Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain and spinal cord injury

The Australian Traumatic Brain Injury Initiative: Review and Recommendations for Outcome Measures for Use With Adults and Children After Moderate-to-Severe Traumatic Brain Injury

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to select a set of measures to comprehensively predict and assess outcomes following moderate-to-severe traumatic brain injury (TBI) across Australia. The aim of this article was to report on the implementation and findings of an evidence-based consensus approach to develop AUS-TBI recommendations for outcome measures following adult and pediatric moderate-to-severe TBI. Following consultation with a panel of expert clinicians, Aboriginal and Torres Strait Islander representatives and a Living Experience group, and preliminary literature searches with a broader focus, a decision was made to focus on measures of mortality, everyday functional outcomes, and quality of life. Standardized searches of bibliographic databases were conducted through March 2022. Characteristics of 75 outcome measures were extracted from 1485 primary studies. Consensus meetings among the AUS-TBI Steering Committee, an expert panel of clinicians and researchers and a group of individuals with lived experience of TBI resulted in the production of a final list of 11 core outcome measures: the Functional Independence Measure (FIM); Glasgow Outcome Scale-Extended (GOS-E); Satisfaction With Life Scale (SWLS) (adult); mortality; EuroQol-5 Dimensions (EQ5D); Mayo-Portland Adaptability Inventory (MPAI); Return to Work /Study (adult and pediatric); Functional Independence Measure for Children (WEEFIM); Glasgow Outcome Scale Modified for Children (GOS-E PEDS); Paediatric Quality of Life Scale (PEDS-QL); and Strengths and Difficulties Questionnaire (pediatric). These 11 outcome measures will be included as common data elements in the AUS-TBI data dictionary. Review Registration PROSPERO (CRD42022290954).

Influence of Foreign Versus US Nativity on the Trajectory of Functional Independence Over the 10 Years After Traumatic Brain Injury: A Model Systems Study

OBJECTIVE

Although racial/ethnic disparities have been documented in numerous outcomes after traumatic brain injury (TBI), research has yet to explore differences in rehabilitation outcomes based upon nativity (foreign-born vs US-born individuals). The purpose of this study was to compare the functional outcomes over the first 10 years after TBI for individuals born in the United States with those who were foreign-born.

SETTING/PARTICIPANTS

A sample of 10 695 individuals in the TBI Model Systems database with a coding for country of birth the United States ( n = 9435) versus other than the United States ( n = 1260) was used.

DESIGN/MAIN MEASURES

Outcome measures at 1, 2, 5, and 10 years after TBI included the Motor and Cognitive subscales of the Functional Independence Measure and the Supervision Rating Scale.

RESULTS

Foreign-born individuals exhibited lower motor functional independence trajectories than those born in the United States, even after controlling for demographic and injury-related covariates. However, foreign-born individuals generally showed a stronger upward quadratic trajectory in motor functional independence with the greatest gains between the 5- and 10-year time points, whereas those born in the United States improved more quickly but then plateaued between the 5- and 10-year time points; these differential effects over time dissipated with the addition of demographic and injury-related covariates. Foreign-born individuals also exhibited lower cognitive functional independence trajectories, as well as greater supervision needs trajectories, than those born in the United States, even after controlling for demographic and injury-related covariates.

CONCLUSION

These findings dovetail with literature suggesting that racially/ethnically diverse groups exhibit reduced functional independence after TBI. The findings may also suggest potential systematic barriers such as healthcare access and language barriers that may influence the frequency, rate, and quality of care received. The results highlight the importance of uncovering cultural distinctions and can aid in facilitating research examining foreign nativity-based disparities following TBI.

Trajectories of Cognitive and Motor Functional Independence in Hispanic Individuals During the 10 yrs After Traumatic Brain Injury

OBJECTIVE

This study examined demographic and injury-related predictors of cognitive and motor functional independence in Hispanics with traumatic brain injury at years 1, 2, 5, and 10 after hospital discharge.

DESIGN

Hispanic participants ( n = 1360) from the TBI Model Systems Study were included if they had at least one Functional Independence Measure (FIM) Cognitive and Motor score at any time point (years 1, 2, 5, or 10). Hierarchical linear modeling was used to examine baseline predictors of FIM Cognitive and Motor trajectories across this period.

RESULTS

FIM Cognitive trajectories showed a quadratic movement (initial increase followed by a plateau or slight decrease), whereas FIM Motor trajectories showed a cubic movement (initial increase, followed by a plateau, then another increase). Higher FIM Cognitive trajectories were predicted by younger age, shorter length of posttraumatic amnesia, higher education, and having experienced a nonviolent mechanism of injury. Higher FIM Motor trajectories were predicted by younger age, shorter posttraumatic amnesia, and a nonviolent mechanism of injury.

CONCLUSIONS

The baseline predictors of functional trajectories identified may help create tailored, evidence-based rehabilitation interventions along the continuum of recovery during the first 10 yrs for Hispanics with traumatic brain injury at risk for reduced functional outcomes.

Effect of durations and pressures of cupping therapy on muscle stiffness of triceps

Cupping therapy has been used for the alleviation of muscle soreness in athletes. However, clinical studies of cupping therapy show conflicting results. Lack of standardized guidelines of the dose-response relationship of cupping therapy, such as appropriate cupping duration and negative pressure, limits the adoption of cupping therapy in clinical practice. The objectives of this study were to investigate the effect of various pressures and durations of cupping therapy on reducing muscle stiffness. The 2 × 2 factorial design with the repeated measures and counterbalanced design was used to test four cupping protocols, including two negative pressures at -225 and -300 mmHg and two durations at 5 and 10 min, in 12 healthy young people. B-mode and elastographic ultrasound was used to assess muscle stiffness of the triceps before and after cupping therapy. The region of interest of elastographic image was divided into the superficial and deep layers for assessing the effect of cupping therapy on stiffness of various depths of the triceps. Normalized stiffness was calculated as a ratio of pre-cupping stiffness divided by post-cupping stiffness of each participant. The two-way analysis of variance (ANOVA) was used to examine the main effects of the pressure and duration factors and the interaction effect between the pressure and duration factors. The results showed that there were no interactions between the pressure and duration factors (overall layer p = 0.149, superficial layer p = 0.632, and deep layer p = 0.491). The main effects of duration of the overall, superficial and deep layers were p = 0.538, p = 0.097 and p = 0.018, respectively. The results showed that 10-min cupping at -300 mmHg is more effective on reducing stiffness of the deep layer of the triceps compared to 5-min cupping (p = 0.031). This study provides the first evidence that the dose of cupping therapy could significantly affect changes of triceps stiffness and the deep layer of the muscle is more sensitive to cupping therapy compared to the superficial and overall layers.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

INTRODUCTION

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

METHODS

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

RESULTS

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

CONCLUSIONS

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013190.

Testosterone replacement in hypogonadal men during inpatient rehabilitation following traumatic brain injury: Results from a double-blind, placebo-controlled clinical pilot study

BACKGROUND

Endocrinopathy, including hypogonadism, is common following traumatic brain injury (TBI). Prior evidence suggests hypogonadism is associated with poorer function.

OBJECTIVE

Determine the feasibility, safety, and efficacy of testosterone (T) therapy in hypogonadal men following TBI in acute rehabilitation.

