Cost-benefits associated with social outcome from neurobehavioural rehabilitation

Mapping the costs and socioeconomic characteristics involved in traumatic brain injuries: a scoping review

OBJECTIVE

To identify the articles in the existing literature that analyse healthcare costs according to the socioeconomic position (pre- or post-injury) for traumatic brain injury survivors. Secondary aims were to describe the types of costs and socioeconomic characteristics and to determine whether socioeconomic characteristics affect the risk of traumatic brain injury or whether the consequences of trauma alter living conditions post-injury.

METHODS

This scoping review followed the methods proposed by Arksey and O'Malley. The literature search was performed in 5 databases.

RESULTS

Twenty-two articles were included, published between 1988 and 2023. Only 2 articles (9%) followed the guidelines for economic evaluation of healthcare programmes and 2 articles (9%) evaluated socioeconomic position "completely" with 3 main individual measures of socioeconomic characteristics (i.e., education, income, and occupation). The relationship between costs and socioeconomic characteristics could vary in 2 ways in traumatic brain injury: socioeconomic disadvantage was mostly associated with higher healthcare costs, and the cost of healthcare reduced the survivors' living conditions.

CONCLUSION

This work highlights the need for a detailed and methodologically sound assessment of the relationship between socioeconomic characteristics and the costs associated with trauma. Modelling the care pathways of traumatic brain injury would make it possible to identify populations at risk of poor recovery or deterioration following a TBI, and to develop specific care pathways. The aim is to build more appropriate, effective, and equitable care programmes.

Overview of randomized controlled trials of moderate to severe traumatic brain injury: A systematic review

BACKGROUND

Given the complexity of post-TBI medical, surgical, and rehabilitative care, research is critical to optimize interventions across the continuum of care and improve outcomes for persons with moderate to severe TBI.

OBJECTIVE

To characterize randomized controlled trials (RCTs) of moderate to severe traumatic brain injury (TBI) in the literature.

METHOD

Systematic searches of MEDLINE, PubMed, Scopus, CINAHL, EMBASE and PsycINFO for RCTs up to December 2022 inclusive were conducted in accordance with PRISMA guidelines.

RESULTS

662 RCTs of 91,946 participants published from 1978 to 2022 met inclusion criteria. The number of RCTs published annually has increased steadily. The most reported indicator of TBI severity was the Glasgow Coma Scale (545 RCTs, 82.3%). 432 (65.3%) RCTs focused on medical/surgical interventions while 230 (34.7%) addressed rehabilitation. Medical/surgical RCTs had larger sample sizes compared to rehabilitation RCTs. Rehabilitation RCTs accounted for only one third of moderate to severe TBI RCTs and were primarily conducted in the chronic phase post-injury relying on smaller sample sizes.

CONCLUSION

Further research in the subacute and chronic phases as well as increasing rehabilitation focused TBI RCTs will be important to optimizing the long-term outcomes and quality of life for persons living with TBI.

The Measure of an Outcome: Comparing Norming and Stacking to Benchmark the Effectiveness of Brain Injury Rehabilitation Services

Practitioners have a clinical, ethical, academic, and economic responsibility to dispassionately consider how effective their services are. Approaches to measure how "good" or "bad" healthcare is include clinical audit, satisfaction surveys, and routine outcome measurement. However, the process of comparing the clinical outcomes of a specific service against the 'best' services in the same specialism, also known as benchmarking, remains challenging, and it is unclear how it affects quality improvement. This paper piloted and compared two different approaches to benchmarking to assess clinical outcomes in neurorehabilitation. Norming involved comparing routine measures of clinical outcome with external validators. Stacking involved pooling and comparing internal data across several years. The analyses of routine clinical outcome data from 167 patients revealed significant differences in the patient characteristics of those admitted to the same service provider over time, but no differences in outcomes achieved when comparing with historical data or with external reference data. These findings illustrate the potential advantages and limitations of using stacking and norming to benchmark clinical outcomes, and how the results from each approach might be used to evaluate service effectiveness and inform quality improvement within the field of brain injury rehabilitation.

