Measuring acute rehabilitation needs in trauma: preliminary evaluation of the Rehabilitation Complexity Scale

Is the Rehabilitation Complexity Scale useful in individuals undergoing in-hospital pulmonary rehabilitation?

OBJECTIVE

To assess validity and responsiveness of the Extended Rehabilitation Complexity Scale (RCS-Ev13) to in-hospital pulmonary rehabilitation (PR) in individuals with chronic respiratory diseases (CRD).

DESIGN

cross-sectional multicentric study. Assessments in individuals attending units on two non-consecutive days.

SETTING

14 Italian in-hospital PR units.

PARTICIPANTS

Five hundred forty-seventh individuals (59.2% male, age 72 [65-78] years): 317 with Chronic Respiratory Failure due to various causes (CRF group); 96 with chronic obstructive pulmonary disease without CRF (COPD), 39 Tracheostomized and Ventilated (Tx/V), and 95 with other diseases (Miscellaneous).

INTERVENTION

Assessment of RCS-Ev13 before and after the PR program.

MAIN OUTCOME MEASURES

RCS-Ev13 and outcome measures: Barthel Index (BI), Barthel Index Dyspnoea (BiD), Medical Research Council Scale for dyspnoea (MRC), COPD Assessment Test (CAT), Short Physical Performance Battery (SPPB), Six-Minute Walking Test (6MWT).

RESULTS

The highest RCS-Ev13 admission values (median; IQR) were found in TX/V (17; 15-18) as compared to other groups (8; 7-10, 10; 9-12, 8; 8-10 in COPD, CRF and Miscellaneous respectively, p<0.001). At admission and discharge, RCS-Ev13 correlated strongly with BI, 6MWT, and SPPB and moderately with MRC and BiD (r: 0.43 to 0.60). After the program RCS-Ev13 as well as all outcome measures improved significantly in all groups (p< 0.001 for all). The size of improvement was different among groups according to the different variables. In the overall group the effect size was high for changes in RCS-E v13 (Cohen's d = -2.0984), CAT = (-1.1937), MRC (- 1.0505), BiD (- 0.9364) and SPPB (0.9231) while moderate for 6MWT (0.7670) and BI (0.6574).

CONCLUSIONS

RCS-E v13 varies according to different CRDs, is responsive to PR, has good construct and concurrent validity, and correlates with most of the accepted outcome measures of PR. Its scoring may provide useful information on the care burden of individuals undergoing PR.

The ability of the Rehabilitation Complexity Scale (RCS) to capture disability in respiratory patients admitted for in-hospital rehabilitation

The aim of this pilot retrospective study was to test the Rehabilitation complexity scale (RCS-E v13) in patients from 15 Italian pulmonary rehabilitation (PR) units and correlate RCS-E v13 to the most used clinical and functional outcome measures. At admission and discharge, clinical data [comorbidities with the Cumulative Illness Rating Scale (CIRS)], Barthel Index (BI), Barthel Index dyspnea (BI-d), COPD Assessment Test (CAT), and six-minute walking test (6MWT) were collected, and RCS-E total score calculated. Two-hundred nineteen patients [30.6% COPD, 43.4% chronic respiratory failure (CRF), and 26% with invasive ventilation (IV)], aged 69.9 (11.2) years were considered. RCS-E at admission 8.63 (1.69), 11.06 (2.50), 16.56 (2.97) and discharge 0.84 (1.02), 2.19 (1.5), 7.09 (1.47)] for COPD, CRF and IV respectively were statistically differed among groups (ANOVA p = <0.0001). RCS-E v13 total score strongly negatively correlated with 6MWT [(rho= -0.7305 (-07883; -0.6598)] and BI [(rho= - 0.6989 ( -0.7626; - 0.6217)]) while weakly with CAT [(rho = 0.2939 (0.1601; 0.4170)] and BI-d [(rho = 0.3512 (0.2243; 0.4663)]. Change in RCS-E v13 total score [(mean change of -8.70 (95% IC -9.00; -8.40)] )  as in all single RCS-E v13 items [care -0.59 (95%IC -0.69, -0.48); risk -0.56 (95%IC -0.78;-0.46); nursing needs -2.11 (95%IC -2.22;-2.01); medical needs -2.29 (95%IC -2.39;-2.18); therapy disciplines -1.45 (95%IC -1.57; -1.33); therapy intensity -2.00 (95%IC -2.07; -1,93); equipment -0.23( 95%IC -0.30; -0.16)] was found significant after PR. The RCS-E v13 application for patients with respiratory diseases is feasible and highlights a huge difference among different conditions. Its application seems to present an important care burden and relation with motor disability and effort tolerance but a lower relation with dyspnea during activities of daily living, comorbidities, and disease impact. A more robust sample and prospective analysis on the usefulness of the RSC-E v13 in patients with respiratory diseases during rehabilitation are welcomed.

