognition Domain score
        Total FIM score
                               Research Methods
Data Analysis
  Patient satisfaction
    Dichotomized responses to “very satisfied” (score
    4) or “less than very satisfied” (score 1, 2, and 3)
    A proportional satisfaction score on the 0-1 scale
    was generated
         Number of “very satisfied” responses divided by the
          total responses and coded as 1
         Counting remaining responses (score 1, 2, and 3)
          divided the total responses and then coded as 0
         The ratio between “very satisfied” and “less than very
          satisfied” became the proportional satisfaction score
                   Research Methods

Data Analysis
  Descriptive information – percentage,
  mean, median, SD
  Repeated measures analysis of variance
  (ANOVA)
  Paired-proportion tests
  Chi-square tests
  Correlation analysis
  Logistic regression analysis
  Linear regression analysis
                                    Results
Characteristics of the Study Sample
  All patients admitted to the five facilities
  were eligible for the study
  Age over 50
  Patients with speech difficulties, aphasia,
  or severe cognitive impairment were
  excluded from the study
  185 patients had complete FIM scores at
  discharge 143 patients (81%) completed
  interviews at follow-up  120 patients 50
  years and older
                                      Results
Characteristics of the Study Sample
  Patients were divided into three impairment
  groups based on the Rehabilitation
  Impairment Categories (RICs)
    Neurological Impairment Group including stroke,
    brain dysfunction, spinal cord injury, and other
    neurological deficits
    Orthopedic Impairment Group including
    amputation of extremities, fractures or joint
    replacement
    “Other” category including cardiovascular
    dysfunction, pain or multiple disabilities
                                                               Results
Table 7. Percentage of Diagnoses in Each Impairment Subgroup
                                                      N             %

Neurological Impairment Subgroup                     67
      Stroke                                         52             78
      Brain Dysfunction                              6              9
      Spinal Cord Injury                             8              12
      Other Neurological Conditions                  1              1

Orthopedic Impairment Subgroup                       44
      Fractures                                      13             30
      Joint Replacements                             24             54
      Amputations                                    7              16
Table 8. Characteristics of the Study Sample
                                           Neurological      Orthopedic
                              Overall      Impairment        Impairment       Other
Age
 mean (SD)                  70.7 (10.2)        70.9 (10.0)
                                                                      Results(9.7)
                                                             70.2 (10.7)  71.6
 median                         71                 72            69            73

Gender, %
 Male                           48                 46            48            56
 Female                         52                 54            52            44

Marital, %
 Married                        46                 46            43            56
 Non married                    54                 54            57            44

Ethnicity, %
  White                         75                 63            77            78
  Non White                     25                 37            23            22

Impairment group
  N=                            120                67            44             9
  %                             100                56            37             7

LOS
 mean (SD)                   13.7 (7.5)        16.5 (7.9)     9.0 (3.8)     14.9 (6.4)
 median                         11                15              8            11
                      Results – Aim 1

Aim 1: Examine whether functional
status measured by the Functional
Independence Measure (FIM) changes
from discharge to follow-up following
medical rehabilitation.
Analysis: Repeated measures ANOVA
(2x2) with one between subject factor
(neurological and orthopedic group) and
one repeated factor (discharge versus
follow-up) to examine functional status
change over time.
                                             Results – Aim 1

     Functional Status Change Over Time in
     the Overall Sample
Table 11. Functional Status Change Over Time in the Overall Sample
Source of                                Mean
Variation                    df          Square          F           p value
Motor Function               1           8665.6        100.8           0.0
Error                       110           85.9

Cognitive Function           1           499.5          39.6          0.0
Error                       110          12.6

Total FIM                    1          13326.1        126.7          0.0
Error                       110          105.2
                                  Results – Aim 1

 Functional Status Change Over Time
 between Two Impairment Groups
Motor Function
Source of Variation   df    Mean Square    F      p value
Impairment group       1      1008.8       9.4     .003
Time                   1      8874.0      104.9   <.001
Group × Time           1       228.6       2.7      .1
Error                 109      84.6
                                  Results – Aim 1