DESIGN

Randomized, double blind, placebo-controlled pilot trial.

SETTING

Inpatient rehabilitation brain injury unit.

PARTICIPANTS

Men ages 18 -65, post moderate to severe TBI receiving inpatient rehabilitation.

INTERVENTIONS

Transdermal T gel or placebo.

MAIN OUTCOME MEASURES

Revised FIM™ score, strength, adverse events.

RESULTS

Of 498 screened, 70 participants were enrolled, and 22 meeting all criteria were randomized into placebo (n = 10) or physiologic T therapy (n = 12). There was no significant difference between groups in rate of improvement on the FIM™ (intercepts t = -0.31, p = 0.7593, or slopes t = 0.61, p = 0.5472). The Treatment group demonstrated the greatest absolute improvement in FIM™ scores and grip strength compared to Placebo or Normal T groups. There was no difference in adverse events between groups. Percentage of time with agitation or aggression was highest in the Placebo group.

CONCLUSIONS

Although there were no significant differences in rates of recovery, treatment group subjects showed greater absolute functional and strength improvement compared to the Placebo or Normal T groups.

Nutrition and Exercise in Critical Illness Trial (NEXIS Trial): a protocol of a multicentred, randomised controlled trial of combined cycle ergometry and amino acid supplementation commenced early during critical illness

INTRODUCTION

Survivors of critical illness often experience significant morbidities, including muscle weakness and impairments in physical functioning. This muscle weakness is associated with longer duration mechanical ventilation, greater hospital costs and increased postdischarge impairments in physical function, quality of life and survival. Compared with standard of care, the benefits of greater protein intake combined with structured exercise started early after the onset of critical illness remain uncertain. However, the combination of protein supplementation and exercise in other populations has demonstrated positive effects on strength and function. In the present study, we will evaluate the effects of a combination of early implementation of intravenous amino acid supplementation and in-bed cycle ergometry exercise versus a 'usual care' control group in patients with acute respiratory failure requiring mechanical ventilation in an intensive care unit (ICU).

METHODS AND ANALYSIS

In this multicentre, assessor-blinded, randomised controlled trial, we will randomise 142 patients in a 1:1 ratio to usual care (which commonly consists of minimal exercise and under-achievement of guideline-recommended caloric and protein intake goals) versus a combined intravenous amino acid supplementation and in-bed cycle ergometery exercise intervention. We hypothesise that this novel combined intervention will (1) improve physical functioning at hospital discharge; (2) reduce muscle wasting with improved amino acid metabolism and protein synthesis in-hospital and (3) improve patient-reported outcomes and healthcare resource utilisation at 6 months after enrolment. Key cointerventions will be standardised. In-hospital outcome assessments will be conducted at baseline, ICU discharge and hospital discharge. An intent-to-treat analysis will be used to analyse all data with additional per-protocol analyses.

ETHICS AND DISSEMINATION

The trial received ethics approval at each institution and enrolment has begun. These results will inform both clinical practice and future research in the area. We plan to disseminate trial results in peer-reviewed journals, at national and international conferences, and via nutritional and rehabilitation-focused electronic education and knowledge translation platforms.

TRIAL REGISTRATION NUMBER

NCT03021902; Pre-results.

Utility of Functional Metrics Assessed During Acute Care on Hospital Outcomes: A Systematic Review

OBJECTIVE

Traditionally, illness severity, social factors, and comorbid conditions have been examined as predictors of hospital outcomes. However, recent research in the rehabilitation setting demonstrated that physical function outperformed comorbidity indices as a predictor of 30-day readmission. The purpose of this study was to review the literature examining the association between acute hospital physical function and various hospital outcomes and health care utilization. TYPE: Systematic review.

LITERATURE SURVEY

A review of the MEDLINE database was performed. Search terms included acute functional outcomes and frailty outcomes. Studies up to September 2017 were included if they were in English and examined how functional metrics collected at acute care hospitalization affected hospital outcomes.

METHODOLOGY

Cohort characteristics and measures of associations were extracted from the studies. Outcomes include hospital readmission, length of stay, mortality, discharge location, and physical function post acute care. The studies were assessed for potential confounders as well as selection, attrition, and detection bias.

SYNTHESIS

A total of 30 studies were identified (hospital readmissions: 6; discharge location: 11; length of stay: 4; mortality: 15; function: 6). Thirteen different metrics assessed function during acute care. Lower function during acute care was associated with statistically significant higher odds of hospital readmission, lower likelihood of discharge to home, longer hospital length of stay, increased mortality, and worse functional recovery when compared to patients with higher function during acute care, when adjusted for age and gender. The Barthel Index may be a useful marker for mortality in the elderly whereas the Functional Independence Measure instrument may be valuable for examining discharge location.

CONCLUSIONS

There is increasing evidence that function measured during acute care predicts a broad array of meaningful clinical outcomes. Further research would help direct the use of practical, yet parsimonious functional metrics that effectively screen high-need, high-cost patients to deliver optimal care.

LEVEL OF EVIDENCE

I.

Impact of Early Inpatient Rehabilitation on Adult Burn Survivors' Functional Outcomes and Resource Utilization

On July 2012, a rehabilitation hospital merged with a trauma center where the regional burn center is located. That rehabilitation center provides the only burn rehabilitation program in our region. The objective of this study was to determine if earlier initiation of inpatient rehabilitation after merger had an effect on burn survivors' functional outcomes and resource utilization. A retrospective review of electronic data of burn survivors' functional outcomes (functional independence measure [FIM] ratings on admission, at discharge, and percent change), and resource utilization (waiting time for rehab, burn center length of stay [LOS], rehab LOS, physiotherapy and occupational therapy rehabilitation workload [RehabWorkload], and discharge destination) was undertaken. Adult burn survivors who required inpatient rehabilitation and were transferred from the burn center to the inpatient rehabilitation service before the merger (July 2010-June 2012) were compared with those transferred after the merger (July 2012-June 2014). One hundred thirty-eight burn survivors were transferred from the burn center to the inpatient rehabilitation service during the study period. Sixty (43.5%) were transferred before and 78 (56.5%) were transferred after the merger. There were 97 (70.3%) men and 41 (29.7%) women with a mean age of 47.9 ± 17.9 years. TBSA burn was 24.2 ± 16.9%, and full thickness burn was 13.1 ± 16.4%. The etiology of these burns were flame (72.5%), scald (19.6%), electrical (5.1%), chemical (2.2%), and contact (0.7%). Patients in both groups had similar age, inhalation injury, TBSA, full thickness burn, FIM ratings, RehabWorkload, and burn etiology. Patients transferred before the merger had significantly more chemical burns (5% vs 0%, P = .046), and more work-related burns (26.7% vs 7.7%, P = .004). Patients transferred after the merger had significantly shorter burn center LOS (28.5 ± 20.9 days vs 38.8 ± 34.2 days, P = .043), and shorter waiting time for rehab (0.7 ± 1.1 days vs 1.5 ± 2.3 days, P = .010) than patients transferred before the merger. Early initiation of inpatient rehabilitation, after the burn center and the inpatient rehabilitation service were located in the same hospital, improved burn survivors' resource utilization.

