Development of a pediatric age- and disease-specific severity measure

Risk factors for bloodstream infection in paediatric haematopoietic stem cell transplantation: a systematic review and meta-analysis

BACKGROUND

Haematopoietic stem cell transplantation (HSCT), a standard treatment for paediatric haematological diseases, is highly associated with bloodstream infection (BSI), which may increase mortality.

AIM

To explore the risk factors for BSI in paediatric HSCT recipients.

METHODS

Three English databases and four Chinese databases were searched from inception to March 17th, 2022. Eligible studies included randomized controlled trials, cohort studies, and case-control studies that enrolled HSCT recipients aged ≤18 years and reported BSI risk factors. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), certainty of body of evidence was assessed.

FINDINGS

Fourteen studies involving 4602 persons were included. The incidences of BSI and associated mortality in paediatric HSCT recipients were approximately 10-50% and 5-15%, respectively. Meta-analysis of all studies revealed that previous BSI before HSCT (relative effect (RE): 2.28; 95% confidence interval (CI) 1.19-4.34, moderate certainty) and receiving an umbilical cord blood transplant (RE: 1.55; 95% CI: 1.22-1.97, moderate certainty) were probably associated with an increased risk of BSI. Meta-analysis of studies with low risk of bias reassured that previous BSI before HSCT probably increased the risk of BSI (RE: 2.28; 95% CI: 1.19-4.34, moderate certainty), and revealed that steroid use (RE: 2.72; 95% CI: 1.31-5.64, moderate certainty) was likely a risk factor whereas autologous HSCT was probably a protective factor of BSI (RE: 0.65; 95% CI: 0.45-0.94, moderate certainty).

CONCLUSION

These findings could inform the management of paediatric HSCT recipients, helping identify who may benefit from prophylactic antibiotics.

The Nursing Home Severity Index and Application to Pressure Injury Risk: Measure Development and Validation Study

BACKGROUND

An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning.

OBJECTIVE

This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury.

METHODS

A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident's Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury.

RESULTS

Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P<.001) when adding four severity dimensions to Worst-Braden scores. Significantly higher odds of developing pressure injuries were associated with increasing dimension scores. The use of the three highest propensity deciles predicting the greatest risk of pressure injury improved predictive accuracy by detecting 21 more residents who developed pressure injury (n=58, 65.2% vs n=37, 42.0%) when both severity dimensions and Worst-Braden score were included in prediction modeling.

CONCLUSIONS

The clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331.

Severity of Illness Measures for Pediatric Inpatients

INTRODUCTION

Severity of illness (SOI) measures are commonly used in adults for comparison of treatment and outcomes in similar populations. Less is known about the psychometric properties of measures available to providers and healthcare systems caring for pediatric patients. The purpose of this study was to (1) identify SOI measures used for pediatric patients admitted to acute care hospitals and (2) compare the ability of two SOI measures to predict mortality and length of stay (LOS).

METHODS

Twelve instruments were identified through literature search and one, the pediatric chronic complex condition (CCC), was retained. The CCC and the Charlson/Deyo comorbidity score were applied to an 8-year retrospective, multi-institutional data set using logistic and zero-truncated negative binomial regression models.

RESULTS

Records from 199,001 children were examined. The CCC performed better for predicting mortality (odds ratio = 3.36; 95% confidence interval [CI]: 3.20-3.53) and LOS (incidence rate ratio = 2.24; 95% CI: 2.22-2.26).

CONCLUSIONS

The CCC may be preferable for predicting outcomes among pediatric inpatients. Pediatric SOI measures are not extensively developed and tested nor widely and freely available. The use of the CCC can predict mortality and LOS to guide care, resource allocation, and research for the pediatric population.

Content of inpatient rehabilitation for patients with traumatic brain injury: A comparison of Canadian and American facilities

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIM^TM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p < .001, Cohen's d > .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Comparative Effectiveness of Clostridial Collagenase Ointment to Medicinal Honey for Treatment of Pressure Ulcers

Objective: Compare enzymatic debridement using clostridial collagenase ointment (CCO) with autolytic debridement using medicinal honey in the hospital outpatient setting for treating pressure ulcers (PUs).

Approach: Retrospective deidentified electronic health records from 2007–2013 were extracted from the U.S. Wound Registry. Propensity score matching followed by multivariable analyses was used to adjust for selection bias and assess treatment effects comparing CCO-treated versus honey-treated PUs. Key outcomes included 100% granulation and epithelialization at 1 year.