Functional Status Change from Discharge to
Follow-up
                 Motor FIM Change

     95
     90
     85
     80
     75
     70
     65
     60
            Motor FIM_D             Motor FIM_F

                   Neurological    Orthopedic
                                 Results – Aim 1

 Functional Status Change Over Time
 between Two Impairment Groups

Cognitive Function
Source of Variation   df    Mean Square    F     p value
Impairment group       1       305.1      19.4   <.001
Time                   1       376.0      32.9   <.001
Group × Time           1       142.5      12.5    .001
Error                 109      11.4
                                   Results – Aim 1
Functional Status Change from Discharge to
Follow-up

                 Cognitive FIM Change

     40
     35
     30
     25
     20
           Cognition FIM_D          Cognition FIM_F

                    Neurological    Orthopedic
                                  Results – Aim 1

  Functional Status Change Over Time
  between Two Impairment Groups
Total FIM Score
Source of Variation   df    Mean Square    F      p value
Impairment group       1      2423.4      15.1    <.001

Time                   1      12903.4     121.7   <.001
Group × Time           1       10.1        0.1      .8
Error                 109      106.1
                                   Results – Aim 1

Functional Status Change from Discharge to
Follow-up
                  Total FIM Change

     130
     125
     120
     115
     110
     105
     100
      95
      90
      85
             Total FIM_D             Total FIM_F

                    Neurological    Orthopedic
                       Results – Aim 2

Aim 2: Examine whether patient
satisfaction changes from discharge to
follow-up following medical rehabilitation.
Analysis: Paired-proportion testing
along with chi-square tests to examine
patient satisfaction change over time and
difference between two impairment groups.
                                            Results – Aim 2
       Proportional Satisfaction Scores Change Over
       Time in the Overall Sample

                           At Discharge   At Follow-up   Test Statistics   p value
Overall Sample (n = 111)

Question 1                     0.85           0.65            1.74          0.04
Question 2                     0.81           0.78            0.25          0.40
Question 3                     0.81           0.67            1.22          0.11
Question 4                     0.60           0.65            0.47          0.32
Question 5                     0.86           0.89            0.24          0.41
                          Results – Aim 2
Satisfaction Change Over Time in the Overall
Sample
                                              Results – Aim 2
        Proportional Satisfaction Scores Change Over
        Time in the Neurological Impairment Group

                               At Discharge   At Follow-up   Test Statistics   p value
Neurological
Impairment Subgroup (n = 67)

Question 1                        0.83            0.56            1.93          0.03
Question 2                        0.83            0.72            0.73          0.24
Question 3                        0.81            0.59            1.55          0.06
Question 4                        0.60            0.56            0.30          0.38
Question 5                        0.85            0.87            0.12          0.45
                           Results – Aim 2
Satisfaction Change Over Time in the Neurological
Impairment Group
                                              Results – Aim 2
        Proportional Satisfaction Scores Change Over
        Time in the Orthopedic Impairment Group

                               At Discharge   At Follow-up   Test Statistics   p value
Orthopedic
Impairment Subgroup (n = 44)

Question 1                        0.88            0.79            0.46          0.32
Question 2                        0.78            0.85            0.36          0.36
Question 3                        0.81            0.80            0.05          0.48
Question 4                        0.62            0.80            1.01          0.16
Question 5                        0.88            0.91            0.15          0.44
                          Results – Aim 2
Satisfaction Change Over Time in the Orthopedic
Impairment Group
                             Results – Aim 2

Proportional Satisfaction Scores Change Over
Time between two Impairment Groups
  Chi-Square test results ranged from 0.002 to 1.72
  with p values ranging between 0.19 to 0.96
  indicating that there was no statistical difference
  between the two impairment groups in all five
  questions
                             Results – Aim 3

Aim 3: Examine the relationship between functional
status measured by the Functional Independence
Measure (FIM) at discharge and patient satisfaction
at follow-up from medical rehabilitation.
Analysis: Logistic regression analysis to estimate
the effect of the functional status at discharge on
patient satisfaction at follow-up when controlling for
satisfaction response at discharge.

