104

Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

Efforts and effects of additional medical coverage to maintain or
improve activities of daily living in an acute cardiovascular internal
medicine ward
Yuji Kono, PT, PhD,1 Yoichiro Aoyagi, MD, PhD,2 Tomoko Kayukawa, PT,1
Etsuko Mori, PT, MSc,1 Ayako Ishikawa, PT,1 Kanann Yatsuya, MD, PhD,2
Eriko Mizokoshi, MD, PhD,2 Hideo Izawa, MD, PhD,3 Eiichi Saitoh, MD, DMSc2
Department of Rehabilitation, Fujita Health University Banbuntane Hotokukai Hospital, Nagoya, Japan
Department of Rehabilitation Medicine I, Fujita Health University, Toyoake, Japan3
Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, Nagoya, Japan1
2

ABSTRACT
Kono Y, Aoyagi Y, Kayukawa T, Mori E, Ishikawa A,
Yatsuya K, Mizokoshi E, Izawa H, Saitoh E. Efforts
and effects of additional medical coverage to maintainor improve activities of daily living in an acutecardiovascular internal medicine ward. Jpn J Compr
Rehabil Sci 2017; 8; 104-108.
Purpose: This study investigated the effects of additional
medical coverage to maintain or improve ADLs on thelength of hospital stay and level of ADLs.
Methods: This retrospective study included patients
who were admitted to the cardiovascular internal
medicine ward and were referred to the rehabilitation(rehab) department. Patients who were referred to therehab department within one year after the implementationof additional medical coverage to maintain or improve
ADLs were categorized as the added-coverage ADLs
group, and those who were referred to the rehab
department within one year before the implementation
were categorized as the control group. The evaluation
items included age, number of days before initiation ofrehab, duration of rehab intervention, length of hospitalstay, and Functional Independence Measure (FIM) scoreat discharge.
Results: While the added-coverage ADLs group had
147 patients (women, 101; mean age, 82 ± 10 years),
the control group had 102 patients (women, 54; mean
Correspondence: Yoichiro Aoyagi, MD, PhD
Department of Rehabilitation Medicine I, School of
Medicine, Fujita Health University, 1-98 Dengakugakubo,
Kutsukake, Toyoake, Aichi 470-1192, Japan.
E-mail: yyy@rc5.so-net.ne.jp
Accepted: November 6, 2017.
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.8.104