A Multicenter Randomized Control Trial Comparing a Novel Intramedullary Device (InterTAN) Versus Conventional Treatment (Sliding Hip Screw) of Geriatric Hip Fractures

OBJECTIVES

To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT).

DESIGN

Prospective, randomized, multicenter clinical trial.

SETTING

Five level 1 trauma centers.

PATIENTS

Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months.

INTERVENTION

Computer generated randomization to either IT (n = 123) or SHS (n = 126).

MAIN OUTCOME MEASUREMENTS

The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality.

RESULTS

Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT.

CONCLUSIONS

Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Association of impaired functional status at hospital discharge and subsequent rehospitalization

OBJECTIVE

To determine whether functional status near the time of discharge from acute care hospitalization is associated with acute care readmission.

PATIENTS AND METHODS

Retrospective cohort study of 9405 consecutive patients admitted from an acute care hospital to an inpatient rehabilitation facility between July 1, 2006 and December 31, 2012. Patients' functional status at admission to the rehabilitation facility was assessed by the Functional Independence Measure (FIM) score, and divided into low, middle, or high functional status. The main outcome was readmission to an acute care hospital within 30 days of acute care discharge (for all patients and by subgroup according to diagnostic group: medical, orthopedic, or neurologic).

RESULTS

There were 1182 (13%) readmissions. FIM score was significantly associated with readmission, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for low and middle versus high FIM score category of 3.0 (2.5-3.6; P < 0.001) and 1.5 (95% CI: 1.3-1.8; P < 0.001), respectively. This relationship between FIM score and readmission held across diagnostic category. Medical patients with low functional status had the highest readmission rate (OR: 29%; 95% CI: 25%-32%) and an adjusted OR for readmission of 3.2 (95% CI: 2.4-4.3, P < 0.001) compared to medical patients with high FIM scores.

CONCLUSIONS AND RELEVANCE

For patients admitted to an acute inpatient rehabilitation facility, functional status near the time of discharge from an acute care hospital is strongly associated with acute care readmission, particularly for medical patients with greater functional impairments. Reducing functional status decline during acute care hospitalization may be an important strategy to lower readmissions.

The experience of using the scale of functional independence measure in individuals undergoing spinal cord injury rehabilitation in Brazil

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

The aim of this study was to evaluate the correlation between the level and completeness of the injury with Functional Independence Measure (FIM) score and the validity and responsiveness of the FIM in Brazilian individuals with spinal cord injury admitted to rehabilitation.

SETTING

SARAH Network of Rehabilitation Hospitals, Brasília, Brazil.

METHODS

A total of 218 patients with spinal cord injury admitted for rehabilitation in 2006 was included in this study. The validity was assessed as the ability of the FIM to discriminate different levels of disability (cervical, thoracic and lumbar) at admission and the responsiveness was obtained by analyzing admission and discharge data for each of the three injury groups.

RESULTS

Total FIM score, motor FIM score and each of the 13 items were valid when comparing three groups and comparing groups two by two, except the items 'eating' and 'grooming' among paraplegics, and 'stairs' at cervical and thoracic levels. The scale was not responsive to the five cognitive items, 'stairs' and 'eating', among paraplegics, or 'grooming', 'bathing' and 'dressing upper body' in lumbar level patients. The patient difficulty in performing tasks can vary among populations. Therefore, the continuous evaluation process of psychometric characteristics is important to validate the use of the instrument in different contexts.

Activity limitations experienced by people with stroke who receive inpatient rehabilitation: differences between 2001, 2005, and 2011

OBJECTIVE

To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011.

DESIGN

A multicenter observational study of 3 periods.

SETTING

Inpatient rehabilitation units (N=15).

PARTICIPANTS

Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge.

RESULTS

All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts.

CONCLUSIONS

In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.

The BETA^&reg; nursing measure: Its development and testing for nursing utility

In the specialised nursing fields of rehabilitation, convalescence and gerontology requiring restorative nursing interventions, nurses are unable to measure, assess and evaluate accurately and routinely the outcomes of their patients’ activities of daily living (ADLs) due to the lack of validated nursing measures. The purpose of this study was to develop a nursing scale, named the BETA, which can be used routinely and embedded into the nursing process and care plan, enabling the primary nursing carer to measure, assess and evaluate patients’ ADLs. The first objective was to design and develop the BETA, a routine nursing scale, whereby caregivers and nursing auxiliaries can observe, score and record their patients’ activities of daily living. The second objective was to test the BETA’s nursing utility to be used routinely. Two qualitative studies were done sequentially. Firstly, individual interviews were conducted to collect descriptive data from registered nurses (n = 6), nursing assistants, (n = 8) and caregivers (n = 16), skilled in the field of restorative care. In the first study, the data were analysed using inductive content analysis techniques to design and construct the BETA nursing measure. In the second study, the BETA’s nursing utility was studied by means of the training of and testing the application of the BETA by a new team of professional nurses (n = 6) and caregivers (n = 48) working in a geriatric frail care unit. After 6 months, two homogenous focus groups consisting of registered nurses (n = 3) and caregivers (n = 5) representing this team were interviewed to explore the BETA’s nursing utility. Descriptive data in the second study were analysed using deductive content analysis. The initial results were promising. The high levels of agreement on its acceptance, usefulness and confidence, to be used routinely as a nursing scale, confirmed the BETA’s nursing utility. The BETA nursing scale has the potential to introduce restorative nursing as a new specialisation field in South African nursing, a much needed service required by patients and multidisciplinary teams. This, however, will depend on the construct validity of the BETA, a study to be reported on in a follow-up article.Gespesialiseerde verpleging vir rehabilitasie, herstelling en gerontologie benodig restoratiewe intervensies, maar verpleegsters kan nie die uitkomste van hul pasiënte se aktiwiteite van daaglikse lewe (ADLs) akkuraat en geroetineerd meet, assesseer en evalueer nie, asgevolg van ’n gebrek aan geldige meet instrumente. Die doel van hierdie studie was om die BETA, ’n verplegings meet skaal, te ontwikkel wat roetineweg deel kan word van die verplegingsproses en sorgplan en wat die primêre versorger in staat stel om pasiënte se ADLs te meet, assesseer en evalueer. Die eerste doelwitte was om die BETA skaal te ontwerp en ontwikkel vir primêre versorgers om hul pasiënte se ADLs roetineweg te kan waarneem en opteken. Die tweede doelwit was om die BETA skaal se nuttigheid vir verpleegsters te toets. Daar is twee opeenvolgende kwalitatiewe studies gedoen. Eers is daar individuele onderhoude gevoer om beskrywende data te versamel van geregistreerde verpleegsters (n = 6), verpleegassistente, (n = 8) en versorgers (n = 16), wat bedrewe is in die veld van restoratiewe verpleging. In die eerste studie is die data geanaliseer met behulp van induktiewe inhoudsanalisetegnieke om die BETA skaal te ontwerp en op te stel. In die tweede studie is die BETA se nuttigheid vir verpleging bestudeer deur opleiding en toetsing in die toepassing van die BETA deur ʼn nuwe span geregistreerde verpleegsters (n = 6) en versorgers (n = 48) wat in ʼn versorgingseenheid vir geriatriese verswaktes werk. Na ses maande is twee homogene fokusgroepe gehou, bestaande uit geregistreerde verpleërs (n = 3) en versorgers (n = 5) wat hierdie span verteenwoordig, om die nuttigheid vir verpleging te ondersoek. Beskrywende data in die tweede studie is met behulp van deduktiewe inhoudsanalisetegnieke geanaliseer. Die aanvanklike resultate was belowend. Die BETA se nuttigheidsvlakke vir verpleging het hoë hoogtes van aanvaarding, betroubaarheid en vertroue bevestig. Die BETA-verplegingskaal het die potensiaal om restoratiewe verpleging as ʼn nuwe spesialiseringsveld in Suid-Afrikaanse verpleging te bewerkstellig, ʼn baie nodige diens vir beide pasiënte en multidissiplinêre spanne. Dit sal egter afhang van die geldigheid van die BETA, ʼn studie waaroor daar in ʼn opvolgartikel verslag gedoen sal word.