Results: Five hundred seventeen CCO-treated PUs (446 patients) were matched to corresponding honey-treated PUs (341 patients). The majority of PUs were stage III (CCO 56%, honey 55%). CCO users had significantly fewer total visits (9.1 vs. 12.6; p < 0.001), fewer total selective sharp debridements (2.7 vs. 4.4; p < 0.001), and fewer PUs receiving negative pressure wound therapy (29% vs. 38%; p = 0.002) compared with honey.

Innovation: CCO-treated PUs were 38% more likely to achieve 100% granulation compared to honey-treated PUs at 1 year, p = 0.018. Mean days to 100% granulation were significantly lower for CCO-treated PUs (255 vs. 282 days, p < 0.001). CCO-treated PUs were 47% (p = 0.024) more likely to epithelialize at 1 year compared to PUs treated with honey. Mean days to epithelialization were significantly lower for PUs treated with CCO at 1 year (288 vs. 308 days; p = 0.011).

Conclusion: All stages of PUs treated with CCO achieved faster rates of granulation and subsequent epithelialization compared to PUs treated with medicinal honey as measured by real-world data collected in the hospital outpatient department care setting.

Bacterial bloodstream infections in pediatric allogeneic hematopoietic stem cell recipients before and after implementation of a central line-associated bloodstream infection protocol: A single-center experience

INTRODUCTION

There are only few reports describing the influence of central line-associated bloodstream infection (CLABSI) prevention strategies on the incidence of bacterial bloodstream infections (BBSIs).

METHODS

We performed a retrospective cohort study among pediatric recipients of allogeneic hematopoietic stem cell transplantation (allo-HCT) to assess potential changes in BBSI rates during 3 time periods: pre-CLABSI prevention era (era 1, 2004-2005), CLABSI prevention implementation era (era 2, 2006-2009), and maintenance of CLABSI prevention era (era 3, 2010-2012). BBSI from day 0-365 following allo-HCT were studied. The comparison of person-years incidence rates among different periods was carried out by Poisson regression analysis.

RESULTS

The mean age of patients was 10.0 years. During the study period, 126 (65%) of 190 patients had at least a single BBSI. From day 0-30, day 31-100, day 101-180, and day 181-365, 20%, 28%, 30%, and 17% of patients, respectively, experienced BBSIs. The rate of Staphylococcus epidermidis and gram-negative pathogens significantly declined from 3.16-0.93 and 6.32-2.21 per 100 person-months during era 1 and era 3, respectively (P = .001).

CONCLUSIONS

Patients undergoing allo-HCT during era 3 were associated with decreased risk of BBSI (P = .012). Maintenance of CLABSI protocols by nursing staff and appropriate education of other care providers is essential to lower incidence of BBSI in this high-risk population, and further strategies to decrease infection burden should be studied.

Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes

OBJECTIVES

To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Ten inpatient rehabilitation centers.

PARTICIPANTS

Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being.

RESULTS

The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations.

CONCLUSIONS

This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail.

Implementing a clinical practice guideline for the treatment of bronchiolitis in a high-risk Hispanic pediatric population

INTRODUCTION

Bronchiolitis is the leading cause of hospitalization among infants and young children. Because of its frequency, a clinical practice guideline for bronchiolitis was implemented in this population in an effort to decrease costs and the number of diagnostic evaluations performed and medications used without increasing length of stay or transfers to the pediatric intensive care unit.

METHODS

A retrospective chart review of 322 pediatric admissions to a rural community hospital was conducted (169 before guideline implementation and 153 after guideline implementation), and data were categorically stratified into three groups for comparison purposes. Descriptive statistics were used to analyze the data, with a p value < .05 defining significance.

RESULTS

During the project period, patients with a mean age of 9.6 months were admitted to the hospital with bronchiolitis. Statistically significant decreases in cost per day and decreases in use of antibiotics and chest radiographs were achieved without increasing length of stay or pediatric intensive care unit transfers.

DISCUSSION

This project demonstrated feasibility in implementing an evidence-based clinical practice guideline in a rural hospital to improve patient outcomes.

