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Review article
Effectiveness of Multidisciplinary Rehabilitation Services in Postacute Care: State-of-the-Science. A Review

Presented to the State-of-the-Science Symposium on Post-Acute Rehabilitation: Setting a Research Agenda and Developing an Evidence Base for Practice and Public Policy, February 13, 2007, Arlington, VA.
https://doi.org/10.1016/j.apmr.2007.06.768Get rights and content

Abstract

Prvu Bettger JA, Stineman MG. Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review.

Objectives

To summarize the efficacy of postacute rehabilitation and to outline future research strategies for increasing knowledge of its effectiveness.

Data Sources

English-language systematic reviews that examined multidisciplinary therapy-based rehabilitation services for adults, published in the last 25 years and available through Cochrane, Medline, or CINAHL databases. We excluded multidisciplinary biopsychosocial rehabilitation programs and mental health services.

Study Selection

Using the search term rehabilitation, 167 records were identified in the Cochrane database, 1163 meta-analyses and reviews were identified in Medline, and 226 in CINAHL. The Medline and CINAHL search was further refined with 3 additional search terms: therapy, multidisciplinary, and interdisciplinary. In summary, we used 12 reviews to summarize the efficacy of multidisciplinary, therapy-based postacute rehabilitation; the 12 covered only 5 populations.

Data Extraction

Two reviewers extracted information about study populations, sample sizes, study designs, the settings and timing of rehabilitation, interventions, and findings.

Data Synthesis

Based on systematic reviews, the evidence for efficacy of postacute rehabilitation services across the continuum was strongest for stroke. There was also strong evidence supporting multidisciplinary inpatient rehabilitation for patients with rheumatoid arthritis, moderate to severe acquired brain injury, including traumatic etiologies, and for older adults. Heterogeneity limited our ability to conclude a benefit or a lack of a benefit for rehabilitation in other postacute settings for the other conditions in which systematic reviews had been completed. The efficacy of multidisciplinary rehabilitation services has not been systematically reviewed for many of the diagnostic conditions treated in rehabilitation. We did not complete a summary of findings from individual studies.

Conclusions

Given the limitations and paucity of systematic reviews, information from carefully designed nonrandomized studies could be used to complement randomized controlled trials in the study of the effectiveness of postacute rehabilitation. Consequently, a stronger evidence base would become available with which to inform policy decisions, guide the use of services, and improve patient access and outcomes.

Section snippets

Methods

For the purposes of this review, postacute rehabilitation includes rehabilitation services delivered after acute hospitalization that are given either in institutional (inpatient, skilled nursing, or long-term care facilities) or in community-based (outpatient or home health) settings. We limited our analyses to services provided by multidisciplinary teams, including physicians, nurses, and combinations of physical, occupational, and speech and language therapists, but not by any of the

Summary of Findings on Efficacy

Although there are selection criteria to guide the development and quality of systematic reviews, we had the opportunity to flex these criteria to best address the research question. Of the 12 systematic reviews we evaluated, only 8 made conclusive statements about the efficacy of postacute rehabilitation, and these restricted inclusion primarily to RCTs and only occasionally included nonrandomized designs.7, 8, 9, 10, 11, 12, 13, 14 There is clear evidence of the efficacy of multidisciplinary

Policy Directives

Higher quality evidence of effectiveness is being sought by all decision-makers in order to make rational and informed decisions about care. Unfortunately, in some cases, the health system has evolved based on opinion rather than evidence. For example, the 3-hour rule was constructed in the United States by the Centers for Medicare & Medicaid Services as a threshold to establish the need for inpatient rehabilitation; although this level of intensity has not been evaluated, it has gained such

Conclusions

This review of the effectiveness of postacute rehabilitation aimed to synthesize the state-of-the-science in an effort to rehabilitate rehabilitation research on the effectiveness of care. Policy and health care decision-makers need accurate and appropriate information to ensure that the most feasible and beneficial services are in place for patients in need. Decisions about coverage and access should not be made as arbitrarily as appears to have been the case with many national policies.

Acknowledgments

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

We thank Allen W. Heinemann, PhD, for guidance in developing this manuscript, and the reviewers for their constructive input.

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    Supported in part by the National Institute of Child Health and Human Development and the National Center for Medical Rehabilitation Research (grant no. T32-HD-007425).

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

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    Copyright © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.