1202
ORIGINAL ARTICLE
Factors Predicting Inpatient Rehabilitation Length of Stay of
Acute Stroke Patients in Singapore
Woan Shin Tan, MSocSc, Bee Hoon Heng, MBBS, MSc (Public Health), FAMS,
Karen Sui-Geok Chua, MBBS, MRCP, FAMS, Kay Fei Chan, MBBS, MRCP, FAMS
ABSTRACT. Tan WS, Heng BH, Chua KS, Chan KF. Factors
predicting inpatient rehabilitation length of stay of acute stroke pa-
tients in Singapore. Arch Phys Med Rehabil 2009;90:1202-7.
Objective: To determine the predictors of hospital length of
stay (LOS) of stroke patients at the point of admission.
Design: A retrospective cohort study.
Setting: An acute hospital rehabilitation center in Singapore.
Participants: Stroke patients (N⫽491) admitted between
March 2005 and December 2006.
Interventions: None.
Main Outcome Measures: Rehabilitation LOS was calcu-
lated as the total number of rehabilitation days before dis-
charge. We measured the functional status of patients by using
the Functional Independence Measure (FIM).
Results: The median LOS was 29 days (mean ⫽ 30.8d).
Independent clinical and sociodemographic characteristics
found to significantly predict rehabilitation LOS were FIM
motor score at admission, the presence of more than 3 comor-
bid conditions at admission, living with nonimmediate relatives
before admission, and the hospital subsidy status of the patient.
In particular, the admission FIM motor score explained 43% of
the variation in LOS and decreased the LOS by approximately
1.1 days for each 1-point increase in score.
Conclusion: Patients’ socioeconomic status and family
structure was found to influence LOS and should be considered
in allocating resources and determining treatment need. The
extent of motor function of patients at admission is an impor-
tant factor influencing rehabilitation LOS and is a useful tool
for facilitating rehabilitation resource planning for stroke
patients.
Key Words: Length of stay; Prognosis; Rehabilitation;
Stroke.
© 2009 by the American Congress of Rehabilitation
Medicine
TROKE CAUSED AN ESTIMATED 5.7 million deaths
S worldwide in 2005, and it was projected that, if the current
trend persists, over 50 million healthy life years will be lost
from stroke by 2015.1 It was estimated that stroke accounted
for 10% of all deaths worldwide in 1999, and expenditure on
cerebrovascular diseases ranged between 2% and 4% of total
From Health Services and Outcomes Research Department, National Healthcare
Group (Tan, Heng), Singapore; and Department of Rehabilitation Medicine, Tan Tock
Seng Hospital (Chua, Chan), Singapore.
Presented in part to the National Healthcare Group Annual Scientific Congress,
November 10 –11, 2007, Singapore.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Woan Shin Tan, MSocSc, Health Services and Outcomes
Research Dept, National Healthcare Group, 6 Commonwealth Lane, #04-01/02 GMTI
Building, Singapore 149547, e-mail: woan_shin_tan@nhg.com.sg.
0003-9993/09/9007-00801$36.00/0
doi:10.1016/j.apmr.2009.01.027
Arch Phys Med Rehabil Vol 90, July 2009
health care expenditure.2 Internationally, the social and eco-
nomic burden of stroke is expected to escalate given the tri-
pling of the number of older persons over the next 50 years.3
Because the process of recovery is slow with up to two thirds
of stroke survivors remaining moderately or severely disabled
3 months after the stroke,4 rehabilitation should be commenced
early to maximize their physical and functional outcomes5,6
and to minimize the substantial social and economic burden7
placed on caregivers of these patients.
A key challenge to gaining timely access to rehabilitation
programs is the availability of bed resources to accommodate
the patients. Recovery should not be compromised by the lack
of rehabilitation resources. In this regard, it would be important
for hospital administrators and health care systems to identify
the prognostic variables for LOS to ensure the effective and
efficient management of bed resources. The identification of
the accurate prediction of LOS is also useful in helping to set
a target date for caregivers in their preparation of postdischarge
care.
Stroke is the fourth leading cause of death in Singapore.8
Over the last 2 decades, the number of hospital discharges in
Singapore for cerebrovascular disorders increased from
3,7329 to 8,74510 between 1986 and 2006. The incidence
rate of stroke has been reported to be 1.8/1,000 person years,11
but this is set to rise with the unprecedented aging12,13 of the
population over the next 2 decades. The number of Singapore
residents aged 65 years or older is projected to triple from
305,600 (8.5%) in 2007 to 900,000 (18.7%) in 2030.14,15
In view of the rising demand for stroke rehabilitation ser-
vices, the use of health care resources in the rehabilitation
setting needs to be optimized. Health care professionals gen-
erally rely on clinical experience and analytic reasoning to
estimate the LOS of patients, which involves significant
amounts of either intuitive pattern recognition or intuitive
regression16 of clinical, functional, and socioeconomic factors.