Clinical disease severity of respiratory viral co-infection versus single viral infection: a systematic review and meta-analysis

Background

Results from cohort studies evaluating the severity of respiratory viral co-infections are conflicting. We conducted a systematic review and meta-analysis to assess the clinical severity of viral co-infections as compared to single viral respiratory infections.

Methods

We searched electronic databases and other sources for studies published up to January 28, 2013. We included observational studies on inpatients with respiratory illnesses comparing the clinical severity of viral co-infections to single viral infections as detected by molecular assays. The primary outcome reflecting clinical disease severity was length of hospital stay (LOS). A random-effects model was used to conduct the meta-analyses.

Results

Twenty-one studies involving 4,280 patients were included. The overall quality of evidence applying the GRADE approach ranged from moderate for oxygen requirements to low for all other outcomes. No significant differences in length of hospital stay (LOS) (mean difference (MD) −0.20 days, 95% CI −0.94, 0.53, p = 0.59), or mortality (RR 2.44, 95% CI 0.86, 6.91, p = 0.09) were documented in subjects with viral co-infections compared to those with a single viral infection. There was no evidence for differences in effects across age subgroups in post hoc analyses with the exception of the higher mortality in preschool children (RR 9.82, 95% CI 3.09, 31.20, p<0.001) with viral co-infection as compared to other age groups (I² for subgroup analysis 64%, p = 0.04).

Conclusions

No differences in clinical disease severity between viral co-infections and single respiratory infections were documented. The suggested increased risk of mortality observed amongst children with viral co-infections requires further investigation.

Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation

OBJECTIVE

To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization.

DESIGN

Prospective observational cohort study.

SETTING

Six geographically dispersed rehabilitation centers in the U.S.

PARTICIPANTS

Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations.

RESULTS

More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered.

CONCLUSIONS

Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

Association of various comorbidity measures with spinal cord injury rehabilitation outcomes

OBJECTIVE

To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status.

DESIGN

Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury.

SETTING

Inpatient rehabilitation and community follow-up at 6 SCI treatment centers.

PARTICIPANTS

Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI).

RESULTS

Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school.

CONCLUSIONS

Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account.

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.

Shared decision-making and health care expenditures among children with special health care needs

BACKGROUND AND OBJECTIVES

To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).

METHODS

We identified CSHCN <18 years in the 2002-2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years.

RESULTS

Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits.

CONCLUSIONS

We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.

Physical therapy activities in stroke, knee arthroplasty, and traumatic brain injury rehabilitation: their variation, similarities, and association with functional outcomes

BACKGROUND

The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown.

OBJECTIVE

The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups.

DESIGN

This was a prospective observational cohort study.

METHODS

The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patient's medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities.

RESULTS

All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average=31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average=65.3 minutes per day), whereas the TBI group received the least physical therapy (average=38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome.

LIMITATIONS

The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities.

CONCLUSIONS

All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes.

Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them

OBJECTIVE

There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an "Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults" conference in September 2010 to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and nonsteroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits.

DESIGN

Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists' slide presentations were reviewed to identify the gaps and the types of studies and research methods panelists suggested could best address them.

RESULTS

Fifteen gaps were identified in the areas of treatment (e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation (e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life.

CONCLUSION

Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well-being of older adults with chronic pain.

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.

Analysis of rehabilitation activities within skilled nursing and inpatient rehabilitation facilities after hip replacement for acute hip fracture

OBJECTIVE

To characterize rehabilitation services in two types of postacute facilities in patients who underwent hip replacement following a hip fracture.

DESIGN

Multisite prospective observational cohort from 6 freestanding skilled nursing facilities and 11 inpatient rehabilitation facilities. Patients (n = 218) with hip fracture who had either hemiarthroplasty or total hip arthroplasty followed by rehabilitation at skilled nursing facilities or inpatient rehabilitation facilities were enrolled. Using a point-of-care methodology, we recorded data from actual physical therapy and occupational therapy sessions completed including functional outcomes during the postacute admission.

RESULTS

Onset time from surgical repair to rehabilitation admission was not significantly different between sites. Average skilled nursing facilities length of stay was 24.7 +/- 13.6 days, whereas inpatient rehabilitation facilities was 13.0 +/- 5.7 days (P < 0.01). Total hours of physical therapy and occupational therapy services per patient day were 1.2 in skilled nursing facilities and 2.0 in inpatient rehabilitation facilities. For weekdays only, these data changed to 1.6 in skilled nursing facilities and 2.6 hrs per patient in inpatient rehabilitation facilities (P < 0.01). Patients in inpatient rehabilitation facilities accrued more time for gait training and exercise in physical therapy, which was found to be 48% and 40% greater, respectively, through day 8. In occupational therapy, patients of inpatient rehabilitation facilities had more time allocated to lower body dressing and transfers.

