https://orcid.org/0000-0002-3444-0421
ABSTRACT
Spatial neglect in stroke survivors is associated with a decrease in quality of life. This disorder occurs in 20–80% of stroke survivors and up to 1/3 of stroke survivors will continue to experience chronic impairment. Occupational therapists are uniquely qualified to treat stroke survivors with spatial neglect due to their holistic approach but access to therapy is limited. Diagnostic coding is used to help determine appropriate reimbursement and continuation of care including rehabilitation services. The objectives of this study were to 1) identify the prevalence of diagnostic coding for spatial neglect in stroke survivors, and 2) identify the prevalence and types of rehabilitation for patients with diagnostic coding for spatial neglect. We completed a retrospective cohort analysis using 2018 and 2019 5% Medicare Limited Data Sets from the Centers for Medicare and Medicaid Services. We extracted all ischemic stroke survivors and stratified them by the presence of a secondary diagnostic code indicating spatial neglect. Rehabilitation Current Procedural Terminology codes were used to identify stroke survivors who received rehabilitation. Despite recommendations from clinical practice, only 4.9% had a diagnostic code for spatial neglect. Of those formally diagnosed, only 2.3% received outpatient occupational therapy after being discharged from acute care.
JEL CLASSIFICATION:
1. Introduction
Every year there are 795,000 new strokes in the United States (CitationVirani et al., Citation2020). Spatial neglect is a disorder of lateralized spatial attention, characterized by the inability to attend, orient or respond to stimuli occurring in the space opposite the stroke lesion (Heilman & Rt, Citation1977) which can negatively impact activities of daily living (ADLs) such as dressing (Chen, Hreha, et al., Citation2015). This disorder occurs in 20–80% of stroke survivors (Chen et al., Citation2018; Esposito et al., Citation2021; Hammerbeck et al., Citation2019; Hreha et al., Citation2017) with both left and right cerebral hemisphere infarcts (Esposito et al., Citation2021). Stroke survivors with spatial neglect have longer hospital stays but poorer functional outcomes (Hammerbeck et al., Citation2019). Even after a typical inpatient rehabilitation stay, at least half of the stroke survivors with spatial neglect will continue to have persistent symptoms (Chen, Chen, et al., Citation2015), and up to one-third of stroke survivors will continue to experience chronic neglect lasting longer than a year (Karnath et al., Citation2011).
Spatial neglect is associated with a decrease in quality of life (Sobrinho et al., Citation2018), increased falls (Chen, Hreha, et al., Citation2015), and reduced balance (Nijboer et al., Citation2014). Additionally, anosognosia, or a poor insight to impairments (Nurmi Laihosalo & Jehkonen, Citation2014), causes treatment delays because stroke survivors aren’t aware of their unawareness and have difficulties learning compensatory or restorative techniques (Tham et al., Citation2001). Patients have described frustrations with having poor insight into their deficits (Tobler-Ammann et al., Citation2020), and a documented diagnosis of spatial neglect may allow for earlier and consistent patient/caregiver education.
Novel treatment strategies may improve spatial neglect (Barrett, Citation2021; Barrett & Houston, Citation2019), but access to stroke rehabilitation in the community is a significant barrier. In general, while 78% of stroke survivors receive rehabilitation during acute care (Freburger et al., Citation2018), only between 40% and 56% receive community-based rehabilitation (home health or outpatient therapy) (Prvu Bettger et al., Citation2015;). Outpatient occupational therapy is even more limited in rural and socially disadvantaged counties (Morrow et al., Citation2024).
While spatial neglect is common for stroke survivors, a lack of consistent terminology makes communication between clinicians and disciplines difficult and may contribute to reduced continuity of care (Chen et al., Citation2018; Chen, Zanca, et al., Citation2021). One study discovered 200 different terms used in research to refer to neglect or a subtype such as visual neglect, visuospatial neglect, visuo-spatial neglect, visual inattention, and visual-spatial inattention (Williams et al., Citation2021). Previous publications have described under-documentation for spatial neglect during inpatient rehabilitation. While occupational therapists, physicians, and nurses may document spatial neglect in clinical notes, this rarely translates to formal diagnostic coding (Chen et al., Citation2013).