To improve the accuracy of LOS prediction, prognostic vari-
ables need to be translated into a statistical model.17 Although
a previous Singaporean study18 has examined the determinants
of rehabilitation LOS, it focused on identifying potentially
preventable medical and nonmedical factors determining LOS
in a subacute care setting. In this study, we sought to identify
LOS determinants in an acute inpatient rehabilitation setting by
examining variables that can be assessed at the time of admis-
sion and to determine their relative importance in predicting the
rehabilitation LOS for patients with acute stroke.
List of Abbreviations
LOS length of stay
log logarithm
ln natural logarithm
 PREDICTING STROKE REHABILITATION LENGTH OF STAY, Tan
METHODS
Setting
This study involved a retrospective review of medical
records of acute stroke patients admitted to an inpatient reha-
bilitation center in Singapore between March 2005 and De-
cember 2006. The 93-bedded center is a not-for-profit public
sector facility and is the largest acute inpatient rehabilitation
unit in Singapore. Patients admitted were entered into a com-
prehensive rehabilitation program managed by a multidisci-
plinary team led by a physiatrist working together with phys-
iotherapists, occupational therapists, speech therapists, nurse
clinicians, medical social workers, psychologists, and acupunc-
turists.
Within the public sector, patients may choose to be admitted
to single-bedded private (class A), 2-bedded semiprivate (class
B1), or dormitory-styled subsidized (class B2 and C) wards.
Patients in class A pay the full cost, whereas patients in other
ward classes enjoy subsidies ranging from 20% of the cost for
class B1 rooms to 65% and 80% of the cost for the class B2 and
C rooms, respectively.
Population
Patients included in this retrospective study met the follow-
ing criteria: (1) diagnosis of stroke, which was defined as an
acute onset of neurologic deficit lasting more than 24 hours, of
cerebrovascular origin, and was confirmed by both clinical and
radiographic means, and (2) stroke occurred within the 3
months preceding admission. We excluded patients with trau-
matic brain injuries and/or spontaneous subarachnoid hemor-
rhages because of different etiology, prognostic factors, and
outcomes. Informed consent was waived by the National
Healthcare Group Institutional Review Board.
Data Collection and Study Parameters
Three trained abstractors reviewed the medical records. Based
on clinical judgment and predictors found to be significant in
literature,19-27 we extracted the following data from the case notes:
demographics and preadmission living arrangements, stroke
type, site and side, comorbidity, hospital ward class, and acute
and rehabilitation LOS. Electronic medical data were extracted
to derive information related to functional status at admission.
Because the objective of this study was to predict LOS at
admission, we included only factors present at admission.
The demographic characteristics included age, sex, and eth-
nic group. Information regarding patients’ preadmission living
arrangement was based on documented genograms, which are
pictorial representations of family trees recording information
about the relationship between family members and living
arrangements. In this study, we have classified living arrange-
ments as living with only immediate family (parents, spouse,
children, single siblings), living with nonimmediate family
(cousins, nephews, nieces, or siblings with a distinct family
nucleus of their own), living with others (unrelated persons),
and living alone.
Diagnoses of stroke were made by admitting emergency
room physicians or neurologists or neurosurgeons and con-
firmed by neuroimaging (computed tomography or magnetic
resonance imaging brain scans) within 6 hours of acute admis-
sion. Types of stroke lesions were broadly classified as either
hemorrhagic or ischemic in nature. Brain lesions were classi-
fied by cortical, subcortical, or brainstem groups and by the
involved hemisphere (left, right, and bilateral). Patients’ history
of comorbid conditions such as hypertension, diabetes mellitus,
hyperlipidemia, congestive heart failure, valvular heart disease,
1203
atrial fibrillation, ischemic heart disease, myocardial infarction,
previous stroke, renal diseases, tumor, ulcer disease, asthma,
and chronic obstructive pulmonary disease, and others were
also extracted from the medical records.
We recorded the acute LOS as the number of days spent in
an inpatient hospital before admission to the rehabilitation
center and computed the rehabilitation LOS by subtracting the
date of admission to the rehabilitation center from the date that
the patient is discharged to home, another hospital, or nursing
home.