Effects of the CarFreeMe Traumatic Injuries, a Community Mobility Group Intervention, to Increase Community Participation for People With Traumatic Injuries: A Randomized Controlled Trial With Crossover

Introduction

After traumatic injuries community participation is a common goal, promoting wellbeing and independence. Community mobility and transportation influence an individual's independence in community participation. With the ability to drive safely often compromised after traumatic injuries, the adverse consequences of driving cessation include a loss of identity and reduced participation in chosen activities. In rehabilitation, individualized community mobility intervention is not routinely provided. The primary aim of this trial was to evaluate whether a group-based intervention, the CarFreeMe TI program was more effective than standard intervention, an information sheet of alternative transport, in improving community mobility for people following traumatic injuries. The secondary aim of this study was to evaluate the effect: types of transport used, transport satisfaction, community mobility self-efficacy, quality of life, goal satisfaction and performance, for people following traumatic injuries; and to undertake a preliminary assessment of the potential resource use associated with the intervention, and lessons for implementation.

Design

Prospective, pilot, randomized, blind observer, controlled trial with crossover.

Participants

Twenty individuals with traumatic injuries.

Intervention

Six-week group-based support and education program, the CarFreeMe TI delivered in community settings (intervention) and standard information related to transport options available (control).

Primary Outcome Measures

Community participation using a Global Positioning System device to record the location and number of outings from home.

Secondary Outcome Measures

CarFreeMe TI Transport Questionnaire, Community Mobility Self-efficacy Scale, quality of life measures, Modified Canadian Occupational Performance Measure for goals (importance and satisfaction), participant satisfaction survey results and researcher logs.

Results

Those who received the intervention were more likely to use public transport and transport services and had an improved quality of life, when compared to the control group. The intervention group also reported high levels of improvement in goal performance and satisfaction. Global Positioning System data collection was incomplete, with geolocation data unusable. There was no significant change in number/type of visits away from home.

Conclusions

A group-based community mobility education program promoted modes of active independent transport but did not impact on outings from home. Future research could include passive collection methods using a smartphone to record community participation.

Clinical Trial Registration

https://www.anzctr.org.au/, identifier: ACTRN12616001254482.

Value and Cost Savings From Access to Multi-disciplinary Rehabilitation Services After Severe Acquired Brain Injury

Acquired brain injury (ABI) is a major global public health problem and source of disability. A major contributor to disability after severe ABI is limited access to multidisciplinary rehabilitation, despite evidence of sustained functional gains, improved quality of life, increased return-to-work, and reduced need for long-term care. A societal model of value in rehabilitation matches patient and family expectations of outcomes and system expectations of value for money. A policy analysis of seven studies (2009-2019) exploring outcomes and cost-savings from access to multi-disciplinary rehabilitation identified average lifetime savings of $1.50M per person, with costs recouped within 18 months. Recommendations: Increase access to multi-disciplinary rehabilitation following severe ABI; strengthen prevention focus; increase access to case management; support return-to-work; and systematically collect outcome and cost data.

Estimated Life-Time Savings in the Cost of Ongoing Care Following Specialist Rehabilitation for Severe Traumatic Brain Injury in the United Kingdom

Supplemental Digital Content is Available in the Text.

Objectives:

To evaluate cost-efficiency of rehabilitation following severe traumatic brain injury (TBI) and estimate the life-time savings in costs of care.

Setting/Participants:

TBI patients (n = 3578/6043) admitted to all 75 specialist rehabilitation services in England 2010–2018.

Design:

A multicenter cohort analysis of prospectively collated clinical data from the UK Rehabilitation Outcomes Collaborative national clinical database.

Main Measures:

Primary outcomes: (a) reduction in dependency (UK Functional Assessment Measure), (b) cost-efficiency, measured in time taken to offset rehabilitation costs by savings in costs of ongoing care estimated by the Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA), and (c) estimated life-time savings.

Results:

The mean age was 49 years (74% males). Including patients who remained in persistent vegetative state on discharge, the mean episode cost of rehabilitation was £42 894 (95% CI: £41 512, £44 235), which was offset within 18.2 months by NPCNA-estimated savings in ongoing care costs. The mean period life expectancy adjusted for TBI severity was 21.6 years, giving mean net life-time savings in care costs of £679 776/patient (95% CI: £635 972, £722 786).