Common coding systems are the International Classification of Diseases Version 10 (ICD-10) (World Health, Citation2004) for diagnoses and Current Procedural Terminology (CPT) codes for procedures such as rehabilitation services (Dotson, Citation2013). Diagnostic codes are used to standardize terminology , increase communication between disciplines, and help determine appropriate reimbursement (Hirsch et al., Citation2016) Codes are used by both primary and secondary users (CitationICD—ICD-10-CM—International Classification of Diseases, (ICD-10-CM/PCS Transition). Primary users include physicians, nurses, and medical coders who help apply the appropriate codes to patients and communicate with other clinicians. Secondary users use already documented codes to determine reimbursement, conduct health services research, and track the quality of care (Chang et al., Citation2016). Therefore, underreporting puts both user types at a disadvantage.
The objectives of this study were to 1) identify the prevalence of diagnostic coding for spatial neglect in stroke survivors, and 2) identify the prevalence and types of rehabilitation for patients with diagnostic coding for spatial neglect. To our knowledge, this is the first investigation into the prevalence of diagnostic coding of spatial neglect in Medicare stroke survivors and the rehabilitation they receive.
2. Methods
2.1. Dataset construction
We completed a retrospective cohort analysis using the Centers for Medicare and Medicaid Services (CMS) 2018 and 2019 5% Medicare Limited Data Sets (LDS). These data include demographic and billing information for a random sample of beneficiaries. Ischemic stroke survivors were identified using Diagnosis Related Group (DRG) codes. Patients were excluded if they died in acute care or were discharged to hospice as these patients are not candidates for rehabilitation. Additionally, patients had to be trackable through their Medicare benefits for 364 days past their initial stroke. Continuous variables are reported with means and standard deviations (SD) and categorical variables are reported with frequencies and percentages. Subsamples with less than 11 patients are included but specified as ‘n < 11’ to abide by CMS policy to protect patient confidentiality.
Stroke survivors with neglect were identified using ICD-10 codes R41.4 (Neurologic neglect syndrome) and I69.912 (Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease) (World Health, Citation2004). Because there were so few stroke survivors diagnosed with neglect, we decided to combine all stroke survivors diagnosed with neglect into one group (Neglect Group).
There were two stroke severity variables used to describe the two groups. The National Institutes of Health Stroke Scale (NIHSS) was included; however, this is typically underreported in the LDS. Therefore, we also reported the Stroke Administrative Severity Index (SASI). This provides a level of stroke severity (0–31 points) based on the presence of ICD-10 codes for aphasia (4 points), coma (23 points), dysarthria/dysphagia (2 points), hemiplegia (6 points), neglect (5 points), need for nutritional infusion (6 points), and the need for tracheostomy and/or ventilation (10 points). Points are aggregated and categorized as Mild (0 points), Moderate (1–6 points), or Severe (7–31 points) (Simpson et al., Citation2018). Other descriptive variables included whether a stroke survivor received tissue plasminogen activator (tPA) or endovascular thrombectomy (eVT) during acute care, baseline comorbidities as described by the Charlson Co-Morbidity Index (D’Hoore et al., Citation1996), dual eligibility for Medicare and Medicaid (indicating lower-income patients), and discharge destinations after acute care.
Analyses were performed using SAS, version 9.4 (SAS Institute, Inc.; Cary, NC). The university’s Institutional Review Board deemed this non-human research and, therefore, did not require oversight.
2.2. Therapy evaluations
Outpatient and home health CPT codes (Appendix A) for OT and PT evaluations were extracted and consolidated into either ‘OT Evaluation’ or ‘PT Evaluation’. We did not include recertifications as our focus was on initial access of therapy not on continuation. The presence of CPT codes for therapy evaluations for PT/OT and home health/outpatient were compared for the Neglect Group and No Neglect Diagnosis Group.
2.3. Socially disadvantaged and rural subpopulations
We had two subpopulations of specific interest: rural and socially disadvantaged (SDA) stroke survivors. Rural and nonrural stroke survivors were identified using county Federal Information Processing System (FIPS) codes. SDA stroke survivors were identified using the Community Vulnerability Index (CVI). The CVI is weighted by factors such as poverty, income, education level, disability status, single-parent status, unemployment, housing, and transportation access (Registry, Citation2018). Stroke survivors residing in zip codes in the 90th percentile for this index we considered SDA. Access to both outpatient and home health therapy were analyzed for these subpopulations.
3. Results
3.1. Demographics
Of the 9,076 stroke survivors in this dataset, only 4.9% were formally diagnosed with spatial neglect (). For those diagnosed with spatial neglect, the mean age was 77.5 (10.2), 56.1% were female, and 79.0% were White. For subpopulations, 13.8% of the Neglect Group lived in a rural setting and 7.9% lived in an SDA setting.
