Development and initial validation of the Northwick Park Therapy Dependency Assessment

The use of frailty questionnaires in inpatients in two neurorehabilitation units in the East Midlands - A cross-sectional cohort study with follow-up to 1-year after discharge from inpatient rehabilitation

BACKGROUND

Frailty correlates with poor clinical outcomes and is not routinely assessed in neurorehabilitation inpatient settings.

METHODS

We recruited adults from two neurorehabilitation units. We administered six validated tools for assessing frailty and collected data around length of stay, discharge, readmission and change in rehabilitation outcome measures.

RESULTS

Seventy-eight participants aged between 31 and 84 years were recruited with a range of neurological diagnoses. Frailty prevalence ranged between 23% and 46%, depending on the scale used, with little agreement between tools. Frailty status did not correlate with age, gender, length of stay, discharge destination and rehabilitation outcome measures. One-year readmission was higher in participants rated as frail by the Frail-Non-Disabled Questionnaire, the FRESH-screening questionnaire and the Clinical Frailty Scale.

CONCLUSION

Frailty ascertainment was variable depending on the tool used. Three frailty indices predicted readmission rate at 1 year but no other outcome measures. Therefore, frailty tools may have limited utility in this clinical population.

Development and validation of the MAnchester Needs Tool for Injured Children (MANTIC)

OBJECTIVE

To develop a measure of the needs injured children and their families' needs throughout recovery; The MAnchester Needs Tool for Injured Children (MANTIC).

DESIGN

Tool development, psychometric testing.

SETTING

Five children's major trauma centres in England.

PARTICIPANTS

Children aged 2 to 16 years with any type of moderate/severe injury(ies) treated in a major trauma centre within 12 months of injury, plus their parents.

METHODS

Stage 1a (Item generation): Interviews with injured children and their parents to generate draft items. Stage 1b (Co-production): Feedback about item clarity, relevance and appropriate response options was provided by parents and the patient and public involvement group. Stage 2 (Psychometric development): Completion of the prototype MANTIC by injured children and their parents with restructuring (as necessary) to establish construct validity. Concurrent validity was assessed by correlation with quality of life (EQ-5D-Y). MANTICs were repeated 2 weeks later to assess test-retest reliability.

RESULTS

Stages 1a,b: Interviews (13 injured children, 19 parents) generated 64 items with semantic differential four-point response scale (strongly disagree, disagree, agree, strongly agree). Stage 2: One hundred and forty-four participants completed MANTIC questionnaires (mean age 9.8 years, SD 3.8; 68.1% male). Item responses were strong requiring only minor changes to establish construct validity. Concurrent validity with quality of life was moderate (r = 0.55, P < 0.01) as was test-retest reliability (ICC = 0.46 and 0.59, P < 0.001). Uni-dimensionality was strong (Cronbach's α > 0.7).

CONCLUSION

The MANTIC is a feasible, acceptable, valid self-report measure of the needs of injured children and their families, freely available for clinical or research purposes.

Cohort profile: the Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT), Western Australia, 1991-2020

PURPOSE

Transition back into the community following acute management of acquired brain injury (ABI) is a critical part of recovery. Post-acute rehabilitation and transitional care can significantly improve outcomes. The Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT) is a novel whole-population cohort formed to better understand the needs of individuals with ABI receiving post-acute rehabilitation and disability services in Western Australia (WA), and to improve their outcomes. To do this a unique combination of (1) internal clinical/rehabilitation data, and (2) externally linked health data from the WA Data Linkage System was used, including hospitalisations, emergency department presentations, mental health service use and death records, to measure longitudinal needs and outcomes of individuals with ABI over 29 years, making this the largest, most diverse post-acute ABI cohort in Australia to date.

PARTICIPANTS

Whole-population cohort of individuals (n=1011) with an ABI who received post-acute community-based neurorehabilitation or disability support services through Brightwater Care Group from 1991 to 2020.