  Satisfaction at follow-up = Functional status at
         discharge + satisfaction at discharge
                      Results – Aim 3

Logistic Regression Analysis in the
Neurological Group
Table 14. Results from Logistic Regression Analysis
                                       Parameter      Standard     Wald       p value
                                       Estimate         Error    Chi-Square
The Neurological
Impairment Subgroup
Satisfaction 1 at follow-up
    Motor FIM at discharge               -0.02          0.02        0.63       0.43
    Cognition FIM at discharge           -0.02          0.04        0.31       0.58
    Satisfaction 1 at discharge          -0.58          0.58        0.97       0.32

Satisfaction 2 follow-up
    Motor FIM at discharge               -0.01          0.02        0.38       0.54
    Cognition FIM at discharge            0.00          0.04        0.00       0.96
    Satisfaction 2 at discharge          -0.72          0.57        1.60       0.21

Satisfaction 3 follow-up
    Motor FIM at discharge               -0.03          0.02        1.51       0.22
    Cognition FIM at discharge           -0.02          0.04        0.18       0.67
    Satisfaction 3 at discharge          -0.35          0.57        0.38       0.54

Satisfaction 4 follow-up
    Motor FIM at discharge               -0.04          0.03        2.72       0.10
    Cognition FIM at discharge            0.00          0.05        0.00       0.96
    Satisfaction 4 at discharge          -0.99          0.54        3.34       0.07

Satisfaction 5 follow-up
    Motor FIM at discharge               -0.03          0.03        1.51       0.22
    Cognition FIM at discharge            0.01          0.05        0.03       0.86
    Satisfaction 5 at discharge          -0.29          0.70        0.17       0.68
                      Results – Aim 3

Logistic Regression Analysis in the
Orthopedic Group
Table 14. Results from Logistic Regression Analysis
                                       Parameter      Standard     Wald       p value
                                       Estimate         Error    Chi-Square
The Orthopedic
Impairment Subgroup
Satisfaction 1 at follow-up
    Motor FIM at discharge               -0.10          0.05        4.03       0.04
    Cognition FIM at discharge            0.86          0.59        2.09       0.15
    Satisfaction 1 at discharge          -1.15          0.99        1.35       0.24

Satisfaction 2 follow-up
    Motor FIM at discharge               -0.10          0.05        3.75       0.05
    Cognition FIM at discharge            1.62          1.32        1.51       0.22
    Satisfaction 2 at discharge          -1.66          1.00        2.74       0.10

Satisfaction 3 follow-up
    Motor FIM at discharge               -0.04          0.04        0.88       0.35
    Cognition FIM at discharge            0.63          0.55        1.31       0.25
    Satisfaction 3 at discharge          -0.45          0.89        0.26       0.61

Satisfaction 4 follow-up
    Motor FIM at discharge                0.00          0.05        0.00       0.95
    Cognition FIM at discharge            0.03          0.16        0.03       0.87
    Satisfaction 4 at discharge           0.67          0.81        0.69       0.41

Satisfaction 5 follow-up
    Motor FIM at discharge               -0.04          0.06        0.52       0.47
    Cognition FIM at discharge            0.48          0.67        0.51       0.48
    Satisfaction 5 at discharge          -1.78          1.14        2.41       0.12
                             Results – Aim 4
Aim 4: Examine the relationship between patient
satisfaction at discharge and functional status
measured by the Functional Independence Measure
(FIM) at follow-up from medical rehabilitation.
Analysis: Linear regression analysis to estimate the
effect of patient satisfaction at discharge on
functional status at follow-up when controlling for
functional status at discharge.