Conclusions:

Specialist rehabilitation proved highly cost-efficient for severely disabled patients with TBI, despite their reduced life-span, potentially generating over £4 billion savings in the cost of ongoing care for this 8-year national cohort.

Effectiveness of Post-Hospital Intensive Residential Rehabilitation after Acquired Brain Injury: Outcomes of 256 Program Completers Compared to Participants in a Residential Supported Living Program

Post-hospital residential brain injury rehabilitation outcomes research is a complicated undertaking because of the custom-tailoring of interventions needed to meet the complex and unique need of each individual. As such, there tends to be great variability across program settings, which generally limits large-scale intervention studies. Growing literature demonstrates that post-hospital residential programs are beneficial. The main criticisms of this work include the absence of randomized-controlled studies, lack of clear definition of treatment types/settings, and small sample sizes. This study is a retrospective analysis of program evaluation data for a large, multi-site, national provider of post-hospital residential brain injury rehabilitation services. Specifically, outcome of participants completing Intensive Residential Rehabilitation (IRR) were compared to participants in the Residential Supported Living (RSL) program. Results demonstrate that participants in the IRR program improve and that participants in the RSL group preserve functional ability over time, suggesting that each program is effective in achieving its intended outcome. The IRR treatment group achieved significantly better outcomes than those in the same setting not receiving the intervention. To isolate treatment effects of IRR, a subsample of participants across program types were matched on time post-injury, age, and sex. The treatment effect of IRR was strengthened in this analysis, suggesting that chronicity alone does not account for the variance between the two groups.

What is known about the cost-effectiveness of neuropsychological interventions for individuals with acquired brain injury? A scoping review

The aim of this scoping review was to examine the literature related to economic evaluations of neuropsychological rehabilitation in individuals with acquired brain injury (ABI). PsychINFO, Medline, EMBASE, Cochrane and CINHAL databases were searched in accordance with formal scoping review methodology. Studies were included if published between 1995 and 2019 with a study population of adults aged 18 years or more with any ABI aetiology and there was reported data on resource use, costs or comparative economic analyses as part of an outcome study for rehabilitation interventions. Case studies and trial protocols were excluded. Of 3575 records screened, 30 articles were identified as meeting the inclusion criteria. The majority of studies documented cost savings from provision of various models of multidisciplinary inpatient or outpatient rehabilitation. However, these benefits were estimated without a control group. Eight studies included a cost-effectiveness analysis, and in three, the intervention was reported to be cost-effective compared to the control, one of which saved $9,654 per treated patient. Overall, few eligible studies were identified. Those that included a cost-effectiveness analysis yielded mixed evidence for interventions to be considered cost-effective for ABI. Recommendations for how to incorporate cost-effectiveness analyses into intervention studies are discussed.

Community Participation for People with Trauma Injuries: A Study Protocol of a Crossover Randomised Controlled Trial of the Effectiveness of a Community Mobility Group Intervention (CarFreeMe TI)

Background: Following traumatic brain and spinal cord injuries, maximising community participation leads to better physical and mental health outcomes.

Objectives: To determine the effectiveness and health system resource use of a group intervention (CarFreeMe TI) on community participation in people with complex trauma injuries.

Method: Randomised crossover trial of 54 participants, recruited from rehabilitation services in Adelaide, Australia. Inclusion criteria is a trauma injury, unable to return to full driving, aged over 18 years of age, adequate cognition/behavioural/communication abilities to participate in sessions and mobile. Exclusion criterion is living in setting where alternative transport is provided. Participants will be randomly assigned on a 1:1 allocation basis, to receiving Phase 1 CarFreeMe TI-group-based intervention or Phase 2 information related to transport options. Then, crossover to Phase 1 or 2 will occur. Primary outcome measure is community participation using a Global Positioning System. Secondary outcome measures include Community Mobility Self-efficacy Scale; CarFreeMe TI Transport Questionnaire, AQOL, EQ-5D-5L; Carer's Community Mobility Self-efficacy Scale and Modified Carer Strain Index for carers of participants. Outcome assessors will be blinded to group allocation. All analyses will be on an intention to treat basis with difference in community participation between the groups determined via a GLM ANOVA and the significance between groups on other measures using independent sample t-tests. It is hypothesised that the community mobility intervention (CarFreeMeTI) will result in increased community participation.

