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FIM Score, FIM Efficiency, and Discharge Disposition Following Inpatient Stroke Rehabilitation
The Functional Independence Measure™ (FIM) is a widely accepted scale used to measure the functional abilities of patients undergoing rehabilitation. Scores at the extremes of this scale correlate with discharge disposition, while midrange scores are less well understood. This study evaluated the rate of FIM change with time (“efficiency”), admission and discharge FIM scores, and discharge disposition of 748 patients who underwent stroke inpatient rehabilitation. Patients with low scores at admission or discharge were likely to be discharged to a facility (63% and 78%, respectively), and those with high scores at admission or discharge almost always returned home (88% and 81%, respectively). Those with midrange scores at admission were more likely to return home (62%) than those with similar scores at discharge (33%). Greater FIM efficiency scores were associated with home discharge. Findings provide insight into discharge planning for stroke patients and indicate the need for more detailed evaluation of the midrange group.
About 700,000 strokes occur in the United States each year, and in addition to being common, stroke is a leading cause of death and long-term disability (American Heart Association, 2005; Marsden & Fowler, 1998). Stroke-related functional limitations diminish a person’s quality of life and place economic and social burdens on families and society (Stineman, Maislin, Fiedler, & Granger, 1997). This fact has been well recognized for many years, and a major role of rehabilitation professionals is not only to help patients with stroke improve their function, but also to quantitate their improvement.
Functional status for people undergoing rehabilitation is typically assessed with the Functional Independence Measure Scale™ (FIM). This 126-point scale has a number of advantages: it is widely used, broad-based, simple to administer, well validated, and widely studied (Brosseau, Phillippe, Potvin, & Boulanger, 1996a, 1996b; Dodds, Martin, Stolov, & Deyo, 1993; Hajek, Gagnon, & Ruderman, 1997; Hamilton, Laughlin, Fiedler, & Granger, 1994; Ravaud, Delcey, Michel, & Yelni, 1999; Stineman et al., 1996). There is agreement in the literature that high and low scores correlate with outcome (Alexander, 1994; Black, Soltis, & Bartlett, 1999; Bohannon, Ahlquist, Lee, & Maljanian, 2003; Brosseau et al., 1996a, 1996b; Mauthe, Haff, Hayb, & Krall, 1996; Oczkowski & Barecca, 1993; Sandstrom et al., 1998; Schmidt & Dombovy, 1999; Ween, Alexander, D’Esposito, & Roberts, 1996; Ween, Memoff, & Alexander, 2000; Werner, 1994). In fact, patients with admission and discharge FIM scores >80 have a more than 90% probability of returning to their homes, while those with scores <40 have a 70% probability of being discharged to a skilled nursing facility. (Black et al., 1999; Oczkowski & Barreca, 1993; Werner). However, there is a limited understanding of the predictive values of scores in the 40–79 midrange, although the literature indicates that patients with midrange scores have the greatest variability in discharge disposition (Alexander; Black et al.; Brosseau et al., 1996; Mauthe et al.; Oczkowski & Barecca; Sandstrom et al.; Schmidt & Dombovy; Ween et al.; Werner).
Additional factors that contribute to a patient’s functional improvement and ultimate discharge disposition include the nature and location of the stroke (Chae, Zorowitz, & Johnston, 1996; Schmidt et al., 1996; Werner, 1994), age >80 (Ergeletzis, Kevorkian, & Rintala, 2002), early initiation of rehabilitation (Rossi, 1997), and social support (Lutz, 2004).
Despite the facts that patients with midrange FIM scores compose half of the population of patients with stroke on a rehabilitation unit (Alexander, 1994; Ockowski & Barecca, 1997; Werner, 1994), there is limited research examining midrange scores in relation to discharge disposition. As a result, the applicability of FIM scores for discharge planning is most limited for this large group of patients who have the most problematical outcome. One of the few studies that specifically addressed outcomes associated with midrange FIM scores found that patients in the midrange group (admit FIM of 37–72) had FIM gains significantly higher than those with lower (<37) or higher ( >72) scores, and this fact may indicate that patients with midrange scores may benefit the most from rehabilitation. The authors of the study thought this finding may be useful for selecting patients for rehabilitation programs (Inouye, Hashimoto, Mio, & Sumino, 2001).