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104

age, 82±10 years). In the added-coverage ADLs group,
we found a significant decline in the number of days
before initiation of rehab, duration of rehab
intervention, and length of hospital stay; however, wefound no difference in the FIM score at discharge
between the two groups.
Conclusions: The implementation of additional medical
coverage to maintain or improve ADLs allowed early
initiation of rehab intervention and decreased the durationof rehab intervention and the length of hospital stay while
maintaining the level of ADLs at discharge.
Key words: acute rehabilitation, additional medical
coverage to maintain or improve ADLs, length of
hospital stayIntroduction
When patients with cardiovascular disease are in anacute care hospital, their treatment is prioritized andphysical activity is often restricted. As a result, their
physical function and level of activities of daily living(ADLs) easily decline secondary to prolonged bed
rest, and their hospital stay tends to be extended,
especially in older patients. In fiscal year 2014, thetreatment cost for cardiovascular diseases was thehighest among medical care expenditures, accountingfor 20.1%, and was as high as 5,889.2 billion yen [1].
Lately, the proportion of older patients with heart
failure has increased significantly among patients withcardiovascular disease [2]. According to a survey
conducted by the Japanese Circulation Society, thenumber of Japanese inpatients with heart failure in2012 was approximately 210,000, which is estimatedto increase to 1.3 million by 2030 [3]. Conversely, themean length of hospital stay for patients with heart
failure declined from 33.4 days in 2004-2005 to 30
days in 2007-2011 [4, 5]. Shortening the mean length
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Kono Y et al.: Effects of additional medical coverage to maintain or improve ADL in a cardiovascular internal medicine
ward
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of hospital stay is one of the primary objectives of the
Ministry of Health, Labour and Welfare’s plan for
reducing healthcare costs for implementing appropriate
and efficient provision of medical services [6, 7].
Hence, it is anticipated that the length of stay for patientswith heart failure in an acute care hospital will decline
further in the future, whereas the number of patientswith heart failure will increase. Thus, rehabilitation(rehab) for inpatients with heart failure requires quality
improvement through the implementation of earlystage intervention and enhancement of intervention
programs. Older patients with heart failure often
undergo repeated acute exacerbation during the disease
course [8], which quickly leads to reduced physicalfunction and level of ADLs through repeatedhospitalization. Therefore, it is essential for them toprevent a decline in ADLs through rehab intervention
in the early stage of their hospital course and improve
comprehensive hospital management such as througha holistic approach by an interdisciplinary team.
In fiscal year 2014, additional medical coverage tomaintain or improve ADLs was introduced in therevision of reimbursements of medical fees, allowing
preventive rehab intervention immediately after
admission in an acute care ward to facilitate early
discharge and prevent disuse syndrome. The conditions
required for receiving this additional coverage are as
follows: (a) the proportion of patients with declined
ADL level as evaluated by the Barthel Index atdischarge or transfer compared to that at admission
should be less than 3% and (b) the proportion of
inpatients who have hospital-acquired pressure sores
should be less than 1.5% [9]. The fundamental policies
for additional medical coverage to maintain or improve
ADLs are as follows: (1) to prevent a decline in ADLs
during hospital stay and to facilitate early discharge
for patients who are not indicated for disease-specificrehab and (2) to enhance interdisciplinary safety
management, prevent disuse syndrome and pressure
sores, and share information with patients and theirfamilies. Although early identification of patients who
require rehab intervention is possible by the traditional
system of assigning therapists to a medical ward,
rehab intervention by therapists is initiated only after
an attending physician issues a rehab order. In contrast,
under additional medical coverage to maintain or
improve the ADLs system, therapists may evaluate
and intervene at an early stage after admission, whichis arguably effective, especially for reducing the lengthof hospital stay.
This study investigated the effects of additional
medical coverage to maintain or improve ADLs on thelength of hospital stay and level of ADLs at discharge.

study, we included patients who were admitted to thecardiovascular internal medicine ward in our hospitalfrom July 2014, when the additional medical coverage
to maintain or improve ADLs system was implemented
in the ward, to June 2015. Among the participants,
those who required emergency hospitalization, except
for hospitalization for tests, and those who were referredto the rehab department from the cardiovasculardepartment were included in the added-coverage ADLs
group. However, those who were independent prior toadmission and had not been referred to the rehab
department were recognized as patients for whom
rehabilitation had not been prescribed (Figure 1).
Patients who died during hospitalization and those who
were transferred to another department for treatment ofcomorbid conditions were excluded from this study. In
the control group, we included patients who werereferred to the rehab department from the cardiovasculardepartment and had undergone physical therapy and/or
occupational therapy from April 2013 to March 2014
before the implementation of additional medical
coverage to maintain or improve ADLs. This study wasapproved by the Fujita Health University Ethical
Review Board for Epidemiological and Clinical Studies(Approval number: 15-259).
2. Efforts for the added-coverage ADLs group
Efforts for the added-coverage ADLs group included
the identification of newly admitted patients and theevaluation of their disease status. Also included wasexpediting the rehab orders from attending physicians
to minimize the period of bed rest for patients able toundergo rehab intervention to facilitate early initiation ofrehab after admission and smooth transition to a rehab
program. By participating in ward case conferences, we
promoted close communication with the nursing staff on
the ward and shared information about the ADL ability
level of the patients on the ward. In the control group,
rehab intervention was initiated only after an attending
physician ordered rehab intervention; thus, the rehab
department did not directly deal with patients until theorder was issued. Furthermore, the ward case conferenceswere limited to patients in a rehab program. The rehab

Methods
1. Study design and subjects
In this single-center case registry retrospective

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Figure 1. Patient flow.
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intervention was completed at discharge.