The FIM28 was used to assess functional status at admission.
The multidisciplinary team assessed and scored the FIM within
72 hours of admission and at weekly intervals when the team
met to discuss patients’ rehabilitation progress and postdis-
charge plans. All providers were trained and credentialed in
FIM scoring. It is a widely used functional assessment mea-
sure, which contains 13 items related to self-care, bowel and
bladder continence, mobility, and ambulation, and 5 items
related to communication, social functioning, and cognition.
Rating is conducted on a 7-level ordinal scale, ranging between
1 (totally dependent) and 7 (totally independent). Because
several studies29,30 have examined and confirmed the validity
of aggregating FIM items into motor and cognitive scores, we
summed up the first 13 items to develop the motor score and
the last 5 items to develop the cognitive score. This resulted in
a motor FIM score range of 13 to 91 and a cognitive FIM score
range of 5 to 35.
Statistical Analysis
We first performed univariate analyses to examine the rela-
tionship between rehabilitation LOS and each of the variables.
Because the distribution of LOS was nonnormal, the results of
the analysis were summarized by median values. We used the
Mann-Whitney U test or the Kruskal-Wallis test to assess the
differences among or between groups. Continuous variables
were stratified using certain cutoff points for comparison.
We applied a cutoff of 65 years for age and stratified the
acute hospital LOS based on its median value. The initial
FIM motor score was categorized into 3 levels: (1) 13ⱕse-
vere disability⬍26, (2) 26ⱕ moderate disability ⬍65, and (3)
65ⱕmild disabilityⱕ91 and the initial FIM cognitive score was
similarly classified into (1) 5ⱕsevere disability⬍10, (2) 10ⱕ
moderate disability⬍25, and (3) 25ⱕmild disability ⱕ35.
A multivariate linear regression model was used to select
variables that significantly predict rehabilitation LOS. A back-
ward selection procedure was used to select the covariates of
the final model using P⬎.10 as the removal criterion. To avoid
overfitting the model, only variables found to be significant
(P⬍.10) in the univariate analysis were included in the multi-
variate model. Because the rehabilitation LOS was positively
skewed, we logarithmically transformed the data to produce a
more normal distribution. To interpret the estimated coeffi-
cients resulting from a linear regression on a nonlinearly trans-
formed dependent variable (LOS), we had to back-transform
the fitted values and multiplied it by a smearing factor,31 which
is the mean of the antilog of the unstandardized residuals.
Outliers were not excluded if there was no evidence of a
mistake. We used bivariate scatterplots to ascertain that the
relationship between the explanatory variables and ln-LOS is
linear.
The independence of error terms was checked to ensure there
was no serial correlation. The variance inflation factor was
used to test for multicollinearity, residual plots, and histograms
were used to test for heteroscedasticity and normality. A prob-
ability (P value) of less than .05 was considered to be statisti-
Arch Phys Med Rehabil Vol 90, July 2009
1204 PREDICTING STROKE REHABILITATION LENGTH OF STAY, Tan

Table 1: Demographic, Clinical and Functional Characteristics of motor and cognitive functions correspondingly (table 2). The
Rehabilitation Inpatients (Nⴝ491) mean acute and rehabilitation LOS were 14.2⫾11.4 (median,
Mean or Median or 25th–75th 11.0) and 30.8⫾16.3 (median, 29.0). Approximately 1 in 10
Characteristics Number of Percentage Percentile patients (91.4%) had at least 1 kind of comorbid condition.
Demographic characteristics Hypertension (79.2%), hyperlipidemia (54.8%), and diabetes
Age (y) 61.3 62.0 53–71 mellitus (36.1%) were the 3 most prevalent comorbid condi-
Sex, male 289 58.9 tions.
Ethnicity
Univariate Results
Chinese 405 82.5
Malay 45 9.2 We found that age, sex, ethnicity, and prestroke living ar-
Indian 24 4.9 rangement did not correlate significantly with median LOS.
Others 17 3.5 Although individual comorbid conditions were not signifi-
Prestroke living arrangement cantly associated with median LOS, having more than 3 co-
With immediate family 446 90.8 morbid conditions at admission was associated with a shorter
With nonimmediate family 15 3.1 LOS at 10% significance level (see table 2). Our findings
Alone 19 3.9 indicated a strong association between median LOS and the
Others 11 2.2 choice of hospital ward class, which also serves as a proxy for
Ward class socioeconomic status. The median rehabilitation LOS was also
Private (A, B1) 55 11.2 significantly longer for patients who had a longer acute hospital
Subsidized (B2, C) 436 88.8 stay (0 –11d vs ⱖ12d). Similar results were obtained when the
Comorbidity, any 449 91.4 data were analyzed with log transformation of LOS.