Table 1. Cohort characteristics.
Stroke severity was higher in the Neglect Group versus the No Neglect Diagnosis Group in both the NIHSS (9.9 SD = 7.7 vs. 5.7 SD = 6.4) and SASI (8.9 SD = 5.3 versus 4.7 SD = 4.2). Length of stay (LOS), tPA, and eVT were also higher for the Neglect Group. Stroke survivors in the Neglect Group were discharged to skilled nursing (36.4%) or inpatient rehabilitation (31.5%) most frequently. For the No Neglect Diagnosis Group, the most frequent discharge destination was directly Home (31.9%).
3.2. Access to community-based therapy evaluations
Access to community-based therapy included evaluations for home health therapy, outpatient therapy, or no therapy (). In the Neglect Group, 56.3% of the patients received no home health or outpatient therapy upon discharge compared to 50.6% in the No Neglect Diagnosis Group. For those who received therapy in the Neglect group, 42.1% of the patients received home health physical therapy, 35.5% received home health occupational therapy, 35.5% received both home health physical therapy and occupational therapy and 57.9% received neither home health physical therapy nor occupational therapy.
Table 2. Access to community-based rehabilitation evaluations.
As for outpatient therapy, access is very limited for both groups. For stroke survivors in the Neglect Group, 5.9% received outpatient physical therapy, 2.3% received outpatient occupational therapy, 2.0% received both outpatient physical therapy and occupational therapy. Almost 94% of the Neglect Group did not receive outpatient physical therapy or occupational therapy compared to 90.6% in the No Neglect Diagnosis Group.
3.3. Therapy access for subpopulations with neglect
For the Neglect Group who lived in rural communities, 31.2% of the received home health OT and 44.3% received home health PT (). For nonrural stroke survivors with neglect, 36.2% received home health OT and 41.7% received home health PT. For outpatient therapy,0% of the Neglect Group in rural communities received rehabilitation. However, 6.8% of the Neglect Group in nonrural communities received outpatient PT and 2.6% received outpatient OT.
Table 3. Therapy access for subpopulations with neglect.
For socially disadvantaged (SDA) communities, 65.7% of stroke survivors with neglect received no home health or outpatient therapy. This is compared to 55.5% living in non-SDA communities.
4. Discussion
4.1. Demographics
Only 4.9% of Medicare beneficiaries were formally diagnosed with an ICD-10 code having spatial neglect. This is dramatically less than a recent systematic review which reported the estimated prevalence of spatial neglect to be 30% (Esposito et al., Citation2021). While there are likely many more explanations, this may suggest either clinicians are not assessing for neglect, are not using the diagnostic code for neglect, or that this population did not have neglect.
Time, resources, and knowledge are all barriers to diagnosing spatial neglect (Chen, Zanca, et al., Citation2021). Therapists have expressed early discharges from inpatient rehabilitation specifically as a barrier to a more comprehensive evaluation which may include neglect (Chen, Hreha, et al., Citation2015; Chen, Zanca, et al., Citation2021). Spatial neglect diagnosis can be difficult and multiple assessments may need to be performed to identify the correct subtype of neglect (Grattan & Woodbury, Citation2017). Ironically, formally diagnosing neglect may lead to increased length of stays for inpatient rehabilitation. Diagnostic codes help determine levels of reimbursement and days approved for inpatient rehabilitation stays.
Clinicians have also expressed barriers to spatial neglect treatment as poor communication between disciplines and clinicians and a discontinuity throughout the continuum of rehabilitation care (Chen, Zanca, et al., Citation2021). Patients may not have self-awareness of their spatial neglect deficits (CitationRonchi et al., Citation2014), so clinician communication is particularly crucial as patients may not have the capacity to self-advocate for specialized treatment. Clinicians have previously identified the importance of formal documentation to help with this barrier (Chen, Zanca, et al., Citation2021).
Another important benefit of formal diagnostic coding is to aid in epidemiology, quality of care, and health services research (Chang et al., Citation2016; Chen, Zanca, et al., Citation2021). This is particularly timely as there is a push from the National Institutes of Health (NIH) for a rehabilitation-focused health services research (Frontera et al., Citation2017). Diagnostic coding also allows for the analysis of healthcare disparities to better understand the access to care for rural and SDA subpopulations (Meyer, Citation2011; Sanders et al., Citation2012).
