Variables Associated with Occupational and Physical Therapy Stroke Rehabilitation Utilization and Outcomes

Journal of Allied Health, Spring 2005 by Cook, Chad, Stickley, Lois, Ramey, Kevin, Knotts, Valerie J

Many studies have reported the benefits of a comprehensive stroke team including occupational therapy/physical therapy (OT/PT) services; however, factors associated with access to these services are less known. This study used a subsample of the Health and Retirement Study database, a cross-sectional survey of more than 11,126 Americans aged 65 to 106 years within the contiguous United States. The purposes of this study were to determine the associational factors that contribute to attending OT/PT and determine if attending OT/PT leads to a reduced report of stroke-related problems. The findings indicated that fewer than 10% of stroke survivors in a noninstitutionalized, community-based setting were currently accessing OT/PT. Additionally, access to OT/PT services was highly associated with report of having an attending physician, report of stroke-related weakness, higher monthly income, and older age. The increased odds of reported continued problems associated with a past stroke were associated with failure to access OT/PT services, lower monthly income, Hispanic culture, and age. OT/PT services were typically provided to patients who reported a higher level of physical dysfunction. Despite the greater degree of severity, OT/PT intervention led to reports of lower levels of disability and problems over time. J Allied Health 2005; 34:3-10.

STROKE IS THE leading cause of disability among older adults in the United States and accounts for costly and extensive use of rehabilitation services.1 As stroke survival improves, treatment of stroke-related impairments, functional limitations, and disability become more important. More people survive stroke and return to the community if they have mild to moderate deficits; however, functional outcomes in these individuals remain limited.2 Three months following the onset of stroke, 17% of survivors remain dependent in personal care and 50% are fully independent in personal care. Six months following the onset of stroke, 50% of survivors are dependent in instrumental activities of daily living (ADL) (e.g., self-administration of medication, meal preparation) and only 33% are independent in community mobility.2 Individuals with high levels of recovery (Barthel index of ≥95) continue to have disability related to hand function, performance of basic and instrumental activities of daily living, physical functioning, and participation.' The mean cost of acute management of stroke over a 12-week period is $13,668, with more than 70% of the total cost expended in the initial hospitalization (mean length of stay, 24 days).4 The need for outpatient occupational therapy/physical therapy (OT/PT) following acute rehabilitation may increase the probability of further functional improvement.1

Individuals who survive stroke and receive rehabilitation services in the acute and subacute stages of recovery generally experience improved short-term and long-term survival, experience higher function, return home, and may experience an improved quality of life.5 Early intervention generally includes the multidisciplinary efforts of a sophisticated, dedicated stroke team consisting of medical, pharmaceutical, and rehabilitation personnel/1" The key characteristics of stroke units include teamwork, staff education, functional training, integrated therapies, and nursing.5 Although ample evidence is associated with early multidisciplinary rehabilitative intervention,10,12-16 data pertaining to benefits coupled with specific rehabilitation (i.e., OT/PT) processes are sparse.7,17

Many stroke survivors receive outpatient or community-based care, which may or may not include OT/PT services.10,12 Determination of whether OT/PT services are utilized is often beyond the control of the stroke survivor and rehabilitation clinician. Although direct -access to OT/PT exists in several states within the United States, there are few third'party payers, including Medicare, that allow reimbursement of services without a physician referral.18'Consequently, utilization of OT/PT that involves reimbursement through a third-party payer is dependent on a referral from a physician.19

Factors Involving Utilization and Referral

There are numerous physical risk factors for intracerebral hemorrhage (stroke), including age, male gender, hypertension, and high alcohol consumption.20-23 The association of these physical factors and the incidence of a stroke are well quantified in numerous studies. Conversely, there is little information that outlines what factors, physical or other, determine whether a stroke survivor is referred for OT/PT. Past studies have suggested the negative influence of low monthly income on stroke outcomes but failed to delineate whether OT/PT services were provided or not.24'25 There is little evidence to support whether race, education, care from a physician, or report of continued problems associated with a disorder will influence rehabilitation use; however, past studies have linked these variables to increased general health care utilization.26,27 Logic dictates that having an attending physician, continued problems post-stroke, and the severity of the reported problems would increase the chance of OT/PT utilization, yet there is no known literature to substantiate this assumption.