Discussion: The results will provide proof of concept information on the feasibility and inform allocation of resources for people with complex trauma injuries.

Trial registration: Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12616001254482.

Efficacy of a Micro-Prompting Technology in Reducing Support Needed by People With Severe Acquired Brain Injury in Activities of Daily Living: A Randomized Control Trial

OBJECTIVE

To evaluate the effectiveness of an automated interactive prompting technology in supporting the morning routine of persons with acquired brain injury. The morning routine included maintaining personal hygiene and dressing.

SETTING

An inpatient neurorehabilitation hospital.

PARTICIPANTS

Persons with acquired brain injury who required prompting when following their morning routine (n = 24), but were not limited by physical disability or dysphasia, took part in the study. Participants (67% with traumatic brain injury) had impairment on indices of memory and executive function.

DESIGN

A randomized control trial evaluated the effect of an automated interactive micro-prompting device on the number of prompts by trained staff required for successful completion of the morning routine.

MAIN MEASURES

Study-specific checklists assessed sequence performance, errors, and verbal prompts required over baseline, rehabilitation as usual, intervention, and return to baseline conditions.

RESULTS

The intervention significantly reduced the support required to complete the task compared with usual rehabilitation.

CONCLUSIONS

Micro-prompting technology is an effective assistive technology for cognition, which reduces support needs in people with significant cognitive impairments.

Preliminary investigation of the reliability and validity of the BIRT Independent Living Scale

PURPOSE

Neurorehabilitation aims to increase independence and participation in ordinary life. It is argued that the fundamental indices of this are independent living and engagement in occupational or productive activity. The Brain Injury Rehabilitation Trust Independent Living Scale was designed to capture change in levels of participation and independence following neurorehabilitation. With greater use of outcome measures in health care, it becomes necessary to develop tools which are simple to use and that capture the holistic impact of rehabilitation. This study examines the inter-rater reliability and validity of the Brain Injury Rehabilitation Trust Independent Living Scale, which comprises two single item, multiple-choice sub-scales.

METHOD

Inter-rater reliability was assessed by comparing the ratings on the Brain Injury Rehabilitation Trust Independent Living Scale, by five pairs of graduate psychologists, of 37 individuals who had undergone neurorehabilitation. Retrospective data collected by other members of the clinical team for the Mayo-Portland Adaptability Inventory-4, Supervision Rating Scale and Care And Needs Scale were correlated with the Brain Injury Rehabilitation Trust Independent Living Scale to establish concurrent validity.

RESULTS

Weighted kappa coefficients revealed moderate (occupation) to strong (accommodation) inter-rater reliability for the two sub-scales. All correlations between the Brain Injury Rehabilitation Trust Independent Living Scale and the Mayo-Portland Adaptability Inventory-4, Supervision Rating Scale and the Care And Needs Scale were high, demonstrating good concurrent validity.

CONCLUSIONS

This study highlights some of the psychometric properties of the Brain Injury Rehabilitation Trust Independent Living Scale and demonstrates its utility in assessing independent living ability and level of social participation after neurorehabilitation. Implications for rehabilitation The BIRT Independent Living Scale is a validated method for ranking accommodation and occupation status as an indicator of independent living ability and occupational activity. The two freely available single-item scales emerging from this study provide a brief method for measuring independent living ability and participation following rehabilitation in research and clinical practice. The BIRT Independent Living Scale's simplicity means it does not require specific training to administer, facilitating its use by a wide range of multidisciplinary staff members and researchers.

Behavioural problems in the first year after Severe traumatic brain injury: a prospective multicentre study

OBJECTIVE

To investigate the occurrence of behavioural problems in patients with severe traumatic brain injury during the first year after injury and potential associations with outcome. An additional post hoc objective was to analyse the frequency of behaviours with need for intervention from staff.