Rehabilitation complexity scale and reimbursement of in-hospital pulmonary rehabilitation

Background

The use of case-based reimbursement for medical rehabilitation is greatly discussed. The investigators explored the relationship between disability and reimbursement opportunities in individuals with respiratory diseases undergoing in-hospital pulmonary rehabilitation (PR), considering the correlation (if any) between the Rehabilitation Complexity Scale (RCS-E v13) scores used at admission and the actual reimbursement.

Methods

This study is part of a larger prospective multicenter study conducted by eight Pulmonary Rehabilitation Units in Italy. Here, investigators considered only data from the Lombardy Region. On January 30th or February 28th, 2023, participants were allocated according to the main DRG into 4 groups [tracheostomized/ventilated (TX/V), chronic respiratory failure (CRF), COPD, and miscellaneous group]. We recorded anthropometrics, diagnosis, international outcome measures, and calculated admission and discharge RCS-E v13 scores and hospital stay reimbursement according to the healthcare system (HS).

Results

Three hundred and sixteen participants were evaluated. Patients were elderly, in the majority of cases with CRF, presenting comorbidities, disability, dyspnea, and reduced effort tolerance. At admission, RCS-E v13 showed an average moderate value of complexity. The median (IQR) HS reimbursement/stay was different among groups. RCSE v13 evaluated at admission was weakly (r=0.3471), but significantly related to the HS reimbursement/stay (p<0.0001) mainly due to TX/V and miscellaneous subgroups, while no relationship was found for COPD and CRF patients. After PR, all outcome measures improved significantly in all groups (p<0.001 for all). Higher RCS-E v13 scores at admission did not correspond to a proper amount of reimbursement, being this latter under- or over-estimated if compared to needs assessed by RCS-E v13. RCS-E v13 at discharge decreased for all subgroups (range from -6 to -11) reaching a low value of complexity.

Conclusions

The RCS-E v13 disability score does not fully mirror the HS reimbursement for patients undergoing inhospital PR.

Cross-cultural adaptation and psychometric validation of the Korean version of rehabilitation complexity scale for the measurement of complex rehabilitation needs

