1Japanese Journal of Comprehensive Rehabilitation Science (2017)

Editorial

Outcome indicators in comprehensive inpatient rehabilitation
Shigeru Sonoda, MD, PhD1
President, Kaifukuki Rehabilitation Ward Association, Tokyo, Japan1

Sonoda S. Outcome indicators in comprehensive inpatient
rehabilitation. Jpn J Compr Rehabil Sci 2017; 8: 1-3.
It is important to respond to disability that occurs
after an illness or immobilization in order to overcome
many of the problems of an aging society. No one
denies that one compelling way is rehabilitation.
Whether rehabilitation optimally works or not iscritical. Donabedian proposed to divide the quality ofmedicine into structure, process, and outcome [1].
In relation to rehabilitation, the number of therapists
and the size of gyms are considered as structures; theflow of decision-making on exercise content and theimplementation of conferences are designated asprocesses; and changes in ADL score from admission
to discharge or recovery rate at home are examples ofoutcomes.
Outcome evaluation has been introduced to the
medical service fee system concerning Kaifukuki
Rehabilitation Wards (KRW) where comprehensive
inpatient rehabilitation is carried out. For example, thedegree of improvement in the care-need assessment
has been used as a criterion for the KRW admission
fee. In addition, the medical fee revision in fiscal 2016
required that the KRW achievement index (KRW-AI)
be used to judge whether hospitals can charge arehabilitation fee for more than 2 hours per day for apatient. I will discuss merits and disadvantages ofoutcome indexing using the KRW-AI as an example.
The Functional Independence Measure (FIM) [2] isused to calculate the KRW-AI. The FIM motor (FIM-M)
efficiency score, which is computed by dividing thegain in the motor subscore of the FIM by length of stay(LOS), has been used. When using the FIM-M efficiency
scale as a tool for some outcome comparisons, weCorrespondence: Shigeru Sonoda, MD, PhD
Kaifukuki Rehabilitation Ward Association, Kikuyabuilding 5F, 1-28-9, Higashiueno, Taito-ku, Tokyo 1100015, Japan.
E-mail: doctor.sonoda@nifty.ne.jp
Accepted: November 19, 2016.
No benefits in any form have been or will be received fromany commercial party related directly or indirectly to thesubject of this manuscript.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.1

must take into consideration the characteristics of thegroup to which the patient belongs [3]. The examples
use the Annual Survey for KRW 2015.
Box plots of the FIM-M efficiency scores forpatients with cerebrovascular diseases (16,101 patients),orthopedic disorders (14,971 patients), and disuse
syndrome (2,508 patients) are shown in Figure 1a.
Box plots for patients with the admission FIM-M of
13, 14, … , and 91 are linked from left to right.
Generally speaking, data on orthopedic patients
showed higher median values than those for the othertwo patient groups. Comparison among wards withdifferent coexistence rates of diseases using theaverage or median value for FIM-M efficiency ismeaningless if FIM-M efficiency scores vary in
relation to the kind of disorders among the groups
examined.
Furthermore, we must be aware that FIM-M
efficiency scores will be low both in patients with lowand high admission FIM scores. Needless to say,providing rehabilitation to severely disabled patientsis important and the evaluation of outcome in wards inwhich those patients were intensely managed must notbe low. When we employ FIM-M efficiency scores forgroup comparisons, patients’ characteristics must be
similar among groups.
Standard days of LOS differ among diseases, whichcauses differences in FIM-M efficiency scores amongdiseases. KRW-AI is the adjusted version of theFIM-M efficiency scale related to this point. Dividing
the value of LOS by the prescribed standard days ofLOS (150 or 180 days in case of stroke and 90 days incase of femur fracture with operation, for example) isused instead of LOS when KRW-AI is calculated.
When the actual KRW-AI is computed for a hospital,
the sum of the FIM-M gain of all admitted patients isdivided by the sum of the adjusted LOS of all admittedpatients. In addition, patients with lower FIM-M or
higher FIM-M or elderly patients can be eliminatedbefore the calculation if that patient’s value differs by
30% of that of the total patient population. In thiseditorial, instead of using the actual computation ofKRW-AI, an individual patient’s value (adjustedFIM-M efficiency) that is calculated like the KRW-AI
was employed to provide the information below.
Jpn J Compr Rehabil Sci Vol 8, 2017