One-year follow-up of Chinese people with spinal cord injury: a preliminary study

BACKGROUND

A tertiary spinal cord injury (SCI) center was established in the northern region of Hong Kong, China and a multidisciplinary SCI rehabilitation program was developed to reintegrate patients into the community.

OBJECTIVE

To investigate functional outcomes for Chinese people with SCI across a 1-year period.

DESIGN

Longitudinal prospective design.

METHODS

Thirty community-dwelling participants with traumatic SCI were recruited. Functional status was measured using functional independence measure (FIM) on admission, upon discharge, 1-month, 3-month, 6-month, and 1-year post-discharge. Information on use of assistive devices and life role were also obtained.

RESULTS

Twenty-three (76.67%) participants were men. Seventeen participants (10 with tetraplegia and 7 with paraplegia) were classified ASIA A, B, or C; 13 (7 with tetraplegia and 6 with paraplegia) were classified as ASIA D. Significant differences in FIM motor scores were only found between the tetraplegia group and three other diagnostic groups using Bonferroni post-hoc tests of repeated measure ANOVA (analysis of variance) (P < 0.05). Longitudinally, contrast tests of repeated measure ANOVA showed significant differences during the hospitalization period for all diagnostic groups. People in the ASIA D group showed significant functional improvement even after 1-year post-discharge (P < 0.05). At 1-year post-discharge, only two participants were engaged in either remunerative employment or academic pursuit.

CONCLUSION

Despite functional status improvement, few people with traumatic SCI were re-engaged in productive life role 1 year after discharge. Studies with longer follow-up would be beneficial.

Relationship of patient characteristics and rehabilitation services to outcomes following spinal cord injury: the SCIRehab project

BACKGROUND/OBJECTIVE

To examine associations of patient characteristics along with treatment quantity delivered by seven clinical disciplines during inpatient spinal cord injury (SCI) rehabilitation with outcomes at rehabilitation discharge and 1-year post-injury.

METHODS

Six inpatient SCI rehabilitation centers enrolled 1376 patients during the 5-year SCIRehab study. Clinicians delivering standard care documented details of treatment. Outcome data were derived from SCI Model Systems Form I and II and a project-specific interview conducted at approximately 1-year post-injury. Regression modeling was used to predict outcomes; models were cross-validated by examining relative shrinkage of the original model R(2) using 75% of the dataset to the R(2) for the same outcome using a validation subsample.

RESULTS

Patient characteristics are strong predictors of outcome; treatment duration adds slightly more predictive power. More time in physical therapy was associated positively with motor Functional Independence Measure at discharge and the 1-year anniversary, CHART Physical Independence, Social Integration, and Mobility dimensions, and smaller likelihood of rehospitalization after discharge and reporting of pressure ulcer at the interview. More time in therapeutic recreation also had multiple similar positive associations. Time spent in other disciplines had fewer and mixed relationships. Seven models validated well, two validated moderately well, and four validated poorly.

CONCLUSION

Patient characteristics explain a large proportion of variation in multiple outcomes after inpatient rehabilitation. The total amount of treatment received during rehabilitation from each of seven disciplines explains little additional variance. Reasons for this and the phenomenon that sometimes more hours of service predict poorer outcome, need additional study. Note: This is the first of nine articles in the SCIRehab series.

Knowledge mobilization regarding activity and exercise after spinal cord injury: a Canadian undergraduate curriculum scan

PURPOSE

The purpose of this study was to conduct a curriculum scan of Canadian undergraduate university programs to determine the relative emphasis placed on the activity and exercise after spinal cord injury (SCI), in the context of physical disability studies.

METHOD

Eighty-three Canadian Universities were evaluated for courses discussing: (i) general information about SCI, (ii) physical activity and exercise after SCI, (iii) general information about other physical disabilities and (iv) physical activity and exercise for such disabilities. Online course calendars (2009) were scanned, and their accuracy was verified by instructors or administrative assistants.

RESULTS

The curriculum scan revealed 113 courses that discuss physical disability. Seventy-four of these courses cover information regarding SCI, 47 of which include content relating to activity and exercise. In comparison, 104 courses discuss other physical disabilities, 76 of which cover material related to activity and exercise. Further, the 47 courses that cover activity and exercise after SCI are only offered in 22 Canadian Universities, and only 31 are mandatory for a degree.

CONCLUSIONS

A substantial number of future healthcare professionals lack exposure to material regarding activity and exercise after SCI during their undergraduate education. This curricular oversight likely contributes to ineffective exercise strategies and the relative inactivity of the SCI population. [

IMPLICATIONS FOR REHABILITATION

• Individuals with spinal cord injury are relatively inactive due to the many physical, psychological and social barriers they face regarding activity and exercise participation.• Effective knowledge mobilization regarding activity and exercise after SCI to future healthcare providers is an essential step in promoting participation.• This undergraduate curriculum scan showed that students lack exposure to issues regarding the activity and exercise after SCI in Canadian Universities.• The lack of effective knowledge mobilization in this area likely contributes to the low levels of activity and exercise participation in the SCI population.]

International casemix and funding models: lessons for rehabilitation

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘An understanding of the different international models for funding of health care services and casemix systems, as exemplified by those in the US, Australia and the UK.’

Background: Payment for treatment in healthcare systems around the world is increasingly based on fixed tariff models to drive up efficiency and contain costs. Casemix classifications, however, must account adequately for the resource implications of varying case complexity. Rehabilitation poses some particular challenges for casemix development.

Objective: The objectives of this educational narrative review are (a) to provide an overview of the development of casemix in rehabilitation, (b) to describe key characteristics of some well-established casemix and payment models in operation around the world and (c) to explore opportunities for future development arising from the lessons learned.

Results: Diagnosis alone does not adequately describe cost variation in rehabilitation. Functional dependency is considered a better cost indicator, and casemix classifications for inpatient rehabilitation in the United States and Australia rely on the Functional Independence Measure (FIM). Fixed episode-based prospective payment systems are shown to contain costs, but at the expense of poorer functional outcomes. More sophisticated models incorporating a mixture of episode and weighted per diem rates may offer greater flexibility to optimize outcome, while still providing incentive for throughput.

Conclusion: The development of casemix in rehabilitation poses similar challenges for healthcare systems all around the world. Well-established casemix systems in the United States and Australia have afforded valuable lessons for other countries to learn from, but have not provided all the answers. A range of casemix and payment models is required to cater for different healthcare cultures, and casemix tools must capture all the key cost-determinants of treatment for patients with complex needs.

