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Barra ME, Giulietti JM, DiCarlo JA, Erler KS, Krenz J, Roberts RJ, Lin DJ. Medication Profiles at Hospital Discharge Predict Poor Outcomes After Acute Ischemic Stroke. J Pharm Pract 2024; 37:600-606. [PMID: 36604314 DOI: 10.1177/08971900221150282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objectives: To examine the relationship between medications prescribed during the first 6-months post-stroke and functional outcome. Materials and Methods: A retrospective analysis of ischemic stroke survivors enrolled in an observational stroke recovery study from June-2017 to July-2019 was performed. Survivors with favorable outcomes (modified rankin scale (mRS) score 0-2) were compared to those with unfavorable outcomes (mRS ≥3) 6-months after stroke on the following: discharge medication classes prescribed, achievement of recommended targets for blood pressure control, glycemic control, and LDL ≤70 mg/dL, medication changes, medication interactions, and medication list discrepancies. Results: Unfavorable 6-month outcomes occurred in 36/78 (46.2%) of survivors. Survivors with unfavorable outcomes were more likely to be prescribed a central nervous system-acting agent (97.2% vs 71.4%; P = .0022) and/or an anti-hyperglycemic agent (25.0% vs 9.5%; P = .009) at discharge. After adjustment of baseline covariates, total number of medications prescribed was associated with unfavorable 6-month outcomes (OR 1.13, 95% CI 1.0-1.28). Secondary stroke prevention measures were not achieved in a high proportion of survivors. Medication changes during 6-month follow up were common and survivors with unfavorable outcomes were more likely to have clinically significant drug-drug interactions. Discussion: At 6-months, survivors with unfavorable outcomes were found to be prescribed more medications, particularly central nervous system-acting and anti-hyperglycemic agents. There were also more drug-drug interactions in the medications prescribed compared to those with favorable outcomes. Together, these data suggest the need for enhanced screening of high-risk stroke survivors focused on close monitoring of polypharmacy, drug-drug interactions, and adverse events with pharmacotherapy.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer M Giulietti
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
- School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Julie A DiCarlo
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kimberly S Erler
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - James Krenz
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Erler KS, Robinson EM, Bandini JI, Regel EV, Zwirner M, Cremens C, McCoy TH, Romain F, Courtwright A. Clinical Ethics Consultation During the First COVID-19 Pandemic Surge at an Academic Medical Center: A Mixed Methods Analysis. HEC Forum 2023; 35:371-388. [PMID: 35290566 PMCID: PMC8922390 DOI: 10.1007/s10730-022-09474-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 11/25/2022]
Abstract
While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim to fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters.
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Affiliation(s)
- Kimberly S Erler
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
- School of Health and Rehabilitation Science, MGH Institute of Health Professions, Boston, MA, USA.
| | - Ellen M Robinson
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Patient Care Services Office of Quality, Safety and Practice, Boston, MA, USA
| | - Julia I Bandini
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- RAND Corporation, Boston, MA, USA
| | - Eva V Regel
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Mary Zwirner
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Cornelia Cremens
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Fred Romain
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Respiratory Care, Mass General Hospital, Boston, MA, USA
| | - Andrew Courtwright
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
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Lin DJ, Hardstone R, DiCarlo JA, Mckiernan S, Snider SB, Jacobs H, Erler KS, Rishe K, Boyne P, Goldsmith J, Ranford J, Finklestein SP, Schwamm LH, Hochberg LR, Cramer SC. Distinguishing Distinct Neural Systems for Proximal vs Distal Upper Extremity Motor Control After Acute Stroke. Neurology 2023; 101:e347-e357. [PMID: 37268437 PMCID: PMC10435065 DOI: 10.1212/wnl.0000000000207417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/31/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The classic and singular pattern of distal greater than proximal upper extremity motor deficits after acute stroke does not account for the distinct structural and functional organization of circuits for proximal and distal motor control in the healthy CNS. We hypothesized that separate proximal and distal upper extremity clinical syndromes after acute stroke could be distinguished and that patterns of neuroanatomical injury leading to these 2 syndromes would reflect their distinct organization in the intact CNS. METHODS Proximal and distal components of motor impairment (upper extremity Fugl-Meyer score) and strength (Shoulder Abduction Finger Extension score) were assessed in consecutively recruited patients within 7 days of acute stroke. Partial correlation analysis was used to assess the relationship between proximal and distal motor scores. Functional outcomes including the Box and Blocks Test (BBT), Barthel Index (BI), and modified Rankin scale (mRS) were examined in relation to proximal vs distal motor patterns of deficit. Voxel-based lesion-symptom mapping was used to identify regions of injury associated with proximal vs distal upper extremity motor deficits. RESULTS A total of 141 consecutive patients (49% female) were assessed 4.0 ± 1.6 (mean ± SD) days after stroke onset. Separate proximal and distal upper extremity motor components were distinguishable after acute stroke (p = 0.002). A pattern of proximal more than distal injury (i.e., relatively preserved distal motor control) was not rare, observed in 23% of acute stroke patients. Patients with relatively preserved distal motor control, even after controlling for total extent of deficit, had better outcomes in the first week and at 90 days poststroke (BBT, ρ = 0.51, p < 0.001; BI, ρ = 0.41, p < 0.001; mRS, ρ = 0.38, p < 0.001). Deficits in proximal motor control were associated with widespread injury to subcortical white and gray matter, while deficits in distal motor control were associated with injury restricted to the posterior aspect of the precentral gyrus, consistent with the organization of proximal vs distal neural circuits in the healthy CNS. DISCUSSION These results highlight that proximal and distal upper extremity motor systems can be selectively injured by acute stroke, with dissociable deficits and functional consequences. Our findings emphasize how disruption of distinct motor systems can contribute to separable components of poststroke upper extremity hemiparesis.