DESIGN AND SETTING

In a prospective population based cohort study 114 patients with severe traumatic brain injury were assessed at three weeks, three months and one year after injury.

MAIN MEASURES

Assessments included clinical examination and standardised instruments. Agitation was assessed with the Agitated Behaviour Scale, the course of recovery by the Rancho Los Amigo Scale and outcome by Glasgow Outcome Scale Extended.

RESULTS

Agitation were most common at 3 weeks post injury and 28% ( n=68) of the patients showed at least one agitated behaviour requiring intervention from staff. Presence of significant agitation at 3 weeks after injury was not associated with poor outcome. At 3 months agitation was present in 11% ( n=90) and apathy in 26 out of 81 assessed patients. At 3 months agitation and apathy were associated with poor outcome at one year.

CONCLUSIONS

Most agitated behaviours in the early phase are transient and are not associated with poor outcome. Agitation and apathy are uncommon at three months but when present are associated with poor outcome at one year after injury. In the early phase after a severe traumatic brain injury agitated behaviour in need of interventions from staff occur in a substantial proportion of patients.

Factors influencing community case management and care hours for clients with traumatic brain injury living in the UK

OBJECTIVE

To investigate the relationship between deficits associated with traumatic brain injury (TBI) and case management (CM) and care/support (CS) in two UK community samples.

RESEARCH DESIGN

Prospective descriptive study.

METHOD

Case managers across the UK and from a single UK CM service contributed client profiles to two data sets (Groups 1 and 2, respectively). Data were entered on demographics, injury severity, functional skills, functional-cognition (including executive functions), behaviour and CM and CS hours. Relationships were explored between areas of disability and service provision.

RESULTS

Clients in Group 2 were more severely injured, longer post-injury and had less family support than clients in Group 1. There were few significant differences between Groups 1 and 2 on measures of Functionalskill, Functional-cognition and Behaviour disorder. Deficits in Functionalskills were associated with CS, but not CM. Deficits in measures of executive functions (impulsivity, predictability, response to direction) were related to CM, but not to CS. Insight was related to both CM and CS. Variables related to behaviour disorder were related to CM, but were less often correlated to CS.

CONCLUSIONS

The need for community support is related not only to Functionalskills (CS), but also to behaviour disorder, self-regulatory skills and impaired insight (CM).

Cost effectiveness of inpatient rehabilitation in patients with brain injury

Rehabilitation following acquired brain injury improves health outcomes, reduces disability, and improves quality of life. We assessed the cost effectiveness of inpatient rehabilitation after brain injury in individuals with brain injury admitted to the Irish national tertiary specialist rehabilitation centre in 2011. Patients' score on the Disability Rating Scale (DRS) was recorded on admission and at discharge after intensive inpatient rehabilitation. Cost savings attributed to the rehabilitation programme were calculated as the difference between direct care costs on admission and discharge. Direct costs of care were calculated as the weekly cost of the care-assistant hours required to care for patients on the basis of their level of disability or daily nursing-home bed cost when this was required. Of 63 patients, complete DRS information for admission and discharge was available for 41. DRS scores, and therefore average levels of functioning, differed significantly at admission (2.3, between mildly and moderately dependent) and discharge (1.1, independent in special environments, p<0.01). Average weekly care costs fell from €629 to €242, with costs recouped within 30 months. Thus, substantial savings result from inpatient rehabilitation, and these savings could have been greater had we considered also the economic benefit of enabling patients to return to employment.

Effectiveness of Occupation- and Activity-Based Interventions to Improve Everyday Activities and Social Participation for People With Traumatic Brain Injury: A Systematic Review

This systematic review presents research on the effectiveness of occupation- and activity-based interventions to improve everyday activities and areas of occupation and social participation for people with traumatic brain injury (TBI). Nineteen studies identified through a comprehensive database search were reviewed and synthesized into five themes: (1) multidisciplinary and interdisciplinary treatment approaches, (2) community-based rehabilitation programs, (3) treatment approaches using client-centered goals and relevant contexts, (4) social skills training and peer mentoring interventions, and (5) community mobility interventions. Evidence supports the use of multidisciplinary and interdisciplinary approaches across a variety of settings, with no single treatment approach or setting clearly superior to another. The specific contributions of occupational therapy practitioners and the nature of occupational therapy interventions have not been well studied, making it difficult to determine the extent to which occupation- and activity-based interventions provided by occupational therapy practitioners improve occupational performance and social participation after TBI.