period, 43 were excluded due to death (8) or transfer toanother department (35). Among the remaining 707
patients, 425 were scheduled admissions for medical
tests and 282 were emergency admissions. Amongthese 282 patients, 177 (women, 121; mean age, 82.4 ±9.6 years) who were referred to rehab were defined as
the added-coverage ADLs group (Figure 1; Table 1).
The remaining 102 patients were assigned as the control
group (women, 59; mean age, 81.4 ± 10.6 years). We
observed no significant differences in age, gender, BMI,
LVEF, NT-proBNP, or etiology between the two groups.
Among the 282 emergency admissions, three (1.06%)
demonstrated a decline in the Barthel Index, the causesof which were cerebral infarction in two and septic
shock in one. In comparison to the control group, theadded-coverage ADLs group had a significantly shortertime before the initiation of rehab (11.7 and 3.7 days,
respectively), duration of rehab intervention (30.1 and23.4 days, respectively), and length of hospital stay
(41.8 and 26.1 days, respectively; Table 2). However,no difference was observed in the FIM score at discharge
between the two groups. The mean units of rehab
provided per day were calculated by the total units ofrehab divided by the number of patients, and was almost
the same between the two groups (1.68 units in theadded-coverage ADLs group and 1.63 units in thecontrol group).

3. Study parameters
In both groups, age, gender, body mass index(BMI), severity of heart failure [N-terminal pro-brain
natriuretic peptide (NT-proBNP)], heart function [leftventricular ejection fraction (LVEF)], etiology, lengthof hospital stay, days before rehab initiation, durationof rehab intervention, Functional Independence
Measure (FIM), and total units of rehab provided
during the subject period were investigated based on
medical records.
4. Data analysis
We conducted statistical analyses to compare theadded-coverage ADLs group with the control groupusing the unpaired t-test for age, BMI, NT-proBNP,
LVEF, length of hospital stay, number of days before
rehab initiation, and duration of rehab intervention,and the χ 2 test for etiology and gender. SPSS version
21.0 (SPSS, Tokyo, Japan) was used for the analyses,
and p<0.05 was considered statistically significant.
Results
Among the 750 patients who were admitted to thecardiovascular internal medicine ward during the study
Table 1. Patient characteristics.

Age (yo)
Gender M/F
BMI
LVEF (%)
NT-proBNP (pg/dl)
Etiology (n)Ischemic heart disease
Heart failure
Aortic disease
Arrhythmia
OthersADLs group(n = 177)

Control group(n = 102)p

82.4 ±   9.656/121
21.3 ±   2.356.3 ± 16.3
6717 ± 8205

81.4 ± 10.6
43/59
20.7 ±   2.948.2 ± 18.2
5231 ± 6678

0.565
0.132
0.445
0.198
0.458

21
93
7
14
42

14
51
3
10
24

0.231

Data is expressed as average ± standard deviation.
Abbr.: BMI, body-mass index; LVEF, left ventricular ejection
fraction; NT-proBNP, N- terminal pro-brain natriuretic peptide.
Table 2. Comparison between ADLs group and control group.

Number of days before initiation of rehabilitation
Length of hospital stay (days)
Duration of rehabilitation intervention (days)
FIM score at discharge (points)

ADLs group(n=177)