  Functional status at follow-up = Satisfaction at
     discharge + Functional status at discharge
                     Results – Aim 4

Linear Regression Analysis in the
Neurological Group
Table 15. Results from Linear Regression Analysis
                                      Parameter     Standard
                                      Estimate        Error    t value   p value
The Neurological
Impairment Subgroup
Total FIM score at follow-up
   Satisfaction 1 at discharge           5.11         4.11      1.24      0.22
   Total FIM at discharge                0.45         0.10      4.52     < .0001

Total FIM score at follow-up
   Satisfaction 2 at discharge           5.29         3.98      1.33      0.19
   Total FIM at discharge                0.46         0.10       4.8     < .0001

Total FIM score at follow-up
   Satisfaction 3 at discharge           6.82         3.96      1.72      0.09
   Total FIM at discharge                0.44         0.10      4.56     < .0001

Total FIM score at follow-up
   Satisfaction 4 at discharge           5.25         3.75      1.40      0.17
   Total FIM at discharge                0.44         0.10      4.34     < .0001

Total FIM score at follow-up
   Satisfaction 5 at discharge           0.92         4.15      0.22      0.83
   Total FIM at discharge                0.48         0.10      4.99     < .0001
                     Results – Aim 4

Linear Regression Analysis in the
Orthopedic Group
Table 15. Results from Linear Regression Analysis
                                      Parameter     Standard
                                      Estimate        Error    t value   p value
The Orthopedic
Impairment Subgroup
Total FIM score at follow-up
   Satisfaction 1 at discharge           1.55         1.93      0.80      0.43
   Total FIM at discharge                0.15         0.09      1.66      0.10

Total FIM score at follow-up
   Satisfaction 2 at discharge           1.14         1.67      0.68      0.50
   Total FIM at discharge                0.15         0.09      1.69      0.10

Total FIM score at follow-up
   Satisfaction 3 at discharge          -0.53         1.79     -0.30      0.77
   Total FIM at discharge                0.16         0.09      1.71      0.10

Total FIM score at follow-up
   Satisfaction 4 at discharge          -0.40         1.50     -0.27      0.79
   Total FIM at discharge                0.15         0.09      1.68      0.10

Total FIM score at follow-up
   Satisfaction 5 at discharge           3.61         1.86      1.94      0.06
   Total FIM at discharge                0.16         0.09      1.88      0.07
                Discussion – Aim 1

Aim 1: Examine whether functional
status measured by the Functional
Independence Measure (FIM)
changes from discharge to follow-up
following medical rehabilitation.
                     Discussion – Aim 1
The motor, cognition and total FIM scores
improved significantly from discharge to
follow-up.
The orthopedic group demonstrated
significant improvement in the motor
function and total FIM scores; the
neurological group had obvious increase in
cognitive function.
The trend of change in cognitive function in
the neurological group from discharge to
follow-up was different from the orthopedic
group.
                Discussion – Aim 2

Aim 2: Examine whether patient
satisfaction changes from discharge
to follow-up following medical
rehabilitation.
                             Discussion – Aim 2

The Neurological Group           The Orthopedic Group
  Satisfaction declined in Q1      Satisfaction slightly
  (83% to 56%), Q2 (83% to         decreased in Q1 (88% to
  72%), Q3 (81% to 59%) & Q4       79%) and Q3 (81% to 80%)
  (from 60% to 56%)                Satisfaction increased in Q2
  Satisfaction increased in Q5     (78% to 85%), Q4 (62% to
  (85% to 87%)                     80%), & Q5 (88% to 91%)
                  Discussion – Aim 2

Satisfaction responses declined in
questions 1 and 3 (outcome-related) in
the neurological group
In the orthopedic group, satisfaction
responses increased (from 62% to 80%)
in question 4 (health-related quality of
life) when in the neurological group the
responses decreased from 60% to 56%
             Discussion – Aim 3 & 4

Aim 3: Examine the relationship between
functional status measured by the
Functional Independence Measure (FIM)
at discharge and patient satisfaction at
follow-up from medical rehabilitation.