The aim of this study was to translate and cross-culturally adapt the Rehabilitation Complexity Scale-Extended version 13 (RCS-E v13) to develop the Korean version of the Rehabilitation Complexity Scale (KRCS), and to explore its reliability, and concurrent and construct validity.This research was an observational study of a series of consecutive rehabilitation inpatients who were previously assessed with KRCS and grouped with the Korean rehabilitation patient group version 1.1 (KRPG v1.1). Translation and cross-cultural adaptation of the RCS-E v13 were implemented according to internationally recognized standards. Four hundred thirty inpatients diagnosed with complex neurological or musculoskeletal disabilities were enrolled. Physiatrists were asked to finish the KRCS at admission and to complete a second time with an interval of a minimum of 3 weeks to a maximum of 4 weeks for reliability evaluation. At discharge, the KRCS was completed a third time to explore constructive validity.The Cronbach-α was 0.63. The intraclass correlation coefficient values of the total score, Medical, Nursing, Care, Therapy Disciplines, Therapy Intensity, and Especial Needs domains were 0.86, 0.69, 0.84, 0.83, 0.74, 0.74, and 0.79, respectively (P < .01). The scale was repeatable (Spearman rho 0.69-0.86) and correlated strongly with disability measures (Spearman rho 0.37-0.50). Exploratory factor analysis revealed 2 clear factors ("Medical/Nursing" and "Care/Therapy Disciplines/Therapy Intensity/Equipment"). The goodness-of-fit index in the confirmatory factor analysis was 0.87. The KRCS was associated with a higher explanatory power for rehabilitation resources and length of stay than the KRPG v1.1.Our data suggest that the KRCS is a feasible, reliable, and valid tool that is appropriate for the measurement of clinical complexity in Korean intensive rehabilitation units. Further, it may provide case-mix adjustment to improve the rehabilitation delivery system in Korea.

Psychometric validation of the Italian Rehabilitation Complexity Scale-Extended version 13

In Italy, at present, a well-known problem is inhomogeneous provision of rehabilitative services, as stressed by MoH, requiring appropriate criteria and parameters to plan rehabilitation actions. According to the Italian National Rehabilitation Plan, Comorbidity, Disability and Clinical Complexity should be assessed to define the patient's real needs. However, to date, clinical complexity is still difficult to measure with shared and validated tools. The study aims to psychometrically validate the Italian Rehabilitation Complexity Scale-Extended v13 (RCS-E v13), in order to meet the guidelines requirements. An observational multicentre prospective cohort study, involving 8 intensive rehabilitation facilities of the Emilia-Romagna Region and 1712 in-patients, [823 male (48%) and 889 female (52%), mean age 68.34 years (95% CI 67.69-69.00 years)] showing neurological, orthopaedic and cardiological problems, was carried out. The construct and concurrent validity of the RCS-E v13 was confirmed through its correlation to Barthel Index (disability) and Cumulative Illness Rating Scale (comorbidity) and appropriate admission criteria (not yet published), respectively. Furthermore, the factor analysis indicated two different components ("Basic Care or Risk-Equipment" and "Medical-Nursing Needs and Therapy Disciplines") of the RCS-E v13. In conclusion, the Italian RCS-E v13 appears to be a useful tool to assess clinical complexity in the Italian rehab scenario case-mix and its psychometric validation may have an important clinical rehabilitation impact allowing the assessment of the rehabilitation needs considering all three dimensions (disability, comorbidity and clinical complexity) as required by the Guidelines and the inhomogeneity could be reduced.

The injury trajectory for young people 16-24 years in the six months following injury: A mixed methods study

BACKGROUND

Adolescents and young people are the population at greatest risk of injury and therefore injury-related mortality and morbidity. Inquiry into the injury trajectory of young people is needed to identify this group's specific needs for healthcare. This paper reports the integration of quantitative and qualitative findings from a sequential explanatory mixed methods study examining young people aged 16-24 years' experience and trajectory of traumatic physical injury in the initial six months. The aim of integration was to address the question: In what ways are injured young peoples' experiences and self-management during the initial six months of the injury trajectory impacted by their injury, family support, and provision of healthcare?

METHODS

Key findings from epidemiological datasets on young person injuries from hospital and coronial databases (Phase 1) were combined with key findings from qualitative interviews with 12 injured young people and 10 family members (Phase 2).

RESULTS

The integration of findings from Phase 1 and Phase 2 resulted in three new findings; [1] (Alfred Health, 2014). A young person's perception of the severity of their injury, as well as the amount of time spent in hospital, impacts substantially on the way in which they experience injury, and this is managed differently between genders; [2] (Newnam et al., 2014). Admission to an Intensive care unit, including the intensity and duration of care, is the primary influence on how a family will provide support to the young person in the inpatient period; and [3] (Lyons et al., 2010). Young people's perception and understanding of their recovery from injury is in contrast with how healthcare systems are structured to provide rehabilitation and recovery care.