Control group(n=102)P

3.7 ± 2.0
26.1 ± 12.6
20.3 ± 10.4
95.2 ± 2.0

11.7 ± 6.9
41.8 ± 17.1
25.0 ± 15.1
93.1 ± 6.9<0.001<0.001
0.012
0.578

Data is expressed as average ± standard deviation.
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Discussion
This study demonstrated that the implementation of
additional medical coverage to maintain or improve
ADLs could prevent a decline in ADLs among
inpatients, as well as decrease the number of days
before initiation of rehab, duration of rehab provided,and length of hospital stay. The practice corresponding
to the additional medical coverage to maintain or
improve the ADLs system was effective in maintaining
the level of ADLs and reducing the length of hospitalstay, which had been two challenges for acute care
hospitals providing care for older patients. This
indicates that the system can promote efficient
provision of medical care.
・Effects of assigning therapists to a ward
In Japan, assigning therapists to a medical ward had
been in practice before the introduction of additional
medical coverage to maintain or improve ADLs.
Previous studies investigating the effects of assigning
therapists to a ward reported a reduction in the numberof days before initiation of rehab, duration of rehab
provided, and length of hospital stay; improvementin the level of ADLs at discharge; and increase in therate of returning home [10, 11]. In addition, qualitativeand practical improvements were identified, suchas improvement in communication with attending
physicians and nurses, ward staff’s understanding about
the rehab program, and patients’ ADL ability level on a
medical ward [10], although these are not quantified
outcomes. Furthermore, assignment of therapists to an
intensive care unit was reportedly effective in reducing
the number of days before initiation of sitting square
and reducing the incidence rate of delirium [12].
Furthermore, the results of the present study revealed
that the number of days before initiation of rehab,
duration of rehab provided, and length of hospital staydecreased, whereas the level of FIM at discharge wasmaintained after the implementation of additional
medical coverage to maintain or improve ADLs, whichindicates that the required outcomes were attained witha shorter length of hospital stay. This study supports thefindings of previous studies. The underlying factors of
this desirable outcome may be attributed to theprevention of a decline in ADLs at the initiation ofrehab intervention through assigning therapists to award and early initiation of rehab intervention.
・Mean length of hospital stay
In this study, the mean length of hospital stay in theadded-coverage ADLs group was 26.1 days (median, 21days). The mean length of hospital stay in the JapaneseCardiac Registry of Heart Failure in Cardiology (JCARECARD), a multi-center registry study with 164 facilities
participating nationwide, was 33.9 days (median, 16days) [13] and that in the ATTEND (acute decompensatedheart failure syndromes) registry was 31 days (median,

CW6_AY192D01_E.indd

21 days) [14]. Based on these reports, the length of
hospital stay for emergency admissions in our
cardiovascular internal medicine ward is nearly the sameas the national average. However, while the mean age ofsubjects in JCARE-CARD was 70.7 years and that in the
ATTEND registry was 73.0 years, the mean age of our
subjects was 82.4 years. Our study group population wasapproximately 10 years older than the subject group
populations in the previous studies. Given this age
difference, the results of this study indicate that a
reduction in the length of hospital stay among older
patients with heart failure was attained. This suggests theeffectiveness of the early rehab intervention on the lengthof hospital stay for older patients with heart failure, theproportion of which is anticipated to increase rapidly inthe future in Japan. Behind this effectiveness, an excessive
decline in the level of ADLs was possibly prevented bycontrolling unnecessary bed rest in the acute phaseamong older patients.
・Features and benefits of additional medical
coverage for ADLs
In the conventional system of assigning therapists toa medical ward, physical and occupational therapy
intervention is provided if ordered by an attending
physician or a physiatrist. The feature of additional
medical coverage to maintain or improve ADLs is that
direct preventive intervention by therapists becomes
available in the early stage of hospitalization. The
reduction in the number of days before initiation ofrehab intervention, duration of rehab provided, andlength of hospital stay was possibly attained by selecting
patients with a high risk of declining ADLs byidentifying the disease status and ADL ability of patientsat an early stage after admission and connecting thesepatients to disease-specific rehab programs without
delay. The outcome assessment for additional medical
coverage to maintain or improve ADLs includes theratio of the decline in the level of ADLs to a benchmarkof less than 3%. The decline rate of ADLs in our study
was 1.06%, which is below the benchmark, indicating
the effectiveness in the prevention of decline in the levelof ADLs. The reduction in the level of ADLs among
three patients in this study was attributed to the onset ofcomorbidities, such as stroke; the cause of decline was
not iatrogenic, such as bed rest. Therefore, we believethat the system of additional medical coverage tomaintain or improve ADLs is, to a certain degree,effective in preventing a decline in the level of ADLs.
・Limitations of this study
This study’s control group was a historical control
group, and data was retrospectively obtained frommedical records. Therefore, it was challenging topresent the selection method for the control group andthe details of the data, including the number of units ofrehab provided to each patient. Nevertheless, only asmall number of studies have reported on the effects of
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additional medical coverage to maintain or improve
ADLs; therefore, our study provides meaningful data.

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