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Table.  Patient Characteristics by Outcomesa
Patient Characteristics by Outcomesa
1.
Greysen  SR, Patel  MS.  Annals for Hospitalists Inpatient Notes: bedrest is toxic-why mobility matters in the hospital.  Ann Intern Med. 2018;169(2):HO2-HO3. doi:10.7326/M18-1427PubMedGoogle ScholarCrossref
2.
Brown  CJ, Redden  DT, Flood  KL, Allman  RM.  The underrecognized epidemic of low mobility during hospitalization of older adults.  J Am Geriatr Soc. 2009;57(9):1660-1665. doi:10.1111/j.1532-5415.2009.02393.xPubMedGoogle ScholarCrossref
3.
Wong  EL, Yam  CH, Cheung  AW,  et al.  Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals.  BMC Health Serv Res. 2011;11(1):242. doi:10.1186/1472-6963-11-242PubMedGoogle ScholarCrossref
4.
Naylor  MD, Brooten  D, Campbell  R,  et al.  Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial.  JAMA. 1999;281(7):613-620. doi:10.1001/jama.281.7.613PubMedGoogle ScholarCrossref
5.
Hoyer  EH, Young  DL, Klein  LM,  et al.  Toward a common language for measuring patient mobility in the hospital: reliability and construct validity of interprofessional mobility measures.  Phys Ther. 2018;98(2):133-142. doi:10.1093/ptj/pzx110PubMedGoogle ScholarCrossref
6.
Probasco  JC, Lavezza  A, Cassell  A,  et al.  Choosing wisely together: physical and occupational therapy consultation for acute neurology inpatients.  Neurohospitalist. 2018;8(2):53-59. doi:10.1177/1941874417729981PubMedGoogle ScholarCrossref
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    Research Letter
    January 2019

    Routine Inpatient Mobility Assessment and Hospital Discharge Planning

    Author Affiliations
    • 1Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 2Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 3Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland
    • 4Department of Physical Therapy, University of Nevada Las Vegas, Las Vegas
    • 5Department of Neurosciences, The Johns Hopkins Hospital, Baltimore, Maryland
    • 6Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
    JAMA Intern Med. 2019;179(1):118-120. doi:10.1001/jamainternmed.2018.5145

    Patient mobility is an indicator of health and a predictor associated with clinical outcomes. However, mobility status is not routinely measured in hospitalized patients.1 Consequently, physicians do not recognize when patients experience low baseline mobility and declines in mobility status during hospitalization.2

    Hospitalized patients with impaired mobility often require discharge to a postacute facility. Because physicians do not recognize impaired mobility until after resolution of acute medical or surgical issues, engagement with physical therapists, case managers, and social workers needed for placement is often delayed.3

    Routinely measuring mobility status of inpatients may help facilitate postdischarge planning.4 Hence, we sought to evaluate whether a simple validated mobility assessment tool, completed by nurses as part of routine clinical care, is associated with discharge to a postacute facility.

    Methods

    We conducted a retrospective cohort study on data from 2876 consecutive patients admitted from January 1, 2015, to January 1, 2016, on 2 inpatient units (medical and neurological and/or neurosurgical) at The Johns Hopkins Hospital. Data were obtained from the electronic medical record and the hospital’s administrative database used for statewide reporting. The Johns Hopkins Institutional Review Board approved this study with a waiver of consent based on retrospective analysis of deidentified data. Data were analyzed from January 1, 2018, to May 1, 2018.

    For all patients, mobility status (primary exposure) was measured by nurses as part of routine clinical care on the day of hospital admission and 3 times weekly, using the Activity Measure for Post-Acute Care Inpatient Mobility Short Form (AM-PAC IMSF). This reliable and valid tool consists of 6 items indicating the level of assistance required to perform mobility tasks, with standardized scores ranging from a low of 23.55 to a high of 61.14.5

    Mobility status at hospital admission was evaluated in 2 ways: by tertile and by a 10-point (1-SD) difference in the AM-PAC IMSF score. Admission mobility status is reported according to tertile of the AM-PAC IMSF standardized scale score (low: 23.55-39.45; middle: 40.78-45.44; high: 47.67-61.14 [lower scores are associated with higher odds for facility placement]). Change in mobility status during hospitalization was calculated as the difference between discharge and admission scores, with patients dichotomized as declined vs no change or improved, with associated statistical analyses accounting for admission mobility status along with other covariates (detailed in the methods for the multivariable regression analysis).

    The primary outcome was discharge to a health care facility (including inpatient rehabilitation or skilled nursing).

