For stroke patients, rating scales predict discharge destination

Stroke survivors with higher scores on widely used outcome measures are more likely to be discharged home from the hospital, while those with lower scores are more likely to go to a rehabilitation or nursing care facility, reports a paper in the January issue of The Journal of Neurologic Physical Therapy (JNPT).

Standardized rating scales can help to support decisions about discharge destination for stroke patients leaving the hospital, according to the analysis by Dr. Emily Thorpe, PT, DPT, and colleagues of Walsh University, North Canton, Ohio, under the mentorship of Dr. Robert S. Phillips, PT, DPT, PhD, NCS. "These results provide a framework with which to start the plan of care and discharge process in acute and sub-acute settings," the researchers write.

Outcome Measure Scores to Predict Stroke Discharge - Pooled Evidence Analysis

In a systematic research review, Dr. Thorpe and colleagues identified nine previous studies of the relationship between standardized outcome measures and discharge destination in patients with stroke. Five studies—including more than 6,000 patients—provided evidence suitable for analysis of pooled data, called meta-analysis.

Meta-analyses assessed the predictive value of two outcome measures. Four studies evaluated the Functional Independence Measure (FIM), which assesses the level of assistance needed to perform daily tasks. The FIM is commonly used in hospitalized patients with a wide range of conditions. Two studies used the National Institutes of Health Stroke Scale (NIHSS), which is specifically designed to assess stroke severity and resulting disability. (One of the studies included both measures.)

Both rating scales were good indicators of the discharge destination for stroke patients, according to the meta-analyses. For each one-point improvement in the FIM score (on a scale from 18 to 126), patients were about eight percent more likely to be sent home from the hospital, rather than to a rehabilitation or nursing facility.

On both the FIM and NIHSS, patients who scored in the "above average" range were 12 times more likely to be discharged to home. In contrast, patients with "average" scores were 1.9 times more likely to be discharged to a care facility.

Patients with "poor" scores on the FIM and NIHSS were 3.4 times more likely to be discharged to an institution. For this group, the discharge destination was more likely to be a skilled nursing facility, rather than to an inpatient rehabilitation center.

Interdisciplinary rehabilitation services are crucial to help stroke patients toward regaining their functional ability and lifestyle. With the aging population and increased spending for stroke management, it's more important than ever to provide efficient care for patients recovering from a stroke. About 20 percent of stroke survivors require institutionalized care beyond three months; many patients need continued assistance after they return home.

Outcome measures such as the FIM and NIHSS are widely used to assess the functional abilities or clinical condition of stroke patients. However, it has been unclear how scores on these rating scales are related to discharge destination.

The new analysis provides evidence-based data to support critical decision-making about discharge destination in stroke patients. "Findings from these meta-analyses are consistent with common sense practice: the better a patient's outcome measure score, the greater the likelihood of home discharge," Dr. Thorpe and coauthors write. The results show the "quantitative impact" of outcome measure scores on discharge decisions.

The researchers emphasize that rating scales such as the FIM and NIHSS are just one factor to consider in determining the best discharge destination for each individual patient after a stroke. Dr. Thorpe and colleagues conclude: "Ultimately, standardized outcome measures should be further used and studied among the post-stroke population to improve healthcare policy and compliment clinical judgment in the task of recommending discharge destinations for patients to receive the necessary care for achieving their optimal function."