Healthcare tariffs for specialist inpatient neurorehabilitation services: rationale and development of a UK casemix and costing methodology

Objective: To describe the rationale and development of a casemix model and costing methodology for tariff development for specialist neurorehabilitation services in the UK.

Rationale for development of a new methodology: Patients with complex needs incur higher treatment costs. Fair payment should be weighted in proportion to costs of providing treatment, and should allow for variation over time

Casemix model and band-weighting: Case complexity is measured by the Rehabilitation Complexity Scale (RCS). Cases are divided into five bands of complexity, based on the total RCS score. The principal determinant of costs in rehabilitation is staff time. Total staff hours/week (estimated from the Northwick Park Nursing and Therapy Dependency Scales) are analysed within each complexity band, through cross-sectional analysis of parallel ratings. A ‘band-weighting’ factor is derived from the relative proportions of staff time within each of the five bands.

Costing methodology: Total unit treatment costs are obtained from retrospective analysis of provider hospitals’ budget and accounting statements. Mean bed-day costs (total unit cost/occupied bed days) are divided broadly into ‘variable’ and ‘non-variable’ components. In the weighted costing model, the band-weighting factor is applied to the variable portion of the bed-day cost to derive a banded cost, and thence a set of cost-multipliers. Preliminary data from one unit are presented to illustrate how this weighted costing model will be applied to derive a multilevel banded payment model, based on serial complexity ratings, to allow for change over time.

Medicare's recovery audit contractor program: inpatient rehabilitation facilities are taking back takebacks, but enough?

A perfect storm had been brewing in the last decade: Medicare payment mistakes; Medicare waste, fraud, and abuse; fuzzy medical necessity definitions; erroneous coding; and a strained national budget. The United States Congress responded by inserting Section 306 into the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Section 306 called for the correction of Medicare payment problems by establishing the Recovery Audit Contractor program as the vehicle for the Centers for Medicare & Medicaid Services to recoup Medicare overpayments as far back as 3 yrs from its healthcare providers and to return underpayments to them. The legislation allowed for Medicare to contract with private firms to follow the money and earn a cut. Caught in the eye of the storm, Medicare providers combined are giving back more than they get back. Inpatient Rehabilitation Facilities are taking back takebacks-but enough to remain viable?

Measuring functional and quality of life outcomes following major head injury: common scales and checklists

Traumatic brain injury (TBI) is a major public health issue, which results in significant mortality and long term disability. The profound impact of TBI is not only felt by the individuals who suffer the injury but also their care-givers and society as a whole. Clinicians and researchers require reliable and valid measures of long term outcome not only to truly quantify the burden of TBI and the scale of functional impairment in survivors, but also to allow early appropriate allocation of rehabilitation supports. In addition, clinical trials which aim to improve outcomes in this devastating condition require high quality measures to accurately assess the impact of the interventions being studied. In this article, we review the properties of an ideal measure of outcome in the TBI population. Then, we describe the key components and performance of the measurement tools most commonly used to quantify outcome in clinical studies in TBI. These measurement tools include: the Glasgow Outcome Scale (GOS) and extended Glasgow Outcome Scale (GOSe); Disability Rating Scale (DRS); Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Functional Status Examination (FSE) and the TBI-specific and generic quality of life measures used in TBI patients (SF-36 and SF-12, WHOQOL-BREF, SIP, EQ-5D, EBIQ, and QOLIBRI).

Comparing content of therapy for people with a spinal cord injury in postacute inpatient rehabilitation in Australia, Norway, and The Netherlands

BACKGROUND

Research reports have described the contents of therapy in spinal cord injury (SCI) rehabilitation only as the total number of therapy hours. We developed the Spinal Cord Injury-Interventions Classification System (SCI-ICS) as a tool to classify therapy to improve mobility and self-care into 3 levels (body functions, basic activities, and complex activities) and 25 categories.

OBJECTIVE

The purposes of this study were: (1) to compare specific contents and amount of therapy provided, with the aim of improving mobility and self-care for people with SCI in Australia, Norway, and the Netherlands and (2) to evaluate the use of the SCI-ICS outside the Netherlands.

DESIGN

This was a prospective, descriptive study.

METHODS

Physical therapists, occupational therapists, and sports therapists in 6 centers recorded all therapy provided to all people with a recent SCI in inpatient rehabilitation during 4 designated weeks. Each treatment session was classified using 1 or more SCI-ICS codes. Duration of each intervention was specified.

RESULTS

Seventy-three therapists recorded 2,526 treatments of 79 people with SCI (Netherlands, 48; Australia, 20; Norway, 11). Most therapy time was spent on exercises (overall mean=84%) and on categories at body function and basic activity level of the SCI-ICS. Therapy time significantly differed among countries for 13 of 25 categories. Mean time in minutes per treatment (Netherlands, 28; Australia, 43; Norway, 39) and in hours per patient per week (Netherlands, 4.3; Australia, 5.8; Norway, 6.2) differed significantly.

LIMITATIONS

The short period and small number of patients may have influenced the results.

CONCLUSIONS

Therapy in inpatient SCI rehabilitation in all 3 countries focused on mobility and self-care exercises at body function and basic activity level, but differences were present in focus on the various categories and therapy time. The SCI-ICS can be used reliably to describe therapy in different countries.

The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation

BACKGROUND/OBJECTIVE

Length of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs.

METHODS

Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline.

RESULTS

Average LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics.

CONCLUSIONS

Variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.

Recommendations for the use of common outcome measures in traumatic brain injury research

This article summarizes the selection of outcome measures by the interagency Traumatic Brain Injury (TBI) Outcomes Workgroup to address primary clinical research objectives, including documentation of the natural course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements Workgroups, the TBI Outcomes Workgroup adopted the standard 3-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in TBI from each identified domain, including global level of function, neuropsychological impairment, psychological status, TBI-related symptoms, executive functions, cognitive and physical activity limitations, social role participation, and perceived health-related quality of life. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to some older ("legacy") measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

The Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI): II. Reliability and convergent validity

A standardized measure of neurological dysfunction specifically designed for TBI currently does not exist and the lack of assessment of this domain represents a substantial gap. To address this, the Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI) was developed for TBI outcomes research through the addition to and modification of items specifically relevant to patients with TBI, based on the National Institutes of Health Stroke Scale. In a sample of 50 participants (mean age = 33.3 years, SD = 12.9) <or=18 months (mean = 3.1, SD = 3.2) following moderate (n = 8) to severe (n = 42) TBI, internal consistency of the NOS-TBI was high (Cronbach's alpha = 0.942). Test-retest reliability also was high (rho = 0.97, p < 0.0001), and individual item kappas between independent raters were excellent, ranging from 0.83 to 1.0. Overall inter-rater agreement between independent raters (Kendall's coefficient of concordance) for the NOS-TBI total score was excellent (W = 0.995). Convergent validity was demonstrated through significant Spearman rank-order correlations between the NOS-TBI and the concurrently administered Disability Rating Scale (rho = 0.75, p < 0.0001), Rancho Los Amigos Scale (rho = -0.60, p < 0.0001), Supervision Rating Scale (rho = 0.59, p < 0.0001), and the FIM (rho = -0.68, p < 0.0001). These results suggest that the NOS-TBI is a reliable and valid measure of neurological functioning in patients with moderate to severe TBI.