    Multivariable logistic regression analysis was used to separately evaluate the associations of admission patient mobility status and change in mobility status with the health care facility disposition, adjusting for age, sex, race/ethnicity, payer, primary diagnoses, and Agency for Healthcare Research and Quality Elixhauser comorbidity index. Data analyses were performed using statistical software (SAS, version 9.4; SAS Institute Inc), and statistical significance was defined as 2-sided P < .05.

    Results

    Mobility scores were completed at admission and discharge for more than 95% of patients. Among 2876 patients, 716 (25%) were discharged to a facility (Table).

    Patient mobility score at hospital admission was independently associated with facility placement, with adjusted odds ratios (aOR) for facility placement of 3.1 (95% CI, 2.8-3.6; P < .001) for a 10-point negative difference in AM-PAC IMSF, and 9.8 (95% CI, 7.3-13.2; P < .001) for comparison of lowest vs highest tertile of mobility score and 2.5 (95% CI, 1.8-3.4; P < .001) for comparison of middle tertiles vs highest tertile of mobility score.

    For patients whose mobility score declined (vs no change or improved), after adjustment for mobility score at admission and all covariates, the aOR for facility placement was 3.6 (95% CI, 2.7-4.9; P < .001).

    Discussion

    A validated measure of patient mobility, routinely collected by nurses as part of clinical care, appears to be associated with discharge placement. Recognition of low mobility scores at admission or declining mobility status during hospitalization should prompt early engagement of physical therapists, case managers, and social workers to address issues of patient mobility and facility placement. Additionally, recognition of high mobility scores may allow physicians to choose wisely and decrease low-value physical therapy consults to reallocate this scarce resource to patients who may achieve greater benefit.1,6

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    Article Information

    Accepted for Publication: August 6, 2018.

    Corresponding Author: Erik H. Hoyer, MD, Johns Hopkins University, Physical Medicine and Rehabilitation, 600 N Wolfe St, Phipps 174, Baltimore, MD 21287 (ehoyer1@jhmi.edu).

    Published Online: November 26, 2018. doi:10.1001/jamainternmed.2018.5145

    Author Contributions: Dr Hoyer and Ms Friedman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Hoyer, Young, M. Friedman, Needham.

    Acquisition, analysis, or interpretation of data: Hoyer, Young, L. Friedman, Brotman, Klein, Needham.

    Drafting of the manuscript: Hoyer, Young, Klein.

    Critical revision of the manuscript for important intellectual content: Hoyer, Young, L. Friedman, Brotman, M. Friedman, Needham.

    Statistical analysis: Hoyer, Young, L. Friedman.

    Administrative, technical, or material support: Klein, M. Friedman.

    Supervision: Brotman, Needham.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This research was supported by the Foundation for Physical Therapy's Center of Excellence in Physical Therapy Health Services and Health Policy Research and Training Grant.

    Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We would like to acknowledge Elizabeth Colantuoni, PhD, for statistical consultation, Alan Jette, PhD, and John Probasco, MD, for input on the manuscript. No compensation was received.

    References
    1.
    Greysen  SR, Patel  MS.  Annals for Hospitalists Inpatient Notes: bedrest is toxic-why mobility matters in the hospital.  Ann Intern Med. 2018;169(2):HO2-HO3. doi:10.7326/M18-1427PubMedGoogle ScholarCrossref
    2.
    Brown  CJ, Redden  DT, Flood  KL, Allman  RM.  The underrecognized epidemic of low mobility during hospitalization of older adults.  J Am Geriatr Soc. 2009;57(9):1660-1665. doi:10.1111/j.1532-5415.2009.02393.xPubMedGoogle ScholarCrossref
    3.
    Wong  EL, Yam  CH, Cheung  AW,  et al.  Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals.  BMC Health Serv Res. 2011;11(1):242. doi:10.1186/1472-6963-11-242PubMedGoogle ScholarCrossref
    4.
    Naylor  MD, Brooten  D, Campbell  R,  et al.  Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial.  JAMA. 1999;281(7):613-620. doi:10.1001/jama.281.7.613PubMedGoogle ScholarCrossref
    5.
    Hoyer  EH, Young  DL, Klein  LM,  et al.  Toward a common language for measuring patient mobility in the hospital: reliability and construct validity of interprofessional mobility measures.  Phys Ther. 2018;98(2):133-142. doi:10.1093/ptj/pzx110PubMedGoogle ScholarCrossref
    6.
    Probasco  JC, Lavezza  A, Cassell  A,  et al.  Choosing wisely together: physical and occupational therapy consultation for acute neurology inpatients.  Neurohospitalist. 2018;8(2):53-59. doi:10.1177/1941874417729981PubMedGoogle ScholarCrossref
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