COVID-19 Reveals Opportunities for Better Care of Stroke Patients
Direct Transfer to Postacute Rehabilitation, Reduction in Length of Stay, and Treatment Outcomes
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In Germany, about 19 million hospital treatments and 2 million inpatient treatments in neurorehabilitation centers are delivered each year, a fifth of which are provided as postacute rehabilitation measures after acute care (1). Postacute rehabilitation is indicated particularly after severe disease courses. Its start is often delayed, however, as health insurers require an application for rehabilitation. It is not known how this application process affects the overall treatment duration and outcomes.
On 24 March 2020, the Federal Ministry of Health ruled that, “During the current coronavirus pandemic it is imperative that inpatient beds should not be occupied unless this is absolutely necessary. (…) The process of postacute rehabilitation will temporarily be changed to a process of direct transfer by hospitals. (…) Hospitals therefore consider the requirements for participation in postacute rehabilitation and organize the transfer to postacute rehabilitation without waiting for the responsible health insurance company to approve their application for this service.” This suspension ended on 31 May 2020.
We used this natural experiment to investigate the effects of the approval process. We analyzed anonymized control data from severely (neurorehabilitation phase C) and moderately (neuorehabilitation phase D) affected patients from four neurorehabilitation centers (24 March to 31 May 2020; intervention group; n=302) compared with an earlier period (1 January 2020 to 23 March 2020; control group; n=420). The primary endpoints were the time between the acute event and the start of postacute rehabilitation as well as functional recovery during the rehabilitation measured as changes on the Barthel index (score range=0–100). Secondary endpoints were length of stay in inpatient rehabilitation and severe complications (complication data from two hospitals, intervention group n=213, control group n=340).
The intervention group was slightly younger than the control group (71.96±11.83 versus 73.54±12.44 years; t=1.72; p=0.087). Sex (48.4% versus 45.4% female; χ2=0.47; p=0.491; data not reported in n=172) and the diagnoses did not differ (χ2=8.25; p=0.080). Stroke was the most common main diagnosis (80% versus 73%). We used analysis of covariance (ANCOVA) to determine the (log transformed) latency data (factors: intervention group/control group, rehabilitation phase, group × phase, hospital, diagnosis, covariate: age) to determine the latency (log transformed), and an equivalent ANCOVA with the additional variables Barthel index at admission and length of treatment to determine functional recovery.
Inpatient rehabilitation during the intervention started a median of 7 (phase C) and 10 (phase D) days earlier than in the control period (main group effect ANCOVA: F=52.042; p<0.001; ηp2 = 0.069) (Figure 1). Lengths of stay and complication rates in the rehabilitation centers were similar for both time periods (p≥ 0.186). Functional recovery in moderately affected patients was the same (F=2.6; p=0.11) whereas severely affected patients achieved a better functional recovery during the intervention (F=4.4; p= ,036; ηp2=0.011) (Figure 2). Admission capacity data were collected in one hospital, and a possible confounding seasonal effect was considered on the basis of data from 2018 and 2019. These control analyses showed that admission capacities or seasons of the year did not systematically affect latencies between transfers. Further information can be found at https://osf.io/wpcfd/?view_only=e52cff91bf5a4b458b5e87507acff38e
To summarize, suspending the application process for rehabilitation treatment shortens the overall length of stay (a shorter period in hospital and the same in the rehabilitation center). The complication rate during rehabilitation was no higher; this means that no “bloody [ie premature] transfers” occurred. Instead, a better functional recovery was observed in severely affected patients. Similar effects were also observed in correlation studies (2). We assume that high cerebral plasticity early after the lesion and the avoidance of immobility related complications have a role in this. Actimetric data show that hospital inpatients are immobile for 94% of their stay (3). A longer period of immobility resulted in loss of strength and muscle tissue, and thus the basis for regaining independence in daily life (4). Such immobility related deterioration is probably also responsible for the fact that the control group—in spite of a longer time interval for spontaneous recovery—were admitted to rehabilitation clinics with a mean Barthel index that was comparable to that in the intervention group. Especially severely affected—immobile—patients might therefore benefit from faster transfer to rehabilitation centers where they are given intensive mobilization (5).
Why do application procedures prolong the inpatient stay so notably—namely, 7 and 10 days, respectively? The application process is prone to delays as cooperation is required between different professional groups and institutions, although the criteria for rehabilitation are defined by law. They can be applied without any problems by hospital doctors and can easily be checked post hoc by the funding bodies. Our data confirm the health ministry’s assumption that foregoing applications can help avoid inpatient bed occupancy that is not absolutely necessary. In view of about 150 000 neurological postacute rehabilitations delivered in Germany, our data show that abolishing the application-approval process in neurology alone could save up to 1.5 inpatient days—more than €1bn.
Bettina Studer, Robin Roukens, Svenja Happe, Simone B. Schmidt, Stefan Knecht
St. Mauritius Therapieklinik Meerbusch, Meerbusch (Studer, Knecht)
Institute of Clinical Neuroscience and Medical Psychology, Heinrich-Heine-University Düsseldorf (Studer, Knecht)
Dr. Becker Rhein-Sieg-Klinik, Nümbrecht (Roukens)
Klinik Maria Frieden Telgte (Happe)
Institute for Neurorehabilitation Research, associated institute of Hannover Medical School, BDH-Clinic Hessisch Oldendorf, Hessisch Oldendorf (Schmidt)
Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript received on 28 January 2021, revised version accepted on 19 April 2021.
Translated from the original German by Birte Twisselmann, PhD.
Cite this as:
Studer B, Roukens R, Happe S, Schmidt SB, Knecht S: COVID-19 reveals opportunities for better care of stroke patients—direct transfer to postacute rehabilitation, reduction in length of stay, and treatment outcomes. Dtsch Arztebl Int 2021; 118: 346–7. DOI: 10.3238/arztebl.m2021.0219
|1.||Statistisches Bundesamt: Gesundheit, Grunddaten der Krankenhäuser. Fachserie 2016; 12.|
|2.||Scrutinio D, Monitillo V, Guida P, et al.: Functional gain after inpatient stroke rehabilitation: correlates and impact on long-term survival. Stroke 2015; 46: 2976–80 CrossRef MEDLINE|
|3.||Mattlage AE, Redlin SA, Rippee MA, Abraham MG, Rymer MM, Billinger SA: Use of accelerometers to examine sedentary time on an acute stroke unit. J Neurol Phys Ther 2015; 39: 166–71 CrossRef MEDLINE PubMed Central|
|4.||Gruther W, Benesch T, Zorn C, et al.: Muscle wasting in intensive care patients: ultrasound observation of the M. quadriceps femoris muscle layer. J Rehabil Med 2008; 40: 185–9 CrossRef MEDLINE|
|5.||Knecht S, Roßmüller J, Unrath M, Stephan KMKM, Berger K, Studer B: Old benefit as much as young patients with stroke from high-intensity neurorehabilitation: cohort analysis. J Neurol Neurosurg Psychiatry 2016; 87: 526–30 CrossRef MEDLINE PubMed Central|