Traumatic brain injury: methodological approaches to estimate health and economic outcomes

The effort to standardize the methodology and adherence to recommended principles for all economic evaluations has been emphasized in medical literature. The objective of this review is to examine whether economic evaluations in traumatic brain injury (TBI) research have been compliant with existing guidelines. Medline search was performed between January 1, 1995 and August 11, 2012. All original TBI-related full economic evaluations were included in the study. Two authors independently rated each study's methodology and data presentation to determine compliance to the 10 methodological principles recommended by Blackmore et al. Descriptive analysis was used to summarize the data. Inter-rater reliability was assessed with Kappa statistics. A total of 28 studies met the inclusion criteria. Eighteen of these studies described cost-effectiveness, seven cost-benefit, and three cost-utility analyses. The results showed a rapid growth in the number of published articles on the economic impact of TBI since 2000 and an improvement in their methodological quality. However, overall compliance with recommended methodological principles of TBI-related economic evaluation has been deficient. On average, about six of the 10 criteria were followed in these publications, and only two articles met all 10 criteria. These findings call for an increased awareness of the methodological standards that should be followed by investigators both in performance of economic evaluation and in reviews of evaluation reports prior to publication. The results also suggest that all economic evaluations should be made by following the guidelines within a conceptual framework, in order to facilitate evidence-based practices in the field of TBI.

The clinical and cost-benefits of investing in neurobehavioural rehabilitation: a multi-centre study

Primary objective

The aim of this study was to investigate the cost-benefits of a residential post-acute neurobehavioural rehabilitation programme and its effects on care needs and social participation of adults with acquired brain injury.

Research design

Retrospective multi-centre design.

Methods and procedures

Data on occupation, adaptability and level of support required were collected at admission, discharge and 6-months follow-up. Cost analysis was performed on cost estimates based on level of support.

Main outcomes and results

Significant gains were observed in all areas of functioning, with individuals progressing towards higher levels of independence and more participation in society upon discharge.

Conclusions

Cost-benefits of up to £1.13 million were demonstrated for individuals admitted to rehabilitation within a year of sustaining a brain injury and of up to £0.86 million for those admitted more than 1 year after injury. Functional gains and reductions in levels of care required upon discharge were maintained 6 months later. These results demonstrate that post-acute neurobehavioural rehabilitation can have a positive impact on the lives of individuals with brain injury and that the associated costs are off-set by significant savings in the longer-term.

Bi-factor analyses of the Brief Test of Adult Cognition by Telephone

BACKGROUND

Telephone cognitive batteries are useful for large-scale screening and epidemiological studies, but their brevity and lack of content depth may cause psychometric limitations that hinder their utility.

OBJECTIVE

The current study addressed some of these limitations by rescaling the Brief Test of Adult Cognition by Telephone (BTACT; Tun & Lachman, 2006) using modern psychometric methods.

METHODS

Archival data were obtained from a national sample of 4,212 28 to 84-year-old volunteers in the National Survey of Midlife Development in the United States (Ryff et al., 2007) Cognitive Project (Ryff & Lachman, 2007). We fit a bi-factor model to a combination of item-level, subscale-level, and scale-level data.

RESULTS

The best fitting model contained a general factor and secondary factors capturing test-specific method effects or residual correlations for Number Series, Red/Green Test, and the Rey Auditory Verbal Learning Test. Factor scores generated from this model were compared with conventional BTACT scores. Important score differences (i.e., >0.3 standard deviation units) were found in 28% of the sample. The bi-factor scores demonstrated slightly superior validity than conventional BTACT scores when judged against a number of clinical and demographic criterion variables.

CONCLUSIONS

Modern psychometric approaches to scoring the BTACT have the benefit of linear scaling and a modest criterion validity advantage.