4.2. Therapy evaluations
Despite ongoing treatment recommendations from clinical practice guidelines (Winstein Carolee et al., Citation2016), our results suggest that many stroke survivors with neglect might be discharged home without crucial rehabilitation services. Over 56% of stroke survivors with neglect were discharged into the community without home health or outpatient therapy. While some of these patients may have had a full recovery of their symptoms during acute or inpatient rehabilitation, it is likely these stroke survivors are still living with deficits that may impact quality of life (Karnath, Citation2015). Additionally, caregiver burden is high for stroke survivors with neglect that could be addressed with community-based rehabilitation (Chen et al., Citation2017). Treatment may even improve patients’ ability to return to work (Kerkhoff, Citation2021).
Spatial neglect experts typically approach treatment with multiple approaches due partially to the complex nature of the ailment (Chen et al., Citation2018). Outpatient therapy facilities may offer several specialized treatment options for spatial neglect including virtual reality (Morse et al., Citation2020; Ogourtsova et al., Citation2017), prism therapy (Chen, Diaz-Segarra, et al., Citation2021), and activity-based interventions (CitationLiu et al., Citation2019). Unfortunately, as shown in our analysis, 93.9% of neglect patients do not receive outpatient therapy in the first year. Furthermore, no rural stroke survivors with neglect received outpatient therapy. This may be explained by a lack of therapists in rural areas (MacDowell et al., Citation2010). Recently, telerehabilitation has emerged as an option to improve access and specialty care for stroke survivors living in rural areas (Morse et al., Citation2020).
For stroke survivors certified by a physician as homebound, 60 days of home health rehabilitation is an option (Winstein Carolee et al., Citation2016). Though research specifically for home health treatments for spatial neglect is limited, stroke survivors may benefit in many ways. Spatial neglect rehabilitation in the patient’s home could help identify safety risks to reduce falls and help patients and caregivers adopt compensatory and restorative techniques for their ADL routines. Unfortunately, only 35.5% of those diagnosed with neglect received both home health occupational and physical therapy. Furthermore, 57.9% of stroke survivors with neglect received no home health and 65.7% of those living in SDA communities did not receive home health or outpatient therapy.
4.3. Future research needs
There is a need to better understand if the prevalence of neglect is accurately reflected in the diagnostic coding, and if it is not accurate, there is a need to identify the facilitators and barriers to improve coding for spatial neglect. Additionally, cost-effectiveness studies for spatial neglect treatments could help clinicians, insurers, and policymakers understand the importance of treatment. Finally, telerehabilitation is emerging as a possible option for spatial neglect (Morse et al., Citation2022). However, continued research on telerehabilitation efficacy and effectiveness is important, and understanding barriers to clinician and patient telerehabilitation use for spatial neglect will be imperative to promote widespread adoption.
4.4. Limitations
There were limitations to consider in our study. First, this was a retrospective study using only Medicare beneficiaries. Results may not be generalizable to other populations. Second, patients may have received therapy that was not billed to Medicare. Third, results may be affected by an under-ascertainment bias. Finally, this study only examined ischemic stroke survivors and the results may not be generalizable to transient ischemic attacks or hemorrhagic strokes.