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Affiliation(s)
- David J Lin
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital.
| | - Richard Hardstone
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Julie A DiCarlo
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Sydney Mckiernan
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Samuel B Snider
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Hannah Jacobs
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Kimberly S Erler
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Kelly Rishe
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Pierce Boyne
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Jeff Goldsmith
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Jessica Ranford
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Seth P Finklestein
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Lee H Schwamm
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Leigh R Hochberg
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
| | - Steven C Cramer
- From the Center for Neurotechnology and Neurorecovery (D.J.L., R.H., J.A.D., S.M., H.J., K.S.E., K.R., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology; Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School; Department of Occupational Therapy (H.J., K.S.E.), MGH Institute of Health Professions, Boston, MA; Department of Rehabilitation (P.B.), Exercise and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, OH; Department of Biostatistics (J.G.), Columbia University Mailman School of Public Health, New York, NY; Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston; School of Engineering (L.R.H.), Brown University, Providence, RI; and Department of Neurology (S.C.C.), University of California, Los Angeles, California Rehabilitation Hospital
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Juengst SB, Agtarap S, Venkatesan UM, Erler KS, Evans E, Sander AM, Klyce D, O'Neil Pirozzi TM, Rabinowitz AR, Kazis LE, Giacino JT, Kumar RG, Bushnik T, Whiteneck GG. Developing multidimensional participation profiles after traumatic brain injury: a TBI model systems study. Disabil Rehabil 2023:1-11. [PMID: 37296112 DOI: 10.1080/09638288.2023.2221900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 03/08/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
Purpose. To characterize societal participation profiles after moderate-severe traumatic brain injury (TBI) along objective (Frequency) and subjective (Satisfaction, Importance, Enfranchisement) dimensions.Materials and Methods. We conducted secondary analyses of a TBI Model Systems sub-study (N = 408). Multiaxial assessment of participation included the Participation Assessment with Recombined Tools-Objective and -Subjective questionnaires (Participation Frequency and Importance/Satisfaction, respectively) and the Enfranchisement Scale. Participants provided responses via telephone interview 1-15 years post-injury. Multidimensional participation profiles (classes) were extracted using latent profile analysis.Results. A 4-class solution was identified as providing maximal statistical separation between profiles and being clinically meaningful based on profile demographic features. One profile group (48.5% of the sample) exhibited the "best" participation profile (High Frequency, Satisfaction, Importance, and Enfranchisement) and was also the most advantaged according to socioeconomic indicators. Other profile groups showed appreciable heterogeneity across participation dimensions. Age, race/ethnicity, education level, ability to drive, and urbanicity were features that varied between profiles.Conclusions. Societal participation is a critical, but inherently complex, TBI outcome that may not be adequately captured by a single index. Our data underscore the importance of a multidimensional approach to participation assessment and interpretation using profiles. The use of participation profiles may promote precision health interventions for community integration.Implications for RehabilitationOur study found unidimensional measures of societal participation in traumatic brain injury (TBI) populations that focus exclusively on frequency indicators may be overly simplistic and miss key subjective components of participationTaking a multidimensional perspective, we documented four meaningfully distinct participation subgroups (including both objective and subjective dimensions of societal participation) within the TBI rehabilitation populationMultidimensional profiles of participation may be used to group individuals with TBI into target groups for intervention (e.g., deeper goal assessment for individuals who do not rate standard participation activities as important, but also do not participate and do not feel enfranchised).
