Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation A Randomized Clinical Trial
Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation A Randomized Clinical Trial
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DOI：
10.1001/jamanetworkopen.2019.8199
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发表时间：
2019-07-01
影响因子：
13.8
通讯作者：
Rodebaugh, Thomas L.
中科院分区：
文献类型：
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作者：
Lenze, Eric J.;Lenard, Emily;Rodebaugh, Thomas L.
重要性增强医疗康复（EMR）是物理和职业治疗师参与患者的系统和标准化方法。更高的患者参与治疗可能会导致改善功能恢复的康复环境，如熟练的护理设施（SNFs）。目的为了确定EMR是否改善老年人的功能恢复。设计，设置和参与者一项双盲，平行组，随机临床试验，从2014年7月29日至2018年7月13日进行。在229名65岁或以上的成年人中，接受了2个美国SNF。参与者随机接受EMR（n = 114）与标准护理康复（n = 115）。意向治疗分析used.INTERVENTIONS干预组接受他们的物理和职业治疗的治疗师在EMR培训。基于动机和行为改变的模型，EMR是一种提高患者参与度和治疗强度的技术工具包。对照组接受标准的护理康复从物理和职业治疗师没有受过培训的EMR.Main结果和措施的主要结果是改变功能的日常生活和活动能力，作为评估与巴氏指数，其中措施10个基本活动的日常生活或流动性项目（量表范围，0-100），从SNF入院到出院;次要结局为10 m步态速度、6分钟步行试验、出院处置、再住院和第30、60和90天自我报告的功能状态。为了检查康复过程中，治疗师的参与与患者和患者的活动时间在therapeutic sessions.RESULTS的229名参与者，149（65.1%）是女性; 177（77.3%）是白色，51（22.3%）是黑色的，平均（SD）年龄为79.3（8.0）岁。分配到EMR组的受试者的功能恢复比分配到标准治疗组的受试者更好（Barthel指数评分平均增加35分; 95% CI，31.6-38.3 vs 28分; 95% CI，25.2-31.7分; P = 0.007）。没有证据表明住院时间存在差异（平均值[SD]，23.5 [13.1]天）。然而，在次要结局指标方面，包括SNF出院后90天的自我报告功能（根据Barthel指数测量），没有时间组间差异（平均[SE]评分：EMR，83.65 [2.20];标准治疗，84.67 [2.16]; P = 0.96）。EMR治疗师使用中位数（四分位距）24.4（21.0-37.3）每次治疗的激励信息vs 2.3（1.1-2.9）对于未经培训的治疗师（P <0.001），EMR患者在平均（SD）52.5（6.6%）的治疗会话时间与41.2（6.8%）的未经培训的治疗师（P = .001）。结论和相关性加强医疗康复适度改善短期功能恢复选定的老年人康复SNF。然而，没有证据表明这些益处可以长期持续。这项研究证明了参与和激励老年人进行康复治疗的价值，但需要更多的工作来将这些益处扩展到出院后的长期结果。
IMPORTANCE Enhanced medical rehabilitation (EMR) is a systematic and standardized approach for physical and occupational therapists to engage patients. Higher patient engagement in therapy might lead to improved functional recovery in rehabilitation settings, such as skilled nursing facilities (SNFs).OBJECTIVE To determine whether EMR improves older adults' functional recovery.DESIGN, SETTING, AND PARTICIPANTS A double-blind, parallel-group, randomized clinical trial was conducted from July 29, 2014, to July 13, 2018, in 229 adults aged 65 years or older admitted to 2 US SNFs. Participants were randomized to receive EMR (n = 114) vs standard-of-care rehabilitation (n = 115). Intention-to-treat analysis was used.INTERVENTIONS The intervention group received their physical and occupational therapy from therapists trained in EMR. Based on models of motivation and behavior change, EMR is a toolkit of techniques to increase patient engagement and therapy intensity. The control group received standard-of-care rehabilitation from physical and occupational therapists not trained in EMR.MAIN OUTCOMES AND MEASURES The primary outcome was change in function in activities of daily living and mobility, as assessed with the Barthel Index, which measures 10 basic activities of daily living or mobility items (scale range, 0-100), from SNF admission to discharge; secondary outcomes were gait speed for 10m, 6-minute walk test, discharge disposition, rehospitalizations, and self-reported functional status at days 30, 60, and 90. To examine the rehabilitation process, therapists' engagement with patients and patient active time during therapy were measured for a sample of the sessions.RESULTS Of the 229 participants, 149 (65.1%) were women; 177 (77.3%) were white, and 51 (22.3%) were black; mean (SD) age was 79.3 (8.0) years. Participants assigned to EMR showed greater recovery of function than those assigned to standard of care (mean increase in Barthel Index score, 35 points; 95% CI, 31.6-38.3 vs 28 points; 95% CI, 25.2-31.7 points; P = .007). There was no evidence of a difference in the length of stay (mean [SD], 23.5 [13.1] days). However, there were no group by time differences in secondary outcome measures, including self-reported function after SNF discharge out to 90 days as measured on the Barthel Index (mean [SE] score: EMR, 83.65 [2.20]; standard of care, 84.67 [2.16]; P = .96). The EMR therapists used a median (interquartile range) of 24.4 (21.0-37.3) motivational messages per therapy session vs 2.3 (1.1-2.9) for nontrained therapists (P < .001), and EMR patients were active during a mean (SD) of 52.5 (6.6%) of the therapy session time vs 41.2 (6.8%) for nontrained therapists (P = .001).CONCLUSIONS AND RELEVANCE Enhanced medical rehabilitation modestly improved short-term functional recovery for selected older adults rehabilitating in SNFs. However, there was no evidence that the benefits persisted over the longer term. This study demonstrates the value of engaging and motivating older adults in rehabilitation therapy, but more work is needed to extend these benefits to longer-term outcomes after discharge home.