The costs of traumatic brain injury: a literature review

OBJECTIVE

The purpose of this study was to review the literature relating to the psychosocial costs associated with traumatic brain injury (TBI).

METHODS

Nine online journal databases, including MEDLINE, CINAHL, PsychINFO, and PUBMED, were queried for studies between July 2010 and May 2012 pertaining to the economic burden of head injuries. Additional studies were identified through searching bibliographies of related publications and using Google internet search engine.

RESULTS

One hundred and eight potentially relevant abstracts were identified from the journal databases. Ten papers were chosen for discussion in this review. All but two of the chosen papers were US studies. The studies included a cost-benefit analysis of the implementation of treatment guidelines from the US brain trauma foundation and a cost-effectiveness analysis of post-acute traumatic brain injury rehabilitation.

CONCLUSION

Very little research has been published on the economic burden that mild and moderate traumatic brain injury patients pose to their families, careers, and society as a whole. Further research is needed to estimate the economic burden of these patients on healthcare providers and social services and how this can impact current health policies and practices.

CE hospital service utilization is reduced following neuropsychological evaluation in a sample of U.S. veterans

The aim of this study was to evaluate the objective value of neuropsychological evaluation (NPE) through reduction in Emergency Room (ER) visits and hospitalizations. Retrospective analysis examined trends in ER visits and hospitalizations in 440 U.S. veterans who completed NPE between the years of 2003 and 2010. Within-subjects comparisons showed significant decreases in incidence of hospitalization and length of hospitalization in the year after evaluation compared to the year prior. Mean number of hospitalizations declined from 0.31 (SD = 0.64) pre-NPE to 0.22 (SD = 0.59) post-NPE; there were a total of 41 fewer hospitalizations in the year following NPE. Mean length of hospitalization decreased from 1.9 days (SD = 5.6) pre-NPE to 1.06 days (SD = 3.9) post-NPE; there were a total of 368 fewer days of hospitalization post-NPE. This reduction was not attributable to age or time. Incidence of ER visits also decreased from pre-NPE (M = 0.74, SD = 1.3) to post-evaluation (M = 0.69, SD = 1.3), though this was not significant. These findings provide preliminary evidence of the clinical and potential economic value of neuropsychological services within a medical setting. Follow-up studies should examine individual and exam-specific factors that may contribute to reduced utilization.

Long-Term Accommodation and Support for People With Higher Levels of Challenging Behaviour

The purpose of the present article is to describe the issues associated with providing lifelong accommodation and support to people with severe brain injury, neurobehavioural disability, and overt challenging behaviours. In particular, the article focuses on two groups of people within an Australian context: (a) those who live in community settings but whose behaviour is not adequately managed even by specialist outreach behaviour management services, and (b) those who are confined to aged care residential facilities and who show challenging behaviour. These groups bring to the fore different lifelong behaviour management issues. At present, if community-based clients seriously offend or have an adequate psychiatric diagnosis, they may be placed in heavily secured psychiatric units or prison. Otherwise, by default, they will reside in less restrictive options such as family homes and shared supported accommodation. We will argue that the current service system lacks the ability to apply appropriate structure and control to many clients with serious challenging behaviours, and propose that specialised facilities would make an important addition to the service system. Conversely, young clients confined to residential aged care facilities live in impoverished environments that often contribute to challenging behaviour that can be enormously disruptive, distressing, and unsafe. We will review the recent Australian State and Federal Government initiative aimed at transitioning some young people out of nursing homes, and we raise considerations for future service development. There are many individuals with the potential to make significant gains in a tightly structured setting before returning to the community, while others will manage well with long-term placement in a setting designed for residents with neurobehavioural disability. Case studies and service data are used to support these arguments, and key elements of accommodation and rehabilitation models for those in need of long-term neurobehavioural support are described.