FINDINGS TO DATE

Comprehensive baseline demographic, clinical and rehabilitation data, outcome measures and linked health data have been collected and analysed. Non-traumatic brain injury (eg, stroke, hypoxia) was the main diagnostic group (54.9%, n=555), followed by traumatic brain injury (34.9%, n=353) and eligible neurological conditions (10.2%, n=103). Mean age at admission was 45.4 years, and 67.5% were men (n=682). The cohort demonstrated significant heterogeneity, socially and clinically, with differences between ABI groups across a number of domains.

FUTURE PLANS

ABI-RESTaRT is a dynamic whole-population cohort that will be updated over time as individuals enrol in the service. Future analyses will assess longitudinal brain injury outcomes, the changing health and social needs of individuals with ABI and evaluate and inform post-acute services to best support these individuals.

REGISTRATION

This cohort is not linked to a clinical trial, and is not registered.

The use of cognitive screens within major trauma centres in England: A survey of current practice

Introduction

Major trauma centres are effective in reducing morbidity and mortality rates following serious injury. Many patients attending major trauma centres present with traumatic brain injuries, requiring specialist assessment in screening for potential cognitive deficits. Numerous cognitive screens exist but it is currently unclear which are used most frequently within major trauma centres. This study aimed to identify which screening tools are used most frequently in major trauma centres in England to enable discussion around their suitability for this clinical population.

Method

Electronic surveys were distributed via a mailing list to Clinical Psychologists and Clinical Neuropsychologists in major trauma centres across England to gather data on the use of cognitive screens.

Results

Fourteen Clinical Psychologists in Neuropsychology participated. Results suggest major trauma centres in England are currently using the ACE-III (50%) or MoCA (42%) as the most frequently used screens for cognitive difficulties following traumatic brain injury. Cognitive screening pathways are multi-disciplinary involving OTs (86%), psychologists (qualified 79%; assistant 57%) psychiatrists (36%), mental health nurses (7%) and therapy assistants (7%).

Conclusions

Major trauma centres are using evidence-based cognitive screens at present, but further work is needed to develop more effective, better validated cognitive screens for traumatic brain injury populations. Increased inter-professional discussion on the practice of cognitive screening would be beneficial for patients seen within major trauma centres.

Evaluating the Functional and Cognitive Examination for patients with acute acquired brain injury

Background/Aims:

The Functional and Cognitive Examination is a cross-battery neuropsychological baseline assessment. It was designed specifically for patients with acquired brain injury in the acute rehabilitation stage. This investigation focused on the utility of the Functional and Cognitive Examination to identify the association between the functional and cognitive performance of acquired brain injury patients and the construct validity of the battery.

Methods:

The Functional and Cognitive Examination is administered as a standard for all patients admitted to the inpatient neurological assessment and specialist rehabilitation unit. Forty two patients had been recruited over a two year period. Raw scores have been analysed and descriptive data is provided. Spearman's correlations were used to observe associations between functional and cognitive performance. The Functional and Cognitive Examination was also correlated against the Functional Assessment Measure and the Northwick Park Therapy Dependency Assessment.

Findings:

There was a positive association between lower performance on the Functional and Cognitive Examination cognitive component and the Functional and Cognitive Examination functional task. Similarly, lower scores on the Functional Assessment Measure had positive associations with performance on the Functional and Cognitive Examination functional task.

Conclusions:

The Functional and Cognitive Examination is a useful neuropsychological baseline assessment. It illustrates that cognitive and functional components are associated and the Functional and Cognitive Examination outcomes are associated with the Functional Assessment Measure.

Paediatric Rehabilitation Ingredients Measure: a new tool for identifying paediatric neurorehabilitation content

AIM

To develop an instrument (Paediatric Rehabilitation Ingredients Measure [PRISM]) for quantitative estimation of contents of interdisciplinary neurorehabilitation for use in studies of relationships between rehabilitation treatment delivered and severity-adjusted outcomes after acquired brain injury (ABI).

METHOD

The measure was developed using an ingredients-mediators-outcomes model consistent with the International Classification of Functioning, Disability and Health, a literature review, and other current initiatives in the development of rehabilitation treatment taxonomies, with item codevelopment in workshops with rehabilitation professionals. Interrater reliability was assessed in inpatient and residential paediatric rehabilitation settings.

