Earlier Physical Therapy Input Is Associated With a Reduced Length of Hospital Stay and Reduced Care Needs on Discharge in Frail Older Inpatients: An Observational Study

Hartley P, Keevil VL, Alushi L, et al. Earlier physical therapy input is associated with a reduced length of hospital stay and reduced care needs on discharge in frail older inpatients: an observational study. Journal of Geriatric Physical Therapy. 2019;42(2):E7-E14. doi:10.1519/jpt.0000000000000134

Link to Original Article: https://journals.lww.com/jgpt/fulltext/2019/04000/Earlier_Physical_Therapy_Input_Is_Associated_With.10.aspx

Introduction

This research paper examines the impact of early physical therapy assessment on length of stay (LOS), functional outcomes, and care needs in frail older adults who are hospitalized. Frail older adults are more susceptible to poor recovery following hospitalization, and this can lead to longer LOS and a decline in functional ability. The increasing number of frail older people being admitted to hospitals has increased in recent years and is putting pressure on bed occupancy rates. The study aims to explore how geriatric physical therapists can contribute to cost saving measures while maintaining a patient-centered approach. Previous research suggests that higher physical therapy frequency is associated with shorter LOS and better functional recovery in frail older adults. However, there is limited research on the effects of early mobilization and physical therapy assessment in reducing LOS and improving functional outcomes in this population. The distinction is made between early physical therapy assessment and early mobilization, with the former involving the evaluation of impairments, activity limitations, and social situation to devise a management plan for optimizing physical functioning and facilitating discharge. The study used a retrospective observational design to investigate the associations between early assessment and LOS, functional outcomes, and care needs on discharge. The researchers hypothesize that early assessment can reduce LOS by optimizing physical functioning and reducing the need for care on discharge.

Methods

Setting and Participants

The researchers analyzed the data of all admissions from May 2 to August 26, 2016 at National Health Service hospital in the United Kingdom. All patient data who were discharged without physical therapy examination were excluded.

Measures

This section of the research paper provides information on the measures used in the study. The researchers obtained anonymous clinical data from the hospital electronic medical records for their analysis. The exposure variables investigated were early assessment by a physical therapist within 24 hours of admission and late assessment after 24 hours. The outcome variables included length of stay (LOS), Elderly Mobility Scale (EMS) score, walking speed, the need for a new formal care package on discharge, and new institutionalization.

The EMS is a 20-point scale that assesses function in frail older patients, and it has good reliability and validity. A new formal care package refers to care provided by an external agency, while new institutionalization refers to discharge to a care home. Descriptive variables collected included age, gender, presence of a formal care package on admission, falls in the past 12 months, daily contact with family or friends, preadmission abode, Clinical Frailty Scale (CFS) score, Charlson Comorbidity Index (CCI), specific comorbidities, Emergency Department Modified Early Warning Score (ED-MEWS), C-reactive protein level, and the 4-item version of the Abbreviated Mental Test (AMT4). The CFS and CCI are validated measures for assessing frailty and comorbidity, respectively. The ED-MEWS is a measure of acute illness severity. The AMT4 is used to detect cognitive impairment on admission and is correlated with the AMT score.

Analyses

In this research paper, anonymized data was analyzed using IBM SPSS Statistics software. Descriptive statistics were provided for continuous variables and differences between patients who received early versus late physical therapy were evaluated using appropriate statistical tests.

The association between the delay to physical therapy assessment and length of stay (LOS) was assessed using a Cox proportional hazards regression model. Only patients admitted from their own home were included in the analysis, while those admitted from residential or nursing homes were excluded. The event of interest was "Discharge to Usual Residence" within 21 days of hospital admission, with patients who did not meet this outcome within the study time frame censored.

To prevent informative censoring and differentiate those who died, patients who died during the study were given an imputed LOS value of 21.01 days and were censored at the end of the study. The choice of a 21-day cutoff was based on the observation that by this point, over 80% of patients had been discharged. This cutoff aimed to focus on the impact of physical therapy on early optimization of functional abilities and physiological status.

The hazard ratio in this study represents the likelihood of being discharged back to the usual residence within 21 days of admission. Overall, this research investigates the impact of early physical therapy assessment on LOS and aims to optimize physical functioning and reduce the need for care on discharge in frail older adults.

Results

The study analyzed 1003 hospitalized frail older adults, with 584 (58.2%) receiving early physical therapy assessment within 24 hours of admission and 419 (41.8%) receiving late assessment after 24 hours. The two groups did not differ significantly in admission characteristics except for a higher prevalence of certain comorbidities in the late assessment group.

The main findings indicate that early assessment was associated with a shorter median length of stay (LOS) of 6.7 days compared to 10.0 days in the late assessment group, with a significant difference. Moreover, the early assessment group had fewer patients requiring a new package of care on discharge (20.3% versus 27.0% in the late assessment group). Additionally, although it did not reach statistical significance, those in the early assessment group appeared to be less likely to require new institutionalization on discharge (4.1% versus 6.7% in the late assessment group).

Furthermore, a Cox proportional hazards regression model revealed that early assessment was associated with a 29% increased probability of discharge to usual residence compared to late assessment. These significant findings remained after controlling for age, sex, ED-MEWS, CCI, and the EMS score on admission.

Overall, the study supports the notion that early physical therapy assessment in hospitalized frail older adults can lead to a shorter length of stay, improved functional outcomes, and reduced care needs on discharge, including decreased likelihood of institutionalization.

Discussions

This retrospective observational study examined the association between early physical therapy assessment and hospital and functional outcomes in acutely hospitalized older adults. The majority of eligible patients were examined by the physical therapist within 24 hours of admission. The findings suggest that early physical therapy assessment is associated with a shorter length of stay (LOS), reduced need for care on discharge, and a trend toward reduced new institutionalization. There was no significant difference in functional recovery between the early and late assessment groups. The reasons for delayed assessment are unclear, but comorbidities and patient preferences may have played a role. The study has limitations including lack of randomization and blinding, limiting causal inferences and generalizability. The study highlights the importance of physical therapy in comprehensive geriatric assessment and suggests that early assessment may improve hospital outcomes. Early physical therapy may encourage increased physical activity and reduce deconditioning in hospitalized older adults, leading to faster functional recovery. Further prospective interventional studies are needed to confirm the importance of early physical therapy in the care of frail older patients in the hospital setting.

Opportunities for Future Research

1. Investigate the causal mechanisms behind the association between early physical therapy input and reduced length of hospital stay, lower odds of needing care on discharge, and potential prevention of hospital deconditioning.

2. Conduct a prospective study to establish causality between early physical therapy assessment and improved hospital outcomes in frail older adults.

3. Explore the impact of early physical therapy assessment on functional recovery at different time points during hospitalization.

4. Compare the effectiveness of early physical therapy assessment with other interventions aimed at improving hospital outcomes in frail older adults.

5. Examine the impact of different aspects of the dose of physical therapy input, such as frequency and duration, on hospital outcomes in this population.

6. Conduct a multi-center study to determine if the associations found in this study are generalizable to other hospital settings.