Both FIM scores and their changes over time are used to measure changes in functional abilities. An increasing FIM score implies functional improvement and a decreasing score the converse. Rates of change in the form of FIM efficiency (difference between a patient’s admission and discharge FIM scores divided by their length of stay [LOS]) have also been studied. FIM efficiencies >0.6 points/day are typically accepted as clinically significant, whereas a <0.6 unit/day change represents a poor rate of improvement (Werner, 1994). The literature indicates that patients with higher FIM efficiency scores are more likely to be discharged home (Chae, Zorowitz, & Johnson, 1996; Ween et al., 1996; Werner, 1994). However, ways to use FIM efficiency data to plan for stroke patient discharge have not been addressed.
The purposes of this study were to examine differences in the discharge dispositions among patients with high (>80), medium (40–79), and low (<40) FIM scores at admission and discharge and to examine whether differences exist in the rates of functional gains among those discharged to home or a facility following inpatient rehabilitation.
This study used a retrospective review of a clinical and demographic database that has been continuously maintained by data-entry personnel on a 47-bed acute rehabilitation unit of a large Midwestern medical center for more than 10 years. Data collected includes patient demographics, admission and discharge total FIM scores, discharge disposition, stroke etiology, and LOS. This study was reviewed and approved by the institutional review boards of both the rehabilitation unit’s institution and educational institution in which two authors were enrolled.
Setting and Sample
The study included all patients admitted and discharged with a diagnosis of ischemic or hemorrhagic stroke from the rehabilitation unit between January 1, 1997, and December 31, 2001. Occupancy rates ranged between 69% and 77% and the skill mix of the staff, admission criteria, and number of available beds, remained stable over this 5-year period. Patient mean LOS was also stable and ranged between 18 and 21 days. Enrollment did not differentiate between new onset and recurrent stroke. Admission screening included assessment by a Physical Medicine and Rehabilitation physician and unit-based occupational and physical therapists. Patients were required to be able to tolerate 3 hours of therapy per day and received at least 3 hours of therapy while hospitalized on the rehabilitation unit. The patients also needed to have insurance approval (MediCare, Medical Assistance, private) before being admitted to the rehabilitation unit. Patients were excluded from analysis if they did not complete their rehabilitation at the center, died during rehabilitation, were under the age of 18, or had not given consent for use of their medical records in research. A total of 748 patient medical records were used for this retrospective study.
The FIM is a 126-point instrument than comprises 18 individual subscales measuring a variety of physical and cognitive functions. Each subscale is scored from 1 to 7 (1 = total assist, 7 = complete independence), resulting in a total FIM score that ranges from 18 to 126. Because the FIM is well known and validated in the rehabilitation and stroke populations, further detail is not provided, but the interested reader is directed to Brosseau et al., 1996a, 1996b; Dodds et al., 1993; Hajek et al., 1997; Hamilton et al., 1994; Ravaud et al., 1999; and Stineman et al., 1996. Permission to use the FIM in this study was granted in accordance with the clinical agency contract with the Uniform Data System (UDS) for Medical Rehabilitation.
All patients admitted to this rehabilitation unit are routinely assessed using the FIM within 24 hours of admission and at discharge by trained and FIM-credentialed RNs who recorded the data in a paper format throughout the period of the study. The results of these assessments were then transcribed into FIMware® or Easterseals®. These two databases were used exclusively to track FIM data. FIM scores and demographic information, admission and discharge dates, and discharge disposition were extracted from this database and provided to the investigators in an electronic format by the rehabilitation unit’s data-collection personnel.
Descriptive statistics were used to describe the sample in relation to discharge disposition, and a t test was used to test for differences in FIM efficiency score. The two-sample t test was used as an appropriate statistic to compare the two groups (home and facility discharge) on FIM efficiency scores. A total of 489 patients were in the home discharge group and 259 patients in the facility discharge group. The approximate 1 unit of difference in FIM efficiency among the two groups is clinically significant. Statical significance and clinical significance are not the same, and, in accordance with the literature, statistically significant changes of >0.6 points per day in FIM efficiency were accepted as being clinically significant (Werner, 1994).