5. Conclusions
Spatial neglect is likely underdiagnosed and underreported in acute, home health, and outpatient care. Increased use of diagnostic coding might potentially increase clinician awareness, increase inpatient rehabilitation length of stays and reimbursement, and lead to treatment. For stroke survivors who are diagnosed with neglect, community-based rehabilitation access is limited. This is particularly true for rural and socially disadvantaged populations.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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References
- Barrett, A. M. (2021). Spatial neglect and anosognosia after right brain stroke. Continuum (Minneap Minn), 27(6), 1624–13. https://doi.org/10.1212/con.0000000000001076
- Barrett, A. M., & Houston, K. E. (2019). Update on the clinical approach to spatial neglect. Current Neurology and Neuroscience Reports, 19(5), 25. https://doi.org/10.1007/s11910-019-0940-0
- Chang, T. E., Lichtman, J. H., Goldstein, L. B., & George, M. G. (2016). Accuracy of ICD-9-CM codes by hospital characteristics and stroke severity: Paul Coverdell national acute stroke program. Journal of the American Heart Association, 5(6). https://doi.org/10.1161/jaha.115.003056
- Chen, P., Chen, C. C., Hreha, K., Goedert, K. M., & Barrett, A. M. (2015). Kessler foundation neglect assessment process uniquely measures spatial neglect during activities of daily living. Archives of Physical Medicine & Rehabilitation, 96(5), 869–876.e861. https://doi.org/10.1016/j.apmr.2014.10.023
- Chen, P., Diaz-Segarra, N., Hreha, K., Kaplan, E., & Barrett, A. M. (2021). Prism adaptation treatment improves inpatient rehabilitation outcome in individuals with spatial neglect: A retrospective matched control study. Archives of Rehabilitation Research and Clinical Translation, 3(3), 100130. https://doi.org/10.1016/j.arrct.2021.100130
- Chen, P., Fyffe, D. C., & Hreha, K. (2017). Informal caregivers’ burden and stress in caring for stroke survivors with spatial neglect: An exploratory mixed-method study. Topics in Stroke Rehabilitation, 24(1), 24–33. https://doi.org/10.1080/10749357.2016.1186373
- Chen, P., Hreha, K., Kong, Y., & Barrett, A. M. (2015). Impact of spatial neglect on stroke rehabilitation: Evidence from the setting of an inpatient rehabilitation facility. Archives of Physical Medicine and Rehabilitation, 96(8), 1458–1466. https://doi.org/10.1016/j.apmr.2015.03.019
- Chen, P., McKenna, C., Kutlik, A. M., & Frisina, P. G. (2013). Interdisciplinary communication in inpatient rehabilitation facility: Evidence of under-documentation of spatial neglect after stroke. Disability & Rehabilitation, 35(12), 1033–1038. https://doi.org/10.3109/09638288.2012.717585
- Chen, P., Pitteri, M., Gillen, G., & Ayyala, H. (2018). Ask the experts how to treat individuals with spatial neglect: A survey study. Disability & Rehabilitation, 40(22), 2677–2691. https://doi.org/10.1080/09638288.2017.1347720
- Chen, P., Zanca, J., Esposito, E., & Barrett, A. M. (2021). Barriers and facilitators to rehabilitation care of individuals with spatial neglect: A qualitative study of professional views. Archives of Rehabilitation Research and Clinical Translation, 3(2), 100122. https://doi.org/10.1016/j.arrct.2021.100122
- D’Hoore, W., Bouckaert, A., & Tilquin, C. (1996). Practical considerations on the use of the Charlson comorbidity index with administrative data bases. Journal of Clinical Epidemiology, 49(12), 1429–1433. https://doi.org/10.1016/S0895-4356(96)00271-5
- Dotson, P. (2013). CPT® codes: What are they, why are they necessary, and how are they developed? Advances in Wound Care, 2(10), 583–587. https://doi.org/10.1089/wound.2013.0483
- Esposito, E., Shekhtman, G., & Chen, P. (2021). Prevalence of spatial neglect post-stroke: A systematic review. Annals of Physical and Rehabilitation Medicine, 64(5), 101459. https://doi.org/10.1016/j.rehab.2020.10.010
- Freburger, J. K., Li, D., Johnson, A. M., & Fraher, E. P. (2018). Physical and occupational therapy from the acute to community setting after stroke: Predictors of use, continuity of care, and timeliness of care. Archives of Physical Medicine & Rehabilitation, 99(6), 1077–1089.e1077. https://doi.org/10.1016/j.apmr.2017.03.007
- Frontera, W. R., Bean, J. F., Damiano, D., Ehrlich-Jones, L., Fried-Oken, M., Jette, A., Jung, R., Lieber, R. L., Malec, J. F., Mueller, M. J., Ottenbacher, K. J., Tansey, K. E., & Thompson, A. (2017). Rehabilitation research at the national institutes of health: Moving the field forward (executive summary). The American Journal of Occupational Therapy, 71(3), 1–12. https://doi.org/10.5014/ajot.2017.713003
- Grattan, E. S., & Woodbury, M. L. (2017). Do neglect assessments detect neglect differently? The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 71(3), p71031900507103190051–p71031900507103190059. https://doi.org/10.5014/ajot.2017.025015
- Hammerbeck, U., Gittins, M., Vail, A., Paley, L., Tyson, S. F., & Bowen, A. (2019). Spatial neglect in stroke: Identification, disease process and association with outcome during inpatient rehabilitation. Brain Sciences, 9(12), 374. https://doi.org/10.3390/brainsci9120374
- Heilman, K. M., & Watson, R. T. (1977). Mechanisms underlying the unilateral neglect syndrome. Advances in Neurology, 18, 93–106.