Hypertension 389 79.2 Among the clinical characteristics, the median LOS was
Hyperlipidemia 269 54.8 longer for patients diagnosed with hemorrhagic stroke and
Diabetes mellitus 177 36.1 inversely associated with both the FIM motor and cognitive
Previous stroke 90 18.4 scores. The site of the brain lesion and affected hemisphere
Ischemic heart disease 68 13.8 were not significantly associated with median LOS.
Atrial fibrillation 32 6.5
Congestive heart failure 11 2.2
Multivariate Results
Myocardial infarction 9 1.8 Table 3 shows that the significant factors predicting rehabil-
Valvular heart disease 6 1.2 itation LOS were the extent of patients’ dysfunction in physical
Clinical characteristics activity at admission (FIM motor score), ward class, prestroke
FIM motor score at admission 36.4 36.0 23–48 living arrangement, and medical comorbidity, with the fitted
FIM cognitive score at model explaining 46% of the variance in rehabilitation LOS.
admission 23.8 27.0 16–33 We ran diagnostic tests to ensure that assumptions of the
Type of stroke
Ischemic 345 70.3
Hemorrhagic 146 29.7 Table 2: Factors Significantly Associated With Rehabilitation LOS
Acute LOS (d) 14.2 11.0 7–17 by Univariate Analysis
Rehabilitation LOS (d) 30.8 29.0 21–38 N⫽491
Median
Characteristics No. % LOS (d) P*

Demographic characteristics
cally significant. All statistical tests were performed by using Ward class ⬍.001
the Statistical Package for Social Sciences, version 15.0.a Private (A, B1) 55 11.2 36
Subsidized (B2, C) 436 88.8 28
RESULTS Number of comorbid conditions .063
0–3 430 87.6 29
We retrieved a total of 525 case notes over a 21-month
⬎3 61 12.4 25
period from March 1, 2005, to December 31, 2006. We ex-
Clinical characteristics
cluded 3 patients diagnosed with traumatic intracerebral hem-
FIM motor score at admission ⬍.001
orrhage, 25 patients diagnosed with subarachnoid hemorrhage,
Severe: 13–25 140 28.5 40
and 2 patients with missing FIM scores at admission. Four
Moderate: 26–64 328 66.8 25
patients who were transferred to an acute care hospital during
Mild: 65–91 23 4.7 11
the period of rehabilitation stay were also excluded. In total, we
FIM cognitive score at admission ⬍.001
included 491 patients in the analysis.
Severe: 5–9 73 14.9 37
Patient Characteristics Moderate: 10–24 145 29.5 32
Mild: 25–35 273 55.6 25
As shown in table 1, the mean age of patients was 61.3 years
Type of stroke ⬍.001
(median; 62.0y), 58.9% were men, 82.5% were of Chinese
Ischemic 345 70.3 27
ethnicity, and 90.8% resided with their immediate family mem-
Hemorrhagic 146 29.7 31
bers. Of the patients, 70.3% were diagnosed with ischemic
Acute LOS (d) .001
stroke. Those choosing private or semiprivate wards were
0–11 267 54.4 27
11.2%. The mean motor and cognitive scores of the FIM at
ⱖ12 224 45.6 30
admission were 36.3⫾16.0 (median, 36.0) and 23.6⫾10.2 (me-
dian, 27.0), respectively. At admission, almost 95% and 44% *The Mann-Whitney U test or the Kruskal-Wallis test was used to
of the patients were moderately or severely impaired in their assess the differences between groups.

Arch Phys Med Rehabil Vol 90, July 2009

 PREDICTING STROKE REHABILITATION LENGTH OF STAY, Tan 1205

Table 3: Multiple Regression Analysis Predicting Ln-LOS*

Coefficient (SE) ␤ 95% Confidence Interval P

FIM motor score at admission ⫺.022 (0.001) ⫺0.647 (⫺.024 to ⫺0.020) ⬍.001
Ward class
Subsidized *
Private 0.200 (0.059) 3.410 (0.085–0.309) .001
Prestroke living with nonimmediate family
No *
Yes 0.281 (0.106) 0.089 (0.074–0.489) .008
No. of comorbid conditions at admission, ⬎3
No *
Yes ⫺0.177 (0.055) ⫺0.107 (⫺0.284 to ⫺0.068) .001
(Constant) 4.088 (0.047) (3.993–4.176) ⬍.001

NOTE. N⫽491. Adjusted R2⫽0.455. R2 is the percentage of total variance explained by the model. The following variables, in addition to the
reported (significant) variables, were entered into the model: stroke type, acute LOS, and FIM cognitive score at admission.