Researchers identified 935 stroke patients as potential participants for this study. A total of 187 patients were excluded because they did not give consent to have their medical records used for research, were under the age of 18 years, died before completion of their rehabilitation stay, or did not complete their rehabilitation at the facility. The remaining 748 patients meeting the study inclusion criteria had a mean age of 69 years (SD = 13; range from 20 to 97years). Fifty-seven percent were men, 249 had had a hemorrhagic stroke, and 499 had had an ischemic stroke.
Discharge dispositions are outlined in Table 1. At both admission and discharge, low (<40) FIM scores are associated with a discharge to a facility and high (>80) scores are associated with a return to home. A midrange score on admission was associated with discharge to home, but a midrange score on discharge was associated with a discharge to a facility.
The FIM efficiency among those discharged to a home or a facility is summarized in Table 2. FIM efficiencies of patients returning home were much better than patients discharged to a facility (1.92 units/day ± 1.47 versus 0.96 units/day ± 1.07; t = 10.20, p < .001).
Discussion and Implications
The results of this study complement and supplement those in the literature. First, these findings confirm previous reports about the discharge disposition of patients with low and high FIM scores. Low admission and discharge FIM scores are associated with discharge to home for less than one-third of persons with low scores. In contrast, high scores at these times are associated with discharge to home approximately 80% of the time.
Midrange FIM scores present a more complex picture. Patients with midrange scores at admission were likely to be discharged to home (62%), but patients with a similar score at discharge were more likely to be discharged to a facility (67%). This group composes the largest population of stroke patients in many rehabilitation units (more than 50% on our unit). Nevertheless, little is known about the discharge disposition of this midrange group (Alexander, 1994; Black et al., 1999; Brosseau et al., 1996; Mauthe et al., 1996; Oczkowski & Barecca, 1993; Sandstrom et al., 1998; Schmidt & Dombovy, 1999; Ween et al., 1996; Werner, 1994). The results of this study suggest that the dispositions of patients with scores at the high and low ends of the FIM assessment are relatively predictable but that the planning for patients in the midrange group is more problematic.
This study dealt with composite FIM scores. Some might question this choice because research shows that individual subscales or grouping of subscales (e.g., the cognitive and motor FIM) may be significant when anticipating a patient’s discharge destination. This is a legitimate concern; however, there is controversy over the importance of specific FIM items and groupings (Ockowski & Barreca, 1993; Sandstrom et al., 1998; Ween et al., 1996), and we chose to use total scores because doing so seemed the best course at the current level of knowledge. Although many factors, such as stroke location, age, family support, safety, and incontinence, may influence discharge disposition, the decision was made not to analyze these data in order to try to isolate the power of the FIM in relation to discharge disposition.
Other areas may be of concern. One of these is generalizability: It is possible that these findings reflect the largely middle-class nature of the community and may not apply well to larger urban settings. Another is that the study dealt with aggregate numbers, and the findings apply only on a general level to predictions that might be made for an individual.
Future research could address the usefulness of components of FIM scores to assist with discharge planning for the midrange group, the development of clinical pathways that would assist in discharge planning, and the monitoring of patient progress with particular attention to the group of patients with scores in the 40–79 midrange.
FIM scores and FIM efficiencies are associated with discharge disposition. The outcomes of patients with midrange FIM scores is the least well understood, and it may be that FIM efficiency will play an important role in distinguishing whether discharge to either home or a facility would be in the best interest of the patient and family.
About the Authors
Kari L. Bottemiller, MS RN, is a certified clinical nurse specialist in neurology at the Mayo Clinic in Rochester, MN.
Pattie L. Bieber, MS RN, is a nurse manager in orthopedics at the Mayo Clinic.
Jeffrey R. Basford, MD PhD, is a professor of physical medicine and rehabilitation at the Mayo Clinic.
Marcelline Harris, PhD RN, is a clinical nurse researcher at the Mayo Clinic.
Direct correspondence to Kari L. Bottemiller, MS RN, 200 1st Street SW, Rochester, MN 55905, or to firstname.lastname@example.org.
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