CONCLUSIONS

Significant differences in rehabilitation activities were observed, and intensity was notably different within the first 8 therapy days even though baseline demographics and medical complexity were comparable across facility types. Our data suggest that after more complex hip replacement surgery, hip fracture patients can tolerate more intensive therapy earlier within the rehabilitation program.

New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project

BACKGROUND/OBJECTIVE

Limited research evidence is available to show the effectiveness of the many specific interventions provided in spinal cord injury (SCI) rehabilitation; what is available typically focuses on effects of the full rehabilitation package but not specific therapy interventions, medical procedures, patient education, or counseling. Given the problems of conducting randomized controlled trials (RCTs) in rehabilitation, practice-based evidence (PBE) research has been suggested as an alternative methodology for identifying which rehabilitation interventions are associated most strongly with positive outcomes, after controlling for patient differences. Using the PBE research methodology, the SCIRehab project attempts to "open the black box" of acute SCI rehabilitation, provide detailed information on treatments delivered by all rehabilitation disciplines, and contribute to outcomes-based guidelines for clinical decision-making.

METHODS

The SCIRehab project includes 1,500 patients with acute SCI, consecutively admitted to 1 of 6 US inpatient rehabilitation facilities. Details of the rehabilitation process are captured by clinicians from multiple disciplines documenting their interventions in handheld personal digital assistants after sessions with their patients. Outcome data are abstracted from medical records (clinical outcomes data) and obtained from patient interviews at 6 and 12 months after injury. Extensive patient, injury, and other treatment characteristics are abstracted from medical records. SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team.

RESULTS

SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team. These findings are presented in a series of 9 articles.

CONCLUSIONS

To date, SCIRehab's major contribution is a system for categorizing specific contributions of each discipline and a technology for documenting that detail. After data collection is complete, future manuscripts will relate those process elements to outcomes. The SCIRehab Project is an important step toward establishing outcomes-based guidelines for SCI rehabilitation.

Practice-Based Evidence Study Design for Comparative Effectiveness Research

OBJECTIVES

To describe a new, rigorous, comprehensive practice-based evidence for clinical practice improvement (PBE-CPI) study methodology, and compare its features, advantages, and disadvantages to those of randomized controlled trials and sophisticated statistical methods for comparative effectiveness research.

RESEARCH DESIGN

PBE-CPI incorporates natural variation within data from routine clinical practice to determine what works, for whom, when, and at what cost. It uses the knowledge of front-line caregivers, who develop study questions and define variables as part of a transdisciplinary team. Its comprehensive measurement framework provides a basis for analyses of significant bivariate and multivariate associations between treatments and outcomes, controlling for patient differences, such as severity of illness.

RESULTS

PBE-CPI studies can uncover better practices more quickly than randomized controlled trials or sophisticated statistical methods, while achieving many of the same advantages. We present examples of actionable findings from PBE-CPI studies in postacute care settings related to comparative effectiveness of medications, nutritional support approaches, incontinence products, physical therapy activities, and other services.

CONCLUSIONS

Outcomes improved when practices associated with better outcomes in PBE-CPI analyses were adopted in practice.

Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results

Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results.

OBJECTIVES

To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP).

DESIGN

Prospective observational cohort study.

SETTING

Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand.

PARTICIPANTS

Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in FIM score, change in severity of illness, and discharge destination.

RESULTS

For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4.

CONCLUSIONS

This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.

Another Look at Observational Studies in Rehabilitation Research: Going Beyond the Holy Grail of the Randomized Controlled Trial

Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the "black box" of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs.