2Sonoda S: Outcome indicators in comprehensive inpatient rehabilitation

(a)

(b)
Figure 1.(a) Median value and quartile score on the FIM motor efficiency scale.(b) Medianvalue and quartile score on the adjusted FIM motor efficiency scale.
Upper and lower border of the box indicate quartile points and the horizontal line in the box
denotes the median value. Median values are connected with red lines.

Jpn J Compr Rehabil Sci Vol 8, 2017

Sonoda S: Outcome indicators in comprehensive inpatient rehabilitation

3

Figure 2. Effect of age on outcome index.
Upper and lower borders of the box indicate quartile points and the horizontal line in the box denotes the medianvalue. Adjusted FIM-M efficiency scores fit the assumption that “The higher the age, the lower would be theoutcome of rehabilitation.”
Figure 1(b) is a box plot of adjusted FIM-M
efficiency scores under the same conditions as for
Figure 1(a) The difference in the pattern of the adjusted
FIM-M efficiency scores between cerebrovascularpatients and orthopedic patients almost disappeared incomparison with the pattern of FIM-M efficiency. Thismeans that the adjusted FIM-M efficiency scale makes
it possible to acquire a representative value of ADL
efficiency even in wards where patients with various
diseases coexist. There are still some problems to besolved. One is the validity of the standard days ofLOS. One piece of evidence supporting validity is that
almost all patients in the KRW are discharged withinthose days. However, considering the possibility ofarbitrary discharges to avoid reductions in medical
service fees, we must look for other grounds to validate
the standard days of LOS.
Another way is to validate the adjusted FIM-M
efficiency scale itself. The higher the patient’s age, thelower would be the outcome of rehabilitation. I will
discuss which is more valid, the FIM-M efficiency scaleor the adjusted FIM-M efficiency scale, using thisrelationship. Figure 2 shows the median value andquartile points of FIM-M efficiency scores and adjustedFIM-M efficiency scores for patients stratified by age
into five groups. Adjusted FIM-M efficiency scores werelower in the high-age group, which fits the assumption
above. Miyai reported a positive relationship between thedose of rehabilitation exercise and the KRW-AI andbetween obtaining hospital accreditation of the Japan
Council for Quality Health Care and the KRW-AI using
the Annual Survey for KRW 2015 [4], findings thatindicate the usefulness of the adjusted FIM-M efficiency

scale.
In summary, although KRW-AI has some reasonablevalidity even now, not all issues regarding thecharacteristics of patients have been resolved. The​first priority for KRW assessment should be processevaluation, and simultaneously we should improve theadjusted FIM-M efficiency scale to enhance tools for
improving the quality of rehabilitation.
Abbreviations
FIM: Functional Independence Measure
FIM-M: M otor subscore of the Functional Independence
Measure
KRW: Kaifukuki Rehabilitation WardKRW-AI: Kaifukuki Rehabilitation Ward achievement
index
LOS: length of stayReferences1. Donabedian A: The quality of care. How can it beassessed? JAMA 1988; 260: 1743-48.
2. Data management service of the Uniform Data Systemfor Medical Rehabilitation and the Center for Functional
Assessment Research: Guide for use of the Uniform Data
Set for Medical Rehabilitation. version 3.1, State Universityof New York at Buffalo, Buffalo, 1990.
3. Sonoda S: How do we carry out high density and intensity
rehabilitation? Jpn J Rehabil Med 2006; 43: 739-42.
4. Miyai I: Result and application of Annual Survey forKaifukuki Rehabilitation Ward 2015. Kaifukuki Rehabil
15(2): 6-20, 2016.

Jpn J Compr Rehabil Sci Vol 8, 2017