Self-inflicted traumatic brain injury: Characteristics and outcomes

OBJECTIVE

To characterize the population of those receiving inpatient rehabilitation who sustained a traumatic brain injury (TBI) secondary to a suicide attempt and identify differences between such individuals and a demographically-matched control group (n = 230) of those whose TBIs were of an unintentional aetiology.

METHOD

Analysed cases were identified from the TBI Model Systems National Database. Based on ICD-9-CM external cause-of-injury codes, 79 participants incurred a TBI secondary to a suicide attempt. An approximate 1 : 3 matched case-control (age, gender, race, injury year) design was chosen to make statistical comparisons.

RESULTS

Those who sustained a TBI secondary to a suicide attempt had greater pre-existing psychiatric and psychosocial problems (substance use problems (p = 0.01) prior suicide attempt (p < 0.0001), psychiatric hospitalization (p = 0.014) and non-productive activity (p = 0.014)), required more resources during acute and rehabilitative hospitalizations (i.e. charges per day; p = 0.024, p = 0.047) and had greater disability at the time of discharge, even after controlling for injury severity (p = 0.022).

CONCLUSION

Individuals who sustained TBIs secondary to a suicide attempt had increased pre-injury psychiatric and psychosocial problems and poorer outcomes at discharge than those who incurred unintentional injuries. For these individuals, acute and rehabilitation charges per day were higher and could not be accounted for by injury severity.

MINDFIM: A measure of disability in high-functioning traumatic brain injury outpatients

PRIMARY OBJECTIVE

The study aimed at developing a new valid measure of disability in TBI outpatients.

RESEARCH DESIGN AND METHODS

The Rasch model (Winsteps 3.45 software, 2005) was adopted to achieve a linear measure, unidimensional and reliable. The predictive capacity with respect to return to school or job was also tested (logistic regression, STATA 8.0 software, 2004).

EXPERIMENTAL INTERVENTIONS

Either tests of Attention, Memory and Verbal Fluency or the FIM were administered to 160 TBI ambulatory outpatients (52 women, age 14-72, 2-117 months after trauma, 111 cases with coma > or = 1 week). Fifty of them (31%) had returned to school or job.

MAIN OUTCOMES AND RESULTS

A new scale called MINDFIM could be successfully developed. It includes three cognitive and four FIM motor items (Grooming, Upper Body Dressing, Bathing and Tub/Shower Transfer). The scale raises the ceiling affecting existing instruments. The summated scores are predictive of return to community (74% correct classification).

CONCLUSIONS

MINDFIM is valid and useful measure of disability in TBI outpatients.

Rehabilitation outcomes for veterans with polytrauma treated at the Tampa VA

Returning soldiers from Iraq and Afghanistan who have sustained polytrauma have a combination of complex physical and mental morbidities that require extensive therapy and rehabilitation. This study examined the effect of rehabilitation on 116 polytrauma patients with service-connected injuries treated at the Tampa VA; improvements in functional and cognitive abilities were measured using the Functional Independence Measure (FIM) scores and healthcare costs for rehabilitation treatment were also assessed. Intensive rehabilitation therapy increased functional ability in this cohort with an average improvement in total FIM scores of 23 points. Total inpatient costs for these patients exceeded $4 million in approximately 3 years. Rehabilitation nurses face challenges providing quality care to this target patient population, including characterizing war-related polytrauma, providing surveillance, coordinating care, synchronizing care for patients with multiple injuries, and conducting evidence-based pain management.

Functional recovery measures for spinal cord injury: an evidence-based review for clinical practice and research

BACKGROUND/OBJECTIVE

The end goal of clinical care and clinical research involving spinal cord injury (SCI) is to improve the overall ability of persons living with SCI to function on a daily basis. Neurologic recovery does not always translate into functional recovery. Thus, sensitive outcome measures designed to assess functional status relevant to SCI are important to develop.

METHOD

Evaluation of currently available SCI functional outcome measures by a multinational work group.

RESULTS

The 4 measures that fit the prespecified inclusion criteria were the Modified Barthel Index (MBI), the Functional Independence Measure (FIM), the Quadriplegia Index of Function (QIF), and the Spinal Cord Independence Measure (SCIM). The MBI and the QIF were found to have minimal evidence for validity, whereas the FIM and the SCIM were found to be reliable and valid. The MBI has little clinical utility for use in the SCI population. Likewise, the FIM applies mainly when measuring burden of care, which is not necessarily a reflection of functional recovery. The QIF is useful for measuring functional recovery but only in a subpopulation of people with SCI, and substantial validity data are still required. The SCIM is the only functional recovery outcome measure designed specifically for SCI.

CONCLUSIONS

The multinational work group recommends that the latest version of the SCIM (SCIM III) continue to be refined and validated and subsequently implemented worldwide as the primary functional recovery outcome measure for SCI. The QIF may continue to be developed and validated for use as a supplemental tool for the nonambulatory tetraplegic population.

Outcomes studies in cerebrovascular neurosurgery

✓Successfully measuring cerebrovascular neurosurgery outcomes requires an appreciation of the current state-of-the-art epidemiological instruments, their specific relevance to surgical treatments and the underlying pathological entity, and ultimately the right set of questions for the next generation of studies. In this paper the authors address these questions with specific attention to measurement targets, individual modeling scales, and types of studies, all within a conceptual framework for specific disease models in their current state of outcomes modeling in cerebrovascular neurosurgery.

The utility of the functional independence measure (FIM) in discharge planning for burn patients

Determining burn patients' need for inpatient rehabilitation at discharge is difficult and an objective clinical indicator might aid in this decision. The functional independence measure (FIM) is a validated outcome measure that predicts the need for rehabilitation services. This study evaluated the utility of the FIM score for discharge planning in burn patients. A retrospective chart review and FIM score determination was performed on all major burn patients discharged from a regional adult burn centre between July 1, 1999 and June 30, 2000. From 164 adult burn patients discharged, 37 met the American Burn Association criteria for major burns. One patient had insufficient data. Therefore, 36 patients were studied (mean age 47.3 +/- 17.4 years, and mean body area burned 27.4 +/- 12.9%). All 17 patients with FIM scores greater than 110 were discharged home, and patients with FIM score of 110 or lower were discharged to another institution (rehabilitation hospital n = 14, other acute care hospital n = 4, or a nursing home n = 1) p < 0.0001. A discharge FIM score of 110 or lower was strongly associated with the need for inpatient rehabilitation, while a FIM score greater than 110 indicates the patient is independent enough to manage at home. Further prospective studies will be necessary to validate these findings.

A Follow-Up Study of Older Adults With Traumatic Brain Injury: Taking Into Account Decreasing Length of Stay

OBJECTIVE

To examine age-related differences in rehabilitation outcomes following traumatic brain injury (TBI).

DESIGN

Retrospective collaborative study.

SETTING

Patients received acute neurotrauma and inpatient rehabilitation services at 1 of the 17 National Institute on Disability and Rehabilitation Research-designated Traumatic Brain Injury Model Systems (TBIMS) centers.