RESULTS

Although sometimes an initially unfamiliar perspective on rehabilitation practice, PRISM's acceptability amongst professionals was excellent. Internal consistency of scores was sometimes an issue for users unfamiliar with the tool; however, this improved with practice and interrater reliability (assessed by Kendall's W) was good. The tool was felt to have particular value in facilitating interdisciplinary communication and working. Modifications to the design of the tool have improved internal consistency.

INTERPRETATION

PRISM supports identification of the 'active ingredients' of an interdisciplinary rehabilitation package and facilitates interdisciplinary communication. It also has potential as a research tool examining relationships between rehabilitation delivered and severity-adjusted outcomes observed after paediatric ABI.

WHAT THIS PAPER ADDS

Identifying contribution of rehabilitation to outcomes after acquired brain injury requires quantification of rehabilitation 'dose' and 'content'. Previous approaches to 'parsing' of rehabilitation dose and content may have overemphasized one-to-one sessions with therapists. We present a novel, holistic tool for identification of ingredients of an interdisciplinary rehabilitation package. It supports interdisciplinary communication and has potential as a research tool.

Comparison of Rehabilitation Outcomes for Long Term Neurological Conditions: A Cohort Analysis of the Australian Rehabilitation Outcomes Centre Dataset for Adults of Working Age

OBJECTIVE

To describe and compare outcomes from in-patient rehabilitation (IPR) in working-aged adults across different groups of long-term neurological conditions, as defined by the UK National Service Framework.

DESIGN

Analysis of a large Australian prospectively collected dataset for completed IPR episodes (n = 28,596) from 2003-2012.

METHODS

De-identified data for adults (16-65 years) with specified neurological impairment codes were extracted, cleaned and divided into 'Sudden-onset' conditions: (Stroke (n = 12527), brain injury (n = 7565), spinal cord injury (SCI) (n = 3753), Guillain-Barré syndrome (GBS) (n = 805)) and 'Progressive/stable' conditions (Progressive (n = 3750) and Cerebral palsy (n = 196)). Key outcomes included Functional Independence Measure (FIM) scores, length of stay (LOS), and discharge destination.

RESULTS

Mean LOS ranged from 21-57 days with significant group differences in gender, source of admission and discharge destination. All six groups showed significant change (p<0.001) between admission and discharge that was likely to be clinically important across a range of items. Significant between-group differences were observed for FIM Motor and Cognitive change scores (Kruskal-Wallis p<0.001), and item-by-item analysis confirmed distinct patterns for each of the six groups. SCI and GBS patients were generally at the ceiling of the cognitive subscale. The 'Progressive/stable' conditions made smaller improvements in FIM score than the 'Sudden-onset conditions', but also had shorter LOS.

CONCLUSION

All groups made gains in independence during admission, although pattern of change varied between conditions, and ceiling effects were observed in the FIM-cognitive subscale. Relative cost-efficiency between groups can only be indirectly inferred. Limitations of the current dataset are discussed, together with opportunities for expansion and further development.

The Northwick Park Therapy Dependency Assessment scale: a psychometric analysis from a large multicentre neurorehabilitation dataset

Purpose: To assess the internal reliability, construct and concurrent validity and responsiveness of the Northwick Park Therapy Dependency Assessment (NPTDA) scale. Method: A cohort of 2505 neurorehabilitation patients submitted to the UK Rehabilitation Outcomes Collaborative database. Cronbach’s coefficient-α was used to assess internal reliability and factor analysis (FA) to assess construct validity. We compared NPTDA scores at admission and discharge to determine responsiveness. Results: Coefficient-α for the whole scale was 0.74. The exploratory FA resulted in a four-factor model (Physical, Psychosocial, Discharge planning and Activities) that accounted for 43% of variance. This model was further supported by the confirmatory FA. The final model had a good fit: root-mean-square error of approximation of 0.069, comparative fit index/Tucker–Lewis index of 0.739/0.701 and the goodness of fit index of 0.909. The NPTDA scores at admission and discharge were significantly different for each of the factors. Expected correlations were seen between the admission scores for the NPTDA, the Rehabilitation Complexity Scale (r = 0.30, p < 0.01) and the Functional Independence Measure (r = −0.25, p < 0.01). Conclusions: The scale demonstrated acceptable internal reliability and good construct and concurrent validity. NPTDA may be used to describe and quantify changes in therapy inputs in the course of a rehabilitation programme.