*Reference category.

ordinary least squares regression model were not violated. We
found the log-scale residuals to be homoscedastic, which im-
plied that the ordinary least-squares estimates with the logged
dependent variable were unbiased.32 The Durbin-Watson sta-
tistic was 1.988, indicating that the model met the assumption
of independence of the residual. Multicollinearity was also not
detected because the variance inflation factor for all indepen-
dent variables was close to 1.0. When the standardized resid-
uals were plotted against a theoretic normal distribution in a
probability-probability plot, the points formed an approximate
straight line, which indicated normality of the standardized
residuals.
The strongest predictor, after adjustment, was FIM motor
score at admission, which explained 43% of the LOS variation.
The smearing estimator of the fitted model was calculated to be
1.0806. After back-transforming the fitted values and multiply-
ing it by the smearing estimator, we found a 1-point increase in
the admission FIM motor score to be associated with a 1.1-day
decrease in the mean rehabilitation LOS (P⬍.001). The choice
of private wards corresponded to a 1.3-day increase in LOS,
whereas we found residing with nonimmediate family mem-
bers to be associated with a 1.4-day increase in LOS. Having
more than 3 comorbid conditions at admission was signifi-
cantly associated with a reduction in LOS by 1.3 days.
After entering FIM motor score at admission into the model,
we found stroke type, acute LOS, and FIM cognitive score at
admission not to be significantly associated with ln-LOS. We
found patients with hemorrhagic stroke to have lower mean
FIM motor scores compared with those with ischemic stroke
(32.8 vs 38.4, P⬍.001). The mean FIM motor score was also
higher for patients with acute LOS of 11 days or less compared
with those with LOS 12 days and above (38.5 vs 33.5,
P⬍.001). Hence, the variable FIM motor score adequately
captured and explained the impact of hemorrhagic stroke and
acute LOS on rehabilitation LOS.
DISCUSSION
Stroke rehabilitation will become more important as the
population ages. Hospital administrators and rehabilitation pro-
fessionals who are responsible for ensuring an efficient deliv-
ery and accessibility of rehabilitation services will need to
anticipate the resource needs of different patients. There is
limited information regarding drivers of inpatient rehabilitation
resource use by stroke patients in an Asian context.18,21,33
We found the extent of independence in motor functions at
admission to be the strongest predictor of rehabilitation LOS
for stroke patients. A similar relationship has been found in
studies performed in inpatient rehabilitation settings in the
United Kingdom34 and the United States.22 A Taiwanese study
performed by Chung et al33 found the ability of stroke patients
to engage in self-care activities to have a major impact on the
rehabilitation LOS. Although others35,36 have reported cogni-
tive dysfunction to complicate the rehabilitation process and to
prolong LOS, poor cognitive status did not independently in-
crease the LOS in this study. Table 4 shows that the LOS was
determined predominantly by the FIM motor score regardless
of the severity of cognitive dysfunction at admission. However,
both motor and cognitive status of patients should be taken into
account in the planning of care and the setting of rehabilitation
goals. When catering to patients who are more cognitively
impaired, more specialized rehabilitation efforts need to be
committed. This has impact on the rehabilitation manpower
needed particularly as the population ages.
As with other studies, age,23-25 stroke type, and lesion
characteristics24 were not found to significantly influence LOS.