PARTICIPANTS

A sample of 273 older patients (> or =55y) admitted for TBI were taken from the TBIMS National Database. Older patients were matched with subjects 44 years of age or younger, based on severity of injury (Glasgow Coma Scale score, length of coma, intracranial pressure elevations). Due to decreasing length of stay (LOS), only patients admitted from 1996 through 2002 were included.

INTERVENTION

Inpatient interdisciplinary brain injury rehabilitation.

MAIN OUTCOME MEASURES

Acute care LOS, inpatient rehabilitation LOS, admission and discharge FIM instrument and Disability Rating Scale (DRS) scores, FIM and DRS efficiency, acute and rehabilitative charges, and discharge disposition.

RESULTS

One-way analyses of variance demonstrated a statistically significant difference between older and younger patients with respect to LOS in rehabilitation but not for acute care. Total rehabilitative charges, and admission and discharge DRS and FIM scores also showed statistically significant differences between groups. Older patients progressed with significantly less efficiency on both the DRS and FIM scales. Significantly more charges were generated per unit for older patients to improve on the DRS scale, but not the FIM scale. Using chi-square analysis, a statistically significant difference in rate of discharge to home was identified between older (80.5%) and younger (94.4%) patients.

CONCLUSIONS

Results in this study are similar to those in earlier studies with smaller sample sizes. Major differences observed include significantly slower and more costly progress in inpatient rehabilitation for older patients with TBI, as well as a significantly lower rate of discharge to community for older patients. However, even with decreasing LOS in both settings, community discharge rate is still encouraging for older patients with TBI.

Toward a New Payment System for Inpatient Rehabilitation

BACKGROUND

The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment.

OBJECTIVES

We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855).

RESEARCH DESIGN

We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis.

RESULTS

We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions.

CONCLUSION

For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

Toward a New Payment System for Inpatient Rehabilitation

BACKGROUND

The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs.

OBJECTIVES

We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models.

RESEARCH DESIGN

A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting.

RESULTS

We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed.

CONCLUSION

We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.

Rehabilitation outcomes following traumatic spinal cord injury in a tertiary spinal cord injury centre: a comparison with an international standard

STUDY DESIGN

Retrospective descriptive analysis of data of patients with traumatic spinal cord injury (SCI) in a tertiary SCI centre.

OBJECTIVES

To identify the characteristics of the rehabilitation outcomes of patients with different levels of traumatic SCI and to compare the results with data reported in the American Consortium for Spinal Cord Medicine.

SETTING

A newly established tertiary SCI centre in Tai Po Hospital, Tai Po, Hong Kong.

METHODS

A total of 33 patients with traumatic SCI admitted in 2002 were included in the study. They were classified into different ASIA subgroups based on their levels and completeness of injury. The functional status changes measured by the Functional Independence Measure (FIM) (on admission, placement and upon discharge, and at 1 and 3 months post discharge) and discharge placement were recorded as rehabilitation outcomes.

RESULTS

A total, 24 patients were tetraplegic while nine were paraplegic. Seven and two from tetraplegic and paraplegic groups were readmitted with late complications due to urinary tract infection, spasticity and/or occurrence of pressure sores. The mean age was found to be 48.36 (SD=15.64) years. In all, 16 (48.48%) sustained the injury from falling from height. The trend of FIM motor scores at discharge across different ASIA subgroups appeared to be comparable to those reported in the American Consortium for Spinal Cord Medicine with scores generally lower. Significant functional improvements during the hospital phase were found in the two tetraplegic and paraplegic ASIA D subgroups (t3=3.430, P<0.05; t2=4.083, P=0.55, respectively). Significant differences were also revealed among subgroups (F(7,32)=6.625, P<0.0005) with lower level tetraplegic groups appearing to stay much longer in the rehabilitation centre. In all, 64.5% of newly diagnosed patients returned to live in the community.

CONCLUSIONS

This report gives a preliminary overview on the characteristics of rehabilitation outcomes in one of the SCI centres in Hong Kong in relation to the international standard. Longitudinal study with larger population and community integration outcomes might be included in the future to reveal a better picture in the SCI rehabilitation in Hong Kong.

Do preinjury alcohol problems predict poorer rehabilitation progress in persons with spinal cord injury?

OBJECTIVE

To determine whether a history of alcohol-related problems is associated with inpatient rehabilitation progress.

DESIGN

Cross-sectional cohort survey.

SETTING

Acute inpatient rehabilitation program in a level I trauma center.

PARTICIPANTS

Seventy-six of 104 consecutive patients with spinal cord injury (SCI) who met inclusion criteria and had completed interviews and functional outcome data. Participants were on average 38 years old; 84% were white, and 86% were men. Forty-two percent had tetraplegia and 39% had a history of problem drinking.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FIM instrument admission, discharge, and efficiency scores as well as rehabilitation length of stay (LOS).

RESULTS

The group with a history of problem drinking had significantly lower FIM admission, discharge, and efficiency scores and longer rehabilitation LOS. After controlling for potential confounding factors, a history of problem drinking accounted for a significant proportion of the variance in FIM efficiency scores.

CONCLUSIONS

A history of problem drinking may be a risk factor for poorer rehabilitation progress among patients with SCI. They may be more costly to rehabilitate and may be discharged before attaining an adequate level of independence. Despite this, the current rehabilitation prospective payment system does not recognize this common comorbid condition.

Rehabilitation in Skilled Nursing Facilities

OBJECTIVE

To explore the relationship of patients' outcomes with nursing staff levels and therapy intensity within skilled nursing facilities.

DESIGN

Secondary analysis using administrative dataset of 6,897 patients from 68 skilled nursing facilities providing rehabilitation and reimbursed through Medicare+Choice. Independent measures were facility level nursing hours-to-resident ratio and total therapy hours per day. Outcomes included discharge to community and length of stay efficiency.

RESULTS

Patients were 1.53 times more likely to be discharged to the community when nursing staff level was > or = 3.5 hrs per resident per day as compared with <3.5, and patients were 1.22 and 2.02 times more likely to be discharged to the community when therapy averaged 1-1.5 hrs/day and >1.5 hrs/day, respectively, as compared with <1 hr/day. The adjusted mean length-of-stay efficiency was 0.21 points greater in facilities where the nursing staff level was > or = 3.5 hrs per resident per day than in facilities where the level was <3.5 and 0.43 and 0.70 points greater in facilities where patients received 1-1.5 hrs/day and >1.5 hrs/day of therapy, respectively, than in facilities where the average therapy intensity was <1 hr/day.

CONCLUSIONS

Higher nursing staff levels and therapy intensity are related to improved length-of-stay efficiency and increase the likelihood of patients' being discharged to the community.

Toward a taxonomy of rehabilitation interventions: using an inductive approach to examine the “black box” of rehabilitation

A barrier in outcomes and effectiveness research is the ability to characterize the interventions under review. This has been the case especially in rehabilitation in which interventions are commonly multidisciplinary, customized to the patient, and lack standardization in definition and measurement. This commentary describes how investigators and clinicians, working together, in a major multisite stroke rehabilitation outcome study were able to define and characterize diverse stroke rehabilitation interventions in a comprehensive, yet parsimonious, fashion and thus capture what actually transpires in a hospital-based stroke rehabilitation program. We consider the implications of the study's classification system for a more comprehensive taxonomy of rehabilitation interventions and the potential utility of such a taxonomy in operationalizing practice standards, medical record keeping, and rehabilitation research.