Changes in Care and Support Needs Following Community-Based Intervention for Individuals With Acquired Brain Injury

Objective:To examine the care and support and participation outcomes for individuals with severe Acquired Brain Injury (ABI) provided with three consecutive years of Community Approach to Participation (CAP) intervention.Method:A case series study design was undertaken with a total of 43 participants from two private occupational therapy practices specialising in community-based, CAP rehabilitation for people with severe ABI. Data were collected at four time points: January 2004 (Baseline), January 2005 (T1), January 2006 (T2), and January 2007 (T3) and included rating on the Care and Needs Scale (CANS); number of hours of paid and gratuitous weekly support; FIM™ and Community Integration Questionnaire scores; and number of current life roles (as recorded on Part 1 of the Role Checklist). Participants were an average of 6.73 years post injury and were living in a range of community environments and residential facilities.Results:There was considerable change in participants' CANS rating across the intervention period, with statistically significant decreases occurring from Baseline to T1 and T1 to T2. Ninety-five per cent of participants received some level of weekly paid support throughout the intervention period, with the amount varying considerably. Paid care decreased by an average of 10.78 hours per week from 85.85 hours per week at Baseline to 75.06 at T3. Although not statistically significant, this equated to an average cost saving of AU$324.84 per participant per week by the end of CAP intervention. There was an overall mean reduction of 4.96 hours of gratuitous care per week per participant over the intervention period, which was statistically significant. Increases in functional independence, community integration, and role participation were also found. On the FIM™, statistically significant improvement occurred between Baseline and T1 and on the CIQ between Baseline and T1 and T1 and T2. Significant increase on the Role Checklist occurred between Baseline and T1 and between T2 and T3. The number of life roles in which participants engaged increased by an average of 1.65 roles by the end of the intervention period. A reduction in care and support needs (measured by the CANS) was significantly associated with: (1) a reduction in total care hours, (2) and an increase in functional independence on the FIM™, and (3) an increase in community integration on the CIQ.Conclusion:With a long term approach and contextualised intervention targeted at skill development in the areas that underpin personally valued participation, increased role performance and community integration can be achieved by people with severe ABI, even many years post injury. This increased capacity has been found to be associated with a reduction in care and support needs, including paid and gratuitous care hours, over time.

Treatment paths and costs for young adults with acquired brain injury in the United Kingdom

PRIMARY OBJECTIVES

To identify the health and social care services used by young adults aged 18-25 years with acquired brain injury (ABI) and the costs of these supports.

RESEARCH METHODS

A review of existing literature and databases and contact with academics and stakeholders working with people with ABI.

MAIN OUTCOMES AND RESULTS

The likely care pathways of young adults with ABI were mapped over a notional 1-year period after presentation at hospital accident and emergency departments. Most young adults with ABI will use minimal health and social care support following injury but those with subsequent disabilities may cost the health and social care budget in excess of pound47.2 million per year.

CONCLUSION

Lack of available data mean the service use and cost estimates draw from a range of sources. However, the costs may under-estimate the true impact on budgets as incidence rates may be higher than identified and conservative values were selected for unit costs. The model estimates the cost of treatment and support as provided today, but high levels of unmet need remain.

Assessing adaptive behaviour in the post-acute setting following traumatic brain injury: Initial reliability and validity of the Adaptive Behaviour and Community Competency Scale (ABCCS)

PRIMARY OBJECTIVE

Present the rationale for adaptive behavior rating and introduce the Adaptive Behaviour and Community Competency Scale (ABCCS), a comprehensive and detailed measure of adaptive behaviour, for use with persons with traumatic brain injury (TBI) in the post-acute period.

METHODS AND PROCEDURES

Direct-care staff with limited exposure to the ABCCS, completed it twice, two weeks apart, about persons with TBI who were resident in diverse community settings. Other measures to assess validity were administered concurrently.

RESULTS

Intraclass Correlation Coefficients (ICC) for interrater and test-retest reliability of the ABCCS were excellent (ICC=0.9681 and 0.9860 respectively). Evidence for convergent and divergent validity with comparison measures was strong with highly significant correlations with scales measuring similar content (Rho=0.613-0.919) and weak correlations for scales measuring dissimilar content (Rho=0.318-0.397).

CONCLUSIONS

The ABCCS is a reliable and a valid indicator of functioning post-acute TBI and is straightforward enough to be used by direct-care staff.