The current evidence regarding the influence of individual
comorbid conditions is equivocal. Similar to the findings in
other studies,19,21,24 we did not find diabetes mellitus and heart
disease to be significant prognostic variables. In this study,
individual medical comorbid conditions did not independently
influence LOS, but patients with more than 3 conditions had
shorter LOS. Similar findings also draw attention to medical
comorbidity as an indicator for rehabilitation potential with a
higher degree of comorbidity found to be prognostic of poorer
rehabilitation outcomes.37 If we calculate rehabilitation effec-
tiveness, defined as actual functional improvement divided by
potential improvement ([discharge FIM score ⫺ admission
FIM score]/[maximum achievable FIM score ⫺ admission FIM
score]), we find the mean rehabilitation effectiveness for pa-
tients with more than 3 comorbid conditions to be significantly
Table 4: Mean Rehabilitation LOS by FIM Motor and FIM
Cognitive Scores
LOS (d)
FIM Motor Score at Admission
FIM Cognitive Score
at Admission 13–25 26–64 65–91
5–9 44.1 28.3 13.0
10–24 42.6 28.4 15.7
25–35 42.1 26.1 11.8

Arch Phys Med Rehabil Vol 90, July 2009

1206 PREDICTING STROKE REHABILITATION LENGTH OF STAY, Tan
lower than for those who did not (0.26 vs 0.32; P⫽.015). In the
public health care sector in Singapore, even though health
services are subsidized through general taxation, subsidized
patients still pay between 20% and 80% of their inpatient ex-
penses. Although the national catastrophic insurance scheme, Me-
dishield, pays for part of the bill, up to 60% of a large hospital bill
is still being paid for by patients.38 Hence, patients who were
unable to continue to make functional gains could be discharged
earlier to minimize their financial burden. In addition, with
increasing tension between the demand for health services and
the cost of providing them, clinicians may be implicitly
rationing health care resources by allocating resources ac-
cording to the rate at which rehabilitation gains can be
reached. Nonetheless, the availability of the family to pro-
vide postdischarge care and the employment of foreign
domestic helpers as untrained caregivers39 facilitated the
discharge of medically complex patients.
Psychosocial factors, including social support, affect out-
comes of stroke. To measure the extent of social support, living
arrangement is often used. Many studies found living alone or
the absence of caregiver to give rise to longer LOS. However,
similar to findings by Saxena et al,18 this was not found to be
a risk factor in this study; on the contrary, patients who were
living with nonimmediate relatives were associated with a
longer LOS. One possible reason could be that this form of
family structure offered a lower level of social support. As
sources of support can impact the content and the quantity of
support provided,40 family and role structures41 can shape care
strategies and caregivers’ assessment of the patient’s discharge
readiness. To lessen the burden of care, nonimmediate family
members may expect patients to be more independent func-
tionally before discharge. In the United States and United
Kingdom, 25.5% and 29% of households are 1-person house-
holds, whereas in Singapore only 8.2% of households in Sin-
gapore are 1-person households. Hence, the influence of family
structures on health care utilization may be significant for
societies in which family-based households predominate. How-
ever, because the relationship between family structure and
health care utilization for stroke patients is currently not well
understood, more research is required to explore this associa-
tion.
Finally, rehabilitation LOS was found to be longer for pa-
tients who opted for private or semiprivate beds. Functional
gains were associated with a longer rehabilitation LOS,42 and,
reflecting the impact of the public health care subsidy system
on choices, patients who could afford to pay chose to stay
longer. Despite the limited generalizability of our results to
other health care delivery systems in rehabilitation, this draw-
back is not specific to our study. Other authors have also found
organizational structures,43 financing philosophy, and mecha-
nisms44 to significantly influence LOS even within the same
country.
Because of the retrospective nature of the study, we were
unable to control for other potential confounders not recorded
in the medical notes. Although other studies have found the
time duration between stroke symptom onset and rehabilitation
admission,45 prestroke functional status,19 stroke severity,19,21
and ambulation velocity to significantly predict LOS, we were
unable to include these variables because they were not mea-
sured routinely on admission. In addition, because our study
focused on predictors that can be assessed at admission, we
have excluded other factors that could influence the duration of
stay (eg, medical complications, discharge readiness, availabil-
ity of step-down care).
Arch Phys Med Rehabil Vol 90, July 2009
CONCLUSION
The objective of our study was to determine the relative
importance of variables that can be assessed at the time of
admission in predicting acute rehabilitation LOS. We found
patients’ socioeconomic status and family structure to influence
LOS, and they should be considered in allocating resources and
determining treatment need. The results further suggest the
FIM motor score at admission to be a strong predictor of the
duration of stay, although cognitive function was not found to
be an independent predictor. Hence, the use of FIM tools could
be extended to other acute rehabilitation hospital units to fa-
cilitate better management of bed resources.
Acknowledgments: We thank Wai Fung Chong, BN, MBA, for
her assistance during the data-collection phase of the study and the
staff of Tan Tock Seng Rehabilitation Center for their help and support
in this study.
References
1. Strong K, Mathers C, Bonita R. Preventing stroke: saving lives
around the world. Lancet Neurol 2007;6:182-7.
2. Moon L, Moise P, Jacobzone S. ARD-Stroke Experts Group.
Stroke care in OECD countries: a comparison of cost, treatment
and outcomes in 17 countries. Paris:OECD Health Working Pa-
pers, 2003.