Implications for Rehabilitation

The Northwick Park Therapy Dependency Assessment (NPTDA) is designed as a measure therapy intervention, which reflects both quantitative and qualitative aspects of the inputs provided (including staff time and the different types of intervention) during inpatient rehabilitation.

The scale demonstrated acceptable internal reliability and good construct and concurrent validity.

NPTDA is responsive to change in the therapy inputs provided during neurorehabilitation between admission and discharge.

Development of an assessment tool for the multidisciplinary evaluation of neurological dependency: preliminary findings

BACKGROUND

Multidisciplinary inputs are of vital importance in the comprehensive care management and rehabilitation of individuals with long-term neurological conditions. Although many ordinal measures of disability correlate with patient dependency and care, few are based on numbers of different health professionals required, or their skill-mix, for assistance associated with levels of dependency.

AIM AND OBJECTIVES

To develop an instrument to assess dependency in adult patients suffering from severe and complex neurological disability for use by multidisciplinary teams. Objectives were to establish content validity, construct validity, inter-rater reliability and internal consistency, and to demonstrate preliminary clinical utility from the perspective of professional staff.

DESIGN AND METHODS

A mixed methods design utilised qualitative and quantitative approaches. Stage I involved developmental fieldwork using focus groups (n = 3), questionnaires (n = 70), expert panel (n = 20) and direct observation (n = 12). In stage 2, intensive refinement through direct observation, construct validity and reliability testing (n = 100) of the instrument was completed. The research complied with the research governance and ethical standards set by the Department of Health (UK).

RESULTS

In the final format, an instrument was developed which comprised two sections. Section 1: an ordinal scaled basic care section, with 15 categories of dependency and level of descriptors based on numbers, grade and time taken by staff providing assistance. Factor analysis identified one dominant and four subsidiary factors which explained 67% of the total variance. Overall inter-rater agreement was 0.87 (kappa coefficient: range 0.67-1.0), and Cronbach's coefficient alpha was 0.733. Section 2: comprised a nominally measured specialist care section for inputs from nurses and therapists. The mean time taken to complete assessments was 12 minutes.

CONCLUSION

The instrument satisfied preliminary selective criteria for validity and reliability. Further research is necessary to satisfy other requirements of psychometric testing and clinical utility.

Engaging the hearts and minds of clinicians in outcome measurement - the UK Rehabilitation Outcomes Collaborative approach

PURPOSE

This article explores the rationale for choosing the instruments included within the UK Rehabilitation Outcomes Collaborative (UKROC) data set. Using one specialist neuro-rehabilitation unit as an exemplar service, it describes an approach to engaging the hearts and minds of clinicians in recording the data.

KEY MESSAGES AND IMPLICATIONS

Measures included within a national data set for rehabilitation should be psychometrically robust and feasible to use in routine clinical practice; they should also support clinical decision-making so that clinicians actually want to use them. Learning from other international casemix models and benchmarking data sets, the UKROC team has developed a cluster of measures to inform the development of effective and cost-efficient rehabilitation services. These include measures of (1) "needs" for rehabilitation (complexity), (2) inputs provided to meet those needs (nursing and therapy intervention), and (3) outcome, including the attainment of personal goals as well as gains in functional independence.

CONCLUSIONS

By integrating the use of the data set measures in everyday clinical practice, we have achieved a very high rate of compliance with data collection. However, staff training and ongoing commitment from senior staff and managers are critical to the maintenance of effort required to provide assurance of data quality in the longer term.

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.