The National Hospice Outcomes Project: development and implementation of a multi-site hospice outcomes study

Hospice has become a major component of end-of-life care, but little scientific information is available to guide clinicians in knowing when the use of hospice is appropriate, in knowing how to measure the impact of its care, and in knowing which hospice interventions lead to the best outcomes. The National Hospice Outcomes Project (NHOP) arose from the need to identify patient factors and hospice interventions that are associated with better end-of-life outcomes. Clinical Practice Improvement (CPI) methodology allowed us to generate a large comprehensive database that could identify scientifically hospice interventions associated with better outcomes for specific patient populations. The complex interplay of patients, medical and complementary treatments, and families can be evaluated. This paper describes an overview of the research methods used for the NHOP, describes the project's 13 clinical sites and study population of 1,306 patients, and presents some basic findings from the study.

Risk Adjusting Rehabilitation Outcomes

The complexity and mix of rehabilitation patients varies across clinicians and institutions. Comparisons of outcomes across providers must therefore adjust for differences in risk factors across patient populations. Research on risk adjustment has generally focused on acute care hospital outcomes, although techniques for risk adjusting financial outcomes are fairly well developed in rehabilitation, primarily to support Medicare and other prospective payment systems. This article reviews important methodologic issues in risk adjusting rehabilitation outcomes in observational studies of routine clinical practice or for management, such as assessing quality or costs of care. Risk adjusting rehabilitation outcomes is more difficult than risk adjusting other clinical results, such as outcomes of many acute care services. At the outset, characterizing rehabilitation interventions is frequently difficult. Furthermore, outcomes are diverse and depend on myriad factors, including patients' physical and cognitive abilities, underlying medical diseases, sensory and emotional factors, willingness to participate in care, and supportive environments. No risk-adjustment approach can control for every factor affecting outcomes of care. Knowing which risk factors are missing helps guide interpretation of the results and determines how well risk-adjusted outcomes fairly compare providers or treatments.

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.

Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia

OBJECTIVE

To characterize complications among infants hospitalized for bronchiolitis or respiratory syncytial virus (RSV).

STUDY DESIGN

Retrospective data from 684 infants with bronchiolitis or RSV pneumonia, < or =1 year old, admitted to 10 children's hospitals from April 1995 to September 1996. Outcomes included complication rates and effects on hospital and pediatric intensive care unit (PICU) length of stay (LOS) and hospital costs.

RESULTS

Most infants (79%) had one or more complication, with serious complications in 24%. Even minor complications were associated with significantly longer PICU and hospital LOS and higher costs (P<.001). Respiratory complications were most frequent (60%), but infectious (41%), cardiovascular (9%), electrolyte imbalance (19%), and other complications (9%) were common. Complication rates were higher in former premature infants (87%), infants with congenital heart disease (93%), and infants with other congenital abnormalities (90%) relative to infants without risk factors (76%). Infants 33 to 35 weeks gestational age (GA) had the highest complication rates (93%), longer hospital LOS, and higher costs (P<.004) than other former premature infants.

CONCLUSIONS

Complications were common in infants hospitalized for bronchiolitis or RSV pneumonia and were associated with longer LOS and higher costs. Former premature infants and infants with congenital abnormalities are at significantly greater risk for complications. Broader use of RSV prevention should be considered for these higher-risk infants.

Effect of prematurity on respiratory syncytial virus hospital resource use and outcomes

OBJECTIVES

To determine if gestational age (GA) is independently associated with hospital resource use and outcomes among infants hospitalized for respiratory syncytial virus (RSV).

STUDY DESIGN

Analysis of retrospective data from 304 infants (</=1 year) with bronchiolitis or RSV pneumonia admitted to nine children's hospitals from April 1995 to September 1996. Resource use and outcomes examined included admission to the intensive care unit (ICU), intubation, and hospital and ICU length of stay. The Comprehensive Severity Index controlled for severity of illness.

RESULTS

Two hundred fifteen term infants (GA > or =37 weeks) and 89 infants with GA <37 weeks, divided according to GA into 3 subgroups (< or =32, 33 to 35, and 36 weeks), were compared. Significant differences were found for rate of intubation (P=.002) and ICU and hospital length of stay (P=.021 and P<.0001, respectively), with the highest resource use in 33 to 35 weeks GA infants, which remained significant in multiple regression analyses.

CONCLUSIONS

Infants 33 to 35 weeks GA had hospital outcomes that were negative or worse than infants < or =32 weeks GA. Data suggest prematurity < or =35 weeks GA significantly increases the risk for severe outcomes among infants hospitalized for RSV. Infants 36 weeks GA had outcomes similar to term infants. No evidence was observed of gradation or inverse linear risk relation between GA and hospital outcomes.