- Hirsch, J., Nicola, G., McGinty, G., Liu, R., Barr, R., Chittle, M., & Manchikanti, L. (2016). ICD-10: History and context. American Journal of Neuroradiology, 37(4), 596–599. https://doi.org/10.3174/ajnr.A4696
- Hreha, K., Mulry, C., Gross, M., Jedziniak, T., Gramas, N., Ohevshalom, L., Sheridan, A., Szabo, G., Davison, C., & Barrett, A. M. (2017). Assessing chronic stroke survivors with aphasia sheds light on prevalence of spatial neglect. Topics in Stroke Rehabilitation, 24(2), 91–98. https://doi.org/10.1080/10749357.2016.1196906
- ICD - ICD-10-CM - International Classification of Diseases,(ICD-10-CM/PCS Transition. Centers for Disease Control. https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm
- Karnath, H. O. (2015). Spatial attention systems in spatial neglect. Neuropsychologia, 75, 61–73. https://doi.org/10.1016/j.neuropsychologia.2015.05.019
- Karnath, H. O., Rennig, J., Johannsen, L., & Rorden, C. (2011). The anatomy underlying acute versus chronic spatial neglect: A longitudinal study. Brain A Journal of Neurology, 134(Pt 3), 903–912. https://doi.org/10.1093/brain/awq355
- Kerkhoff, G. (2021). Successful return to professional work after neglect, extinction, and spatial misperception - Three long-term case studies. Neuropsychological Rehabilitation, 31(6), 837–862. https://doi.org/10.1080/09602011.2020.1738248
- Liu, K. P. Y., Hanly, J., Fahey, P., Fong, S. S. M., & Bye, R. (2019). A systematic review and meta-analysis of rehabilitative interventions for unilateral spatial neglect and hemianopia poststroke from 2006 through 2016. Archives of Physical Medicine and Rehabilitation, 100(5), 956–979. https://doi.org/10.1016/j.apmr.2018.05.037
- MacDowell, M., Glasser, M., Fitts, M., Nielsen, K., & Hunsaker, M. (2010). A national view of rural health workforce issues in the USA. Rural and Remote Health, 10(3), 1531–1531. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760483/ https://pubmed.ncbi.nlm.nih.gov/20658893
- Meyer, H. (2011). Coding complexity: US health care gets ready for the coming of ICD-10. Health Affairs, 30(5), 968–974. https://doi.org/10.1377/hlthaff.2011.0319
- Morrow, C., Woodbury, M., Simpson, A. N., Almallouhi, E., & Simpson, K. N. (2024). Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors. Topics in Stroke Rehabilitation, 1–7. https://doi.org/10.1080/10749357.2024.2312638
- Morse, H., Biggart, L., Pomeroy, V., & Rossit, S. (2020). Exploring perspectives from stroke survivors, carers and clinicians on virtual reality as a precursor to using telerehabilitation for spatial neglect post-stroke. Neuropsychological Rehabilitation, 1–25. https://doi.org/10.1080/09602011.2020.1819827
- Morse, H., Biggart, L., Pomeroy, V., & Rossit, S. (2022). Exploring perspectives from stroke survivors, carers and clinicians on virtual reality as a precursor to using telerehabilitation for spatial neglect post-stroke. Neuropsychological Rehabilitation, 32(5), 707–731. https://doi.org/10.1080/09602011.2020.1819827
- Nijboer, T. C., Ten Brink, A. F., van der Stoep, N., & Visser-Meily, J. M. (2014). Neglecting posture: Differences in balance impairments between peripersonal and extrapersonal neglect. Neuroreport, 25(17), 1381–1385. https://doi.org/10.1097/wnr.0000000000000277
- Nurmi Laihosalo, M. E., & Jehkonen, M. (2014). Assessing anosognosias after stroke: A review of the methods used and developed over the past 35 years. Cortex; a Journal Devoted to the Study of the Nervous System and Behavior, 61, 43–63. https://doi.org/10.1016/j.cortex.2014.04.008
- Ogourtsova, T., Souza Silva, W., Archambault, P. S., & Lamontagne, A. (2017). Virtual reality treatment and assessments for post-stroke unilateral spatial neglect: A systematic literature review. Neuropsychological Rehabilitation, 27(3), 409–454. https://doi.org/10.1080/09602011.2015.1113187
