For Doctors in a Hurry
- Researchers investigated whether in-hospital physical or occupational therapy is associated with more days spent alive at home after ICU discharge.
- This retrospective cohort study analyzed Medicare claims from 884 ICU hospitalizations, representing 5,330,486 older adults discharged alive.
- Each hour of in-hospital rehabilitation was associated with 8% higher odds of spending more days at home (odds ratio 1.08, 95% confidence interval 1.04-1.08).
- The authors concluded that delivering greater amounts of physical and occupational therapy during hospitalization is associated with increased time spent at home.
- Clinicians should prioritize in-hospital rehabilitation to maximize the time older ICU survivors spend at home during the first 100 post-discharge days.
The Functional Toll of Critical Illness on Older Adults
Millions of patients survive critical illness and intensive care unit (ICU) admissions each year, but this survival often comes with profound physical, cognitive, and psychological impairments [1]. The transition from the ICU to the general medical ward marks a highly vulnerable recovery period, with the vast majority of these patients remaining physically dependent and at high risk for long-term functional decline [2]. While early rehabilitation interventions during critical illness can improve short-term physical outcomes and reduce ICU-acquired weakness [3], the long-term impact of ward-based physical and occupational therapy remains less clearly defined. Comprehensive geriatric assessments and structured rehabilitation pathways have previously been shown to increase the likelihood of older adults returning to their own homes after emergency admissions [4]. Now, a recent retrospective cohort study offers fresh insights into how the precise dose of in-hospital rehabilitation influences a highly patient-centered metric, specifically the number of days older ICU survivors spend alive and at home after discharge.
Quantifying 'Days Alive and at Home'
To evaluate whether in-hospital rehabilitation mitigates long-term functional decline, researchers designed a retrospective cohort study focusing on days alive and at home in the 100 days (DAAH100) following an intensive care unit admission. The investigators utilized a nationally representative sample of older ICU survivors, drawing data from the National Health and Aging Trends Study linked with Medicare claims from 2011 to 2019. The study population consisted of community-dwelling Medicare beneficiaries aged 65 years or older who survived their hospitalization. The primary outcome metric, DAAH100, provides a pragmatic measure of recovery time spent outside of healthcare facilities. The researchers calculated this outcome by subtracting from 100 all post-discharge days spent dead or in an emergency department, observation unit, inpatient medical ward, psychiatric facility, rehabilitation unit, skilled nursing facility, or hospice. The primary exposure was units of in-hospital rehabilitation, defined specifically as physical and occupational therapy. To analyze the relationship between therapy volume and time spent at home, the researchers constructed a proportional odds logistic regression model, a statistical method used to predict the probability of a patient falling into ordered categories of recovery time. This model was adjusted for multiple confounding variables, including patient demographics, pre-hospitalization frailty, baseline functional status, and specific hospitalization characteristics.
Baseline Characteristics and Rehabilitation Delivery
The researchers identified 884 intensive care unit hospitalizations, which translates to a weighted population of 5,330,486 older adults (a statistical adjustment ensuring the sample accurately reflects the broader United States demographic). This cohort consisted entirely of patients who were discharged alive. The demographic profile reflected an advanced age group, with a median age of 81 years (interquartile range [IQR]: 75 to 86), and the gender distribution was nearly equal at 50.5% female. When evaluating the primary outcome, the investigators found that the median days alive and at home in the 100 days after discharge (DAAH100) was 95 days. However, the data revealed a wide interquartile range of 58.4 to 100 days. These findings highlight substantial heterogeneity in time spent at home by older ICU survivors, indicating that while many patients return home quickly, a significant portion experiences prolonged institutionalization, readmission, or death during the critical recovery period. Notably, patients received a remarkably modest amount of physical and occupational therapy during their hospital stay. The data showed a median of 4 units of in-hospital rehabilitation, which equates to approximately 1 hour of total therapy time. Furthermore, this median in-hospital rehabilitation was delivered over 6 days, suggesting that the daily dose of therapy for these older adults was exceptionally low prior to their discharge.
The Dose-Response Benefit of Inpatient Therapy
When evaluating the dose-response relationship between therapy volume and post-discharge outcomes, the researchers determined that the delivery of greater amounts of in-hospital rehabilitation was associated with increased DAAH100 after discharge. After adjustment for confounding variables such as pre-hospitalization frailty and baseline functional status, the data showed that each hour of in-hospital rehabilitation was associated with 8% higher odds of experiencing any of the three highest levels of DAAH100 after discharge. The researchers reported an adjusted odds ratio of 1.08 (95% CI, 1.04 to 1.08), demonstrating a clear statistical benefit to higher volumes of physical and occupational therapy independent of the patient's baseline health. For practicing physicians, these results highlight a direct clinical target during the vulnerable post-ICU recovery phase. The findings suggest that actively prescribing and facilitating more intensive physical and occupational therapy before discharge can directly influence a metric that matters deeply to older patients. By increasing the dose of inpatient rehabilitation, clinicians may help maximize the time their patients spend living independently in the community rather than returning to institutional care facilities.
References
1. Patsaki I, Bachou G, Sidiras G, Nanas S, Routsi C, Karatzanos E. Post Hospital Discharge Functional Recovery of Critical Illness Survivors. Systematic Review. The Journal of Critical Care Medicine. 2023. doi:10.2478/jccm-2023-0011
2. McWilliams D, Gustafson O, Wyer N, et al. Physiotherapy and Optimised Enteral Nutrition In the post-acute phase of critical illness (PHOENIX): protocol for a mixed methods feasibility randomised controlled trial. BMJ Open. 2025. doi:10.1136/bmjopen-2025-100803
3. Fuke R, Hifumi T, Kondo Y, et al. Early rehabilitation to prevent postintensive care syndrome in patients with critical illness: a systematic review and meta-analysis. BMJ Open. 2018. doi:10.1136/bmjopen-2017-019998
4. Ellis G, Whitehead MA, Robinson DJ, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011. doi:10.1136/bmj.d6553