Effect of Co-Morbid Traumatic Brain Injury on Functional Outcome of Persons with Spinal Cord Injuries

OBJECTIVE

This study was undertaken to determine if persons who sustain a spinal cord injury (SCI) and co-morbid brain injury (dual diagnosis [DDS]) evidence smaller functional gains and experience significantly longer rehabilitation lengths of stay than persons with only an SCI.

DESIGN

This retrospective comparison study was performed at a 100-bed rehabilitation hospital specializing in acute SCI and traumatic brain injury rehabilitation. Summary scale outcome data of persons who sustained an SCI were compared with outcome data of a group of persons with a DDS. Comparisons were established by matching groups principally on level of SCI and admission Motor FIM trade mark score and secondarily on education, sex, and age. Outcome measures included admission Motor and Cognitive FIM score, discharge Motor and Cognitive FIM score, Motor and Cognitive FIM change, length of stay, and rehabilitation charges.

RESULTS

Persons with a DDS evidenced a significantly more impaired Cognitive FIM score at admission and discharge from rehabilitation. Persons with a DDS also achieved a significantly lower Motor FIM change than persons with SCI. There were no significant differences between DDS and SCI groups regarding Cognitive FIM change, length of stay, or rehabilitation charges. Injury severity as defined by the Glasgow Coma Scale or intracranial lesions did not predict response to treatment in the DDS group.

CONCLUSION

Persons with a DDS achieved smaller functional gains during rehabilitation than peers with SCI. Brain injuries seem to limit functional gains, although the relationship between brain injury severity and functional change is not linear. Prospective studies are needed to identify factors limiting functional gains in rehabilitation and assist in developing specific treatment programs for persons with SCI and brain injury.

Predictors of personal care assistance for people with spinal cord injury

OBJECTIVE

To assess the predictors of personal care assistance (PCA) use in people with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Follow-up of individuals crossing their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury who underwent their initial rehabilitation at a Spinal Cord Injury Model Systems center.

PARTICIPANTS

A total of 2154 participants (2547 records) who met the inclusion criteria for the National Spinal Cord Injury Database and had valid values for the main outcome measures.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily hours of paid, unpaid, and occasional PCA services.

RESULTS

Differences in an interval version of the motor portion of the FIM trade mark instrument accounted for 26.3% of the variance in total PCA hours, Model Systems differences accounted for 9.3%, and no other predictor accounted for more than 2.1% of the variance.

CONCLUSION

Activities of daily living functioning, as measured by the motor portion of the FIM, was the strongest predictor of PCA use among people with SCI.

Long-term recovery course after traumatic brain injury: a comparison of the functional independence measure and disability rating scale

OBJECTIVES

To study group changes over time after traumatic brain injury (TBI).

DESIGN

Prospective cohort.

SETTING AND PARTICIPANTS

TBI Model System Database with 1160 subjects using cohort with complete data.

MAIN OUTCOME MEASURES

Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation discharge and annually after injury.

RESULTS

Statistically significant differences existed between FIM-total, FIM-Motor, FIM-Cognitive subscales, and DRS at rehabilitation discharge and year 1. Comparisons of year-to-year intervals, years 1 and 3, 1 and 5, and 3 and 5, revealed no statistically significant differences except between years 1 and 3 and 1 and 5 with DRS, and years 1 and 5 with FIM. Including only those more dependent at year 1 revealed statistically significant differences between years 1 and 2 and 1 and 5 on FIM-Cognitive and DRS, but not the FIM-Motor. The proportion of change for FIM and DRS items from year 1 to years 2 and 5 revealed DRS Level of Functioning and Employability items accounted for most DRS change, whereas FIM change was more spread across its components.

CONCLUSIONS

DRS is more sensitive to changes during a shorter time period than FIM and seems to be more appropriate for detecting long-term deficits. However, research studies aimed at detecting meaningful changes year to year after TBI may need to use other tools or consider changes among individuals instead of group changes. DRS Level of Function and Employability Items represent complex functions expected to recover later than the more basic DRS items. Sole use of these two DRS items might provide an efficient means of measuring long-term recovery when resources are limited, whereas expansion of these two items might allow greater sensitivity and detail.

Hierarchical linear modeling of FIM instrument growth curve characteristics after spinal cord injury

OBJECTIVE

To examine the recovery of aspects of functional independence as a continuous process using growth curve analysis.

DESIGN

Retrospective database review of functional outcome assessment data from inception cohort.

SETTING

Inpatient rehabilitation unit; community.

PATIENTS

A total of 142 subjects (79.6% men; age range, 18-77yr; mean age +/- standard deviation, 36.2 +/- 15.5yr) who were admitted to a rehabilitation unit between March 1986 and November 1994 with a minimum of 4 postinjury FIM assessments. Neurologic subgroups included 63 individuals with paraplegia, 36 with low tetraplegia, 24 with high tetraplegia, and 19 with incomplete injury.

MAIN OUTCOME MEASURE

FIM instrument.

RESULTS

Growth curve analyses with hierarchical linear modeling using a decelerating recovery function yielded a reliable model in which longer rehabilitation length of stay was associated with a more rapid rate of recovery but lower plateau. Neurologic injury category had expected effects on rate and degree of recovery. Level of impairment-specific results included an age effect in which older age was associated with lower level of plateau. In specific neurologic groups there was a significant gender effect, in which men made more rapid recovery than women, and a significant effect of level of education, in which higher education was associated with more rapid rate of recovery. Rate of FIM recovery was reliably modeled in the sample with incomplete injuries, but none of the demographic predictors was significant.

CONCLUSIONS

Functional recovery can be modeled as a decelerating rather than simple linear function. The study of predictors of recovery characteristics, including rate of recovery and plateau, offers a valuable way of understanding rehabilitative needs and outcomes. Gender and education effects on the recovery process are intriguing and warrant further investigation.

The tools of disability outcomes research functional status measures

OBJECTIVE

To review the major functional status measures currently used in rehabilitation research, including the domains and scope of functional status measures, as well as the psychometric properties of selected functional status measures and their use in adult rehabilitation populations.

DATA SOURCES

Measures of physical functioning widely used in rehabilitation research.

STUDY SELECTION

Major generic measures included the following activities of daily living and instrumental activities of daily living: the FIM instrument, the Katz Activities of Daily Living Scale, the Level of Rehabilitation Scale, the Barthel index, and the Patient Evaluation and Conference System. Measures were evaluated based on published evidence of validity, reliability, and sensitivity.

DATA EXTRACTION

Measures were chosen on the basis of the amount and quality of published research on the functional measures widely used in rehabilitation medicine. Independent research of computer databases and reviews of functional measures were conducted to determine suitability for inclusion. The quality and validity of the measures were assessed using standard psychometric guidelines.

DATA SYNTHESIS

Measures were evaluated based on published evidence of validity, reliability, sensitivity response and administrative burdens and instrument bias. Each criterion was graded on a 3-point scale reflecting the level of evidence.

CONCLUSION

Researchers in the field of disabilities research need to consider carefully study objectives when measuring physical functioning in people with disabilities.