Development and Validation of Prognostic Indices for Recovery of Physical Functioning Following Stroke: Part 1

Objective: To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning. Design: Retrospective cohort study. Setting: Veterans Affairs Medical Centers throughout the United States. Participants: Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment. Main Outcome Measure: Achievement of physical grade IV or above at final rehabilitation assessment. Results: Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, <= 69 years = 2, 70-79 years = 1, >= 80 years = 0; initial physical grade, I = 0, II = 3, III = 4; initial cognitive stage, I or II = 0, III = 2, IV or V = 3, VI or VII = 4; absence of renal failure = 1; no serious nutritional compromise = 3; the type of rehabilitation services received, consultative = 0, comprehensive = 4; and recovery time between admission and discharge physical grade assessment, 1-2 days - 0, 3-7 days - 4, and >= 8 days - 5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant (P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score >= 9), second (score = 10-12), third (score = 13-15), and fourth (score > 15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively. Conclusion: By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.