Aim 4: Examine the relationship between
patient satisfaction at discharge and
functional status measured by the
Functional Independence Measure (FIM)
at follow-up from medical rehabilitation.
             Discussion – Aim 3 & 4
Results from Logistic Regression
  Motor function at discharge was a
  significant predictor of satisfaction at
  follow-up in the orthopedic group for
  question 1.
  This finding supported an earlier study
  by Mancuso et al. (2003) that better
  motor status at discharge was associated
  with higher patient satisfaction at
  follow-up in a sample of patients with
  orthopedic impairments.
              Discussion – Aim 3 & 4
Results from Linear Regression
  Satisfaction responses at discharge were
  not significant predictors of functional
  status at follow-up.
  This finding was consistent with an
  earlier study by Hall, Milburm, &
  Epstein (1993) that there was no
  evidence for satisfaction predicting self-
  perceived health status at a later time.
                  Clinical Implications
Patients with neurological impairments
such as stroke, brain dysfunction, spinal
cord injury satisfaction responses were
lower at follow-up
For clinicians:
  Setting realistic treatment goals
  Better discharge planning for follow-up
  therapy
  Counseling and family support
                 Clinical Implications

Hospital environment versus home
settings
For clinicians:
  Provide more opportunities for patients to
  experience a “real” home environment or a
  “transitional” environment while patients
  are still in hospital
  Realistic expectations regarding post-
  discharge environment
                 Clinical Implications

The decline of satisfaction responses
from discharge to follow-up suggested
that not only did the functional status
change, patients’ psychological state
also changed.
For clinicians:
  Psychological assessment and consultation
  should be offered as a part of outpatient
  rehabilitation services or home health
  services
               Strengths of the Study

Satisfaction is measured using a multi-
dimensional approach
  Process-related satisfaction
  Outcome-related satisfaction
Emphasis on satisfaction as an outcome
  Important quality indicator of care
Prospective and longitudinal design
  Satisfaction is measured at discharge and
  at follow-up
               Limitations of the Study

The study sample is not randomly selected
and may not be representative of all patients
who received inpatient medical rehabilitation
services.
In the study, 67 patients with neurological
impairments, and 44 patients with orthopedic
impairments
  Limited statistical power
Response variability to the satisfaction
questions
        Future Directions for Study

Satisfaction measurement with different
response format
Different satisfaction questions for the
patient population with different
physical dysfunctions
More studies in satisfaction change over
time in specific impairment
diagnoses/groups
                                   Conclusion

Functional status (motor and cognitive function and
total FIM scores) improved significantly from
discharge to follow-up.
Satisfaction question 1 (related to functional
improvement) demonstrated significant differences
from discharge to follow-up in the neurological
impairment group.
Motor function at discharge was a significant
predictor of satisfaction at follow-up in the
orthopedic group for question 1.
Satisfaction responses at discharge were not
predictors of functional status at follow-up.
                              Conclusion

Patients with orthopedic impairments
demonstrated greatest improvement in motor
function; patients with neurological
impairments have more increase in cognitive
function.
The decline of satisfaction response over time
was unique, and reduction in satisfaction was
observed in the questions related to outcome.
                             Acknowledgement
Sincere appreciation to the committee members:
           Dr. Kenneth J. Ottenbacher
               Dr. Judith C. Drew
               Dr. Steven V. Owen
             Dr. Malcolm P. Cutchin
                Dr. Glenn V. Ostir
          And to other mentors and friends:
  Dr. Janida Rice, Dr. Gayle Weaver, Mrs. Emily Chen,
     Dr. Reginald Tsang, Dr. Bey-Dih Chang, all my
            schoolmates, and many friends.
This research was sponsored by the American Heart Association
 Thank you! 


Any Questions?

								
To top