3. United Nations, Department of Economic and Social Affairs,
Population Division. World population ageing: 1950-2050. New
York: United Nations; 2001.
4. Fong NP, Wong PK, Lau-Ting C, Devathasan G, Chong PN.
Disability, rehabilitation and after-care of stroke patients after
discharge from hospital. Singapore 1983-84. Ann Acad Med Sin-
gapore 1987;16:122-7.
5. Hayes SH, Carroll SR. Early intervention care in the acute stroke
patient. Arch Phys Med Rehabil 1986;67:319-21.
6. Smith ME, Garraway WM, Smith DL, Akhtar AJ. Therapy impact
on functional outcome in a controlled trial of stroke rehabilitation.
Arch Phys Med Rehabil 1982;63:21-4.
7. Anderson CS, Linto J, Stewart-Wynne EG. A population-based
assessment of the impact and burden of caregiving for long-term
stroke survivors. Stroke 1995;26:843-9.
8. Health Facts Singapore 2006: Principle Causes of Death. Singa-
pore: Ministry of Health. Available at: http://www.moh.gov.sg/
mohcorp/statistics.aspx?id⫽5526. Accessed August 29, 2008.
9. Venketasubramanian N. Stroke in Singapore—an overview. Sin-
gapore Med J 1999;40:48-52.
10. Health Facts Singapore 2006: Top 10 Conditions of Hospitalisa-
tion. Singapore: Ministry of Health. Available at: http://
www.moh.gov.sg/mohcorp/statistics.aspx?id⫽5528. Accessed
August 29, 2008.
11. Heng DM, Lee J, Chew SK, Tan BY, Hughes K, Chia KS.
Incidence of ischemic heart disease and stroke in Chinese, Malays
and Indians in Singapore: Singapore Cardiovascular Cohort
Study. Ann Acad Med Singapore 2000;29:231-6.
12. Hollander M, Koudstaal PJ, Bots ML, Grobbee DE, Hofman A,
Breteler MMB. Incidence, risk, and case fatality of first ever
stroke in the elderly population. The Rotterdam Study. J Neurol
Neurosurg Psychiatry 2003;74:317-21.
13. Jacobs BS, Boden-Albala B, Lin I, Sacco RL. Stroke in the young
in the northern Manhattan Stroke Study. Stroke 2002;33:2789-93.
14. Key Annual Statistics 2007. Singapore: Department of Statistics.
Available at: http://www.singstat.gov.sg/stats/keyind.html#
popnarea. Accessed June 1, 2008.
15. Report on the Ageing Population, Five-year Masterplan. Commit-
tee on Ageing Issues. Available at: http://www.mcys.gov.sg/
successful_ageing/report/CAI_report.pdf. Accessed September 5,
2008.
 PREDICTING STROKE REHABILITATION LENGTH OF STAY, Tan
16. Dowie J. Researching doctors’ decisions. Qual Saf Health Care
2004;13:411-2.
17. Pons JM, Borras JM, Espinas JA, Moreno V, Cardona M, Grana-
dos A. Subjective versus statistical model assessment of mortality
risk in open heart surgical procedures. Ann Thorac Surg 1999;67:
635-64.
18. Saxena SK, Ng TP, Yong D, Fong NP, Koh GC. Total direct cost,
length of hospital stay, institutional discharges and their determi-
nants from rehabilitation settings in stroke patients. Acta Neurol
Scand 2006;114:307-14.
19. Appelros P. Prediction of length of stay for stroke patients. Acta
Neurol Scand 2007;116:15-9.
20. Brosseau L, Philippe P, Potvin L, Boulanger YL. Post-stroke
inpatient rehabilitation. I. Predicting length of stay. Am J Phys
Med Rehabil 1996;75:422-30.
21. Chang KC, Tseng MC, Weng HH, Lin YH, Liou CW, Tan TY.
Prediction of length of stay of first-ever ischemic stroke. Stroke
2002;33:2670-4.
22. Harvey RL, Roth EJ, Heinemann AW, Lovell LL, McGuire JR,
Diaz S. Stroke rehabilitation: clinical predictors of resource utili-
zation. Arch Phys Med Rehabil 1998;79:1349-55.
23. Holloway RG, Witter DM Jr, Lawton KB, Lipscomb J, Samsa G.
Inpatient costs of specific cerebrovascular events at five academic
medical centers. Neurology 1996;46:854-60.
24. Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. Acute
stroke care and rehabilitation: an analysis of the direct cost and its
clinical and social determinants. The Copenhagen Stroke Study.
Stroke 1997;28:1138-41.
25. Nakayama H, Jørgensen HS, Raaschou HO, Olsen TS. The influ-
ence of age on stroke outcome. The Copenhagen Stroke Study.
Stroke 1994;25:808-13.
26. Rabadi MH, Blau A. Admission ambulation velocity predicts
length of stay and discharge disposition following stroke in an
acute rehabilitation hospital. Neurorehabil Neural Repair 2005;19:
20-6.
27. Tooth L, McKenna K, Goh K, Varghese P. Length of stay,
discharge destination, and functional improvement: utility of the
Australian National Subacute and Nonacute Patient Casemix Clas-
sification. Stroke 2005;36:1519-25.
28. Wright J. The FIM(TM). The Center for Outcome Measurement in
Brain Injury. Available at: http://www.tbims.org/combi/FIM. Ac-
cessed September 5, 2008.
29. Heinemann AW, Linacre JM, Wright BD, Granger CV. Relation-
ships between impairment and physical disability as measured by
the Functional Independence Measure. Arch Phys Med Rehabil
1993;74:566-73.
30. Stineman MG, Shea JA, Jette A, et al. The Functional Indepen-
dence Measure: tests of scaling assumptions, structure, and reli-
ability across 20 diverse impairment categories. Arch Phys Med
Rehabil 1996;77:1101-8.
1207
31. Duan N. Smearing estimate: a nonparametric retransformation
method. Journal of the American Statistical Association 1983;78:
605-10.
32. Manning WG, Mullahy J. Estimating log models: to transform or
not to transform? J Health Econ 2001;20:461-94.
33. Chung L, Wang YH, Chen TJ, Pan AW. The predictive factors for
length of stay for stroke patients in Taiwan using the path model.
Int J Rehabil Res 2006;29:137-43.
34. Hakim EA, Bakheit AM. A study of the factors which influence
the length of hospital stay of stroke patients. Clin Rehabil 1998;
12:151-6.
35. Patel MD, Coshall C, Rudd AG, Wolfe CD. Cognitive disability
after stroke: clinical determinants and its associations with long-
term stroke outcomes. J Am Geriatr Soc 2002;50:700-6.
36. Paolucci S, Antonucci G, Gialloreti LE, et al. Predicting stroke
inpatient rehabilitation outcome: the prominent role of neuropsy-
chological disorders. Eur Neurol 1996;36:385-90.
37. Patrick L, Knoefel F, Gaskowski P, Rexroth D. Medical comor-
bidity and rehabilitation efficiency in geriatric inpatients. J Am
Geriatr Soc 2001;49:1471-7.
38. Protection against large bills. Singapore: Ministry of Health.
Available at: http://www.whitepagecreation.com/multimedia/
MediShield/medishield.pdf. Accessed September 24, 2008.
39. Lim SC, Doshi V, Castasus B, Lim JK, Mamun K. Factors causing
delay in discharge of elderly patients in an acute care hospital.
Ann Acad Med Singapore 2006;35:27-32.
40. Temkin-Greener H, Bajorska A, Peterson DR, et al. Social support
and risk-adjusted mortality in a frail older population. Med Care
2004;42:779-88.
41. Ohwaki K, Hashimoto H, Sato M, Tokuda H, Yano E. Gender
and family composition related to discharge destination and
length of hospital stay after acute stroke. Tohoku J Exp Med
2005;207:325-32.
42. Ng YS, Jung H, Tay SS, Bok CW, Chiong Y, Lim PA. Results
from a prospective acute inpatient rehabilitation database: clin-
ical characteristics and functional outcomes using the Func-
tional Independence Measure. Ann Acad Med Singapore 2007;
36:3-10.
43. Stineman MG, Ross RN, Hamilton BB, et al. Inpatient rehabili-
tation after stroke: a comparison of lengths of stay and outcomes
in the Veterans Affairs and non-Veterans Affairs health care
system. Med Care 2001;39:123-37.
44. Monane M, Kanter DS, Glynn RJ, Avorn J. Variability in length
of hospitalization for stroke. The role of managed care in an
elderly population. Arch Neurol 1996;53:875-80.
45. Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing
of initiation of rehabilitation after stroke. Arch Phys Med Rehabil
2005;86(12 Suppl 2):S34-40.
Supplier
a. Version 15.0; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL
60606-6307.
Arch Phys Med Rehabil Vol 90, July 2009