CONCLUSION

The injury trajectory and recovery process of young people in the six months following injury have been have conceptualised. These trajectories of recovery can inform the development of anticipatory guidance frameworks for clinicians and guide the provision of and planning for clinical services for injured young people.

Referral decision support in patients with subacute brain injury: evaluation of the Rehabilitation Complexity Scale - Extended

PURPOSE

To test if the Rehabilitation Complexity Scale Extended (RCS-E) can be used as decision support for patient referral to primary rehabilitation as either complex specialized services (CSS) or district specialist services (DSS).

METHOD

Two independent expert teams analyzed medical records on 299 consecutive patients admitted for CSS or DSS rehabilitation. One team provided a golden standard for the patient referrals, and the other team provided RCS-E scores. Models for predicting referrals from RCS-E scores were developed on data for 149 patients and tested on the remaining 150 patients.

RESULTS

The optimal RCS-E sum score threshold for referral prediction was 11, predicting the golden standard for patient referral with sensitivity 88%, specificity 78% and correct classification rate 81%. Improved referral prediction performance was achieved by using RCS-E item-wise score thresholds (sensitivity 81%, specificity 89%, correct classification rate 87%). The RCS-E sum score range for patients referred CSS and DSS by the item-wise model was, respectively, 0-12 and 2-22 suggesting strong non-linear interaction of the RCS-E items.

CONCLUSIONS

We found excellent referral decision support in the RCS-E and the item specific threshold model, when patients with acquired brain injury are to be referred to CSS or DSS as their primary rehabilitation. Implications for Rehabilitation Efficient rehabilitation after acquired brain injury requires rehabilitation settings that meet patient needs. Validated tools for referral decision support make the process more transparent. Patient rehabilitation complexity can be stratified by the RCS-E with high sensitivity, specificity and predictive value of positive test. RCS-E is an excellent tool for referral decision support.

Measuring complexity in neurological rehabilitation: the Oxford Case Complexity Assessment Measure (OCCAM)

Objective:

To investigate validity and reliability of a new measure of case complexity, the Oxford Case Complexity Assessment Measure (OCCAM).

Design:

Data collection on inpatients and outpatients attending for rehabilitation. In subsets, repeat assessments were undertaken two weeks apart, by clinicians unaware of initial data, and on admission and on discharge from inpatient rehabilitation.

Setting:

Specialist neurological rehabilitation service.

Subjects:

Patients receiving rehabilitation after acute onset disability.

Interventions:

Assessment by clinical staff as part of routine care.

Measures:

OCCAM, the INTERMED, Rehabilitation Complexity Scale – Extended (RCS-E), clinical judgement of complexity (0–10 numerical rating scale), length of stay and discharge destination (for inpatients).

Results:

For the OCCAM, the Cronbach’s α coefficient was 0.69 and item-total correlations were moderate to high except for pathology and time. The correlation coefficients with OCCAM were: INTERMED (ρ = 0.694), RCS-E (ρ = 0.736), and team judgement (ρ = 0.796). Inter-rater agreement was excellent (Weighted κ = 0.95). Correlation between admission and discharge scores was ρ = 0.917. Test–retest agreement was good (intraclass correlation coefficient 0.86). Higher mean admission scores were associated with prolonged stays (38.6 ± 12.2 versus 32.9 ± 13.7, P = 0.04) and failure to return home (48.0 ± 13.7 versus mean 32.1 ± 10.7, P < 0.001). The optimal cut-off of OCCAM to detect patients not discharged home was ≥ 34, with corresponding sensitivity and specificity of 84.6% and 62.8%, respectively.

Conclusions:

This preliminary evidence suggests that the OCCAM may measure case complexity reliably, and may predict rehabilitation resource used and outcome. Further research is warranted.