- Prvu Bettger, J., McCoy, L., Smith, E. E., Fonarow, G. C., Schwamm, L. H., & Peterson, E. D. (2015). Contemporary trends and predictors of postacute service use and routine discharge home after stroke. Journal of the American Heart Association, 4(2). https://doi.org/10.1161/jaha.114.001038
- Registry, A. F. T. S. A. D. (2018). CDC SVI documentation 2018. Retrieved July 3, 2022, from https://www.atsdr.cdc.gov/placeandhealth/svi/documentation/SVI_documentation_2018.html
- Ronchi, R., Bolognini, N., Gallucci, M., Chiapella, L., Algeri, L., Spada, M. S., & Vallar, G. (2014). (Un)awareness of unilateral spatial neglect: A quantitative evaluation of performance in visuo-spatial tasks. Cortex; a Journal Devoted to the Study of the Nervous System and Behavior, 61, 167–182. https://doi.org/10.1016/j.cortex.2014.10.004
- Sanders, T. B., Bowens, F. M., Pierce, W., Stasher-Booker, B., Thompson, E. Q., & Jones, W. A. (2012). The road to ICD-10-CM/PCS implementation: Forecasting the transition for providers, payers, and other healthcare organizations. Perspectives in Health Information Management, 9(Winter), 1f–1f. https://pubmed.ncbi.nlm.nih.gov/22548024 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329203/
- Simpson, A. N., Wilmskoetter, J., Hong, I., Li, C. Y., Jauch, E. C., Bonilha, H. S., Anderson, K., Harvey, J., & Simpson, K. N. (2018). Stroke administrative severity index: Using administrative data for 30-day poststroke outcomes prediction. Journal of Comparative Effectiveness Research, 7(4), 293–304. https://doi.org/10.2217/cer-2017-0058
- Sobrinho, K. R. F., Santini, A. C. M., Marques, C. L. S., Gabriel, M. G., Neto, E. D. M., de Souza, L. A. P. S., Bazan, R., & Luvizutto, G. J. (2018). Impact of unilateral spatial neglect on chronic patient’s post-stroke quality of life. Somatosensory & Motor Research, 35(3–4), 199–203. https://doi.org/10.1080/08990220.2018.1521791
- Tham, K., Ginsburg, E., Fisher, A. G., & Tegnér, R. (2001). Training to improve awareness of disabilities in clients with unilateral neglect. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 55(1), 46–54. https://doi.org/10.5014/ajot.55.1.46
- Tobler-Ammann, B. C., Weise, A., Knols, R. H., Watson, M. J., Sieben, J. M., de Bie, R. A., & de Bruin, E. D. (2020). Patients’ experiences of unilateral spatial neglect between stroke onset and discharge from inpatient rehabilitation: A thematic analysis of qualitative interviews. Disability & Rehabilitation, 42(11), 1578–1587. https://doi.org/10.1080/09638288.2018.1531150
- Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., Djousse, L., Elkind, M. S. V., Ferguson, J. F., Fornage, M., Khan, S. S., Kissela, B. M., Knutson, K. L., Kwan, T. W., Lackland, D. T., … Null, N. (2020). Heart disease and stroke statistics—2020 update: A report from the American heart association. Circulation, 141(9), e139–e596. https://doi.org/10.1161/CIR.0000000000000757
- Williams, L. J., Kernot, J., Hillier, S. L., & Loetscher, T. (2021). Spatial neglect subtypes, definitions and assessment tools: A scoping review. Frontiers in Neurology, 12, 742365. https://doi.org/10.3389/fneur.2021.742365
- Winstein Carolee, J., Stein, J., Arena, R., Bates, B., Cherney Leora, R., Cramer Steven, C., Deruyter, F., Eng Janice, J., Fisher, B., Harvey Richard, L., Lang Catherine, E., MacKay-Lyons, M., Ottenbacher Kenneth, J., Pugh, S., Reeves Mathew, J., Richards Lorie, G., Stiers, W., & Zorowitz Richard, D. (2016). Guidelines for adult stroke rehabilitation and recovery. Stroke, 47(6), e98–e169. https://doi.org/10.1161/STR.0000000000000098
- World Health, O. (2004). ICD-10 : International statistical classification of diseases and related health problems : Tenth revision (2nd ed ed.). World Health Organization.