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Affiliation(s)
- Shannon B Juengst
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA
- Department of Physical Medicine & Rehabilitation, UT Houston Health Sciences Center, Houston, TX, USA
| | | | - Umesh M Venkatesan
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
- Department of Physical Medicine & Rehabilitation, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kimberly S Erler
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, USA
| | - Emily Evans
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Angelle M Sander
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Klyce
- Central VA Veterans Affairs Health Care System, Richmond, VA, USA
- Virginia Commonwealth University Health System, Richmond, VA, USA
- Sheltering Arms Institute, Richmond, VA, USA
| | - Therese M O'Neil Pirozzi
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
- Department of Communication Sciences and Disorders, Northeastern University, Boston, MA, USA
| | - Amanda R Rabinowitz
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
- Department of Physical Medicine & Rehabilitation, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lewis E Kazis
- Rehabilitation Outcomes Center (ROC), Spaulding Hospital, Charlestown, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Harvard Medical school Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Raj G Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Tamara Bushnik
- Rusk Rehabilitation, NYU Langone Health, New York, NY, USA
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5
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DiCarlo JA, Erler KS, Petrilli M, Emerson K, Gochyyev P, Schwamm LH, Lin DJ. SMS-text messaging for collecting outcome measures after acute stroke. Front Digit Health 2023; 5:1043806. [PMID: 36910572 PMCID: PMC9996089 DOI: 10.3389/fdgth.2023.1043806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/19/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Traditional methods for obtaining outcomes for patients after acute stroke are resource-intensive. This study aimed to examine the feasibility, reliability, cost, and acceptability of collecting outcomes after acute stroke with a short message service (SMS)-text messaging program. Methods Patients were enrolled in an SMS-text messaging program at acute stroke hospitalization discharge. Participants were prompted to complete assessments including the modified Rankin scale (mRS) and Patient-Reported Outcomes Measurement (PROM) Information System Global-10 at 30, 60, and 90 days postdischarge via SMS-text. Agreement and cost of SMS-text data collection were compared to those obtained from traditional follow-up methods (via phone or in the clinic). Participant satisfaction was surveyed upon program conclusion. Results Of the 350 patients who agreed to receive SMS texts, 40.5% responded to one or more assessments. Assessment responders were more likely to have English listed as their preferred language (p = 0.009), have a shorter length of hospital stay (p = 0.01), lower NIH stroke scale upon admission (p < 0.001), and be discharged home (p < 0.001) as compared to nonresponders. Weighted Cohen's kappa revealed that the agreement between SMS texting and traditional methods was almost perfect for dichotomized (good vs. poor) (κ = 0.8) and ordinal levels of the mRS score (κ = 0.8). Polychoric correlations revealed a significant association for PROM scores ( ρ = 0.4, p < 0.01 and ρ = 0.4, p < 0.01). A cost equation showed that gathering outcomes via SMS texting would be less costly than phone follow-up for cohorts with more than 181 patients. Nearly all participants (91%) found the program acceptable and not burdensome (94%), and most (53%) felt it was helpful. Poststroke outcome data collection via SMS texting is feasible, reliable, low-cost, and acceptable. Reliability was higher for functional outcomes as compared to PROMs. Conclusions While further validation is required, our findings suggest that SMS texting is a feasible method for gathering outcomes after stroke at scale to evaluate the efficacy of acute stroke treatments.
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Affiliation(s)
- Julie A DiCarlo
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Kimberly S Erler
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, United States
| | - Marina Petrilli
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, United States
| | - Kristi Emerson
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Perman Gochyyev
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, United States
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.,Digital Enterprise Service, Mass General Brigham, Somerville, MA, United States
| | - David J Lin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.,School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, United States
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6
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Rajala C, Waterhouse C, Evans E, Erler KS, Bergin MJ, Bannon SM, Slavin MD, Kazis LE. Conceptualization of Participation: A Qualitative Synthesis of Brain Injury Stakeholder Perspectives. Front Rehabilit Sci 2022; 3:908615. [PMID: 36188936 PMCID: PMC9397755 DOI: 10.3389/fresc.2022.908615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/17/2022] [Indexed: 12/04/2022]
Abstract
Background The return to participation in meaningful life roles for persons with acquired brain injury (pwABI) is a goal shared by pwABI, their families, clinicians, and researchers. Synthesizing how pwABI define participation will help to identify the aspects of participation important to pwABI and can inform a person-centered approach to participation outcome assessment. To-date, the qualitative synthesis approach has been used to explore facilitators and barriers of participation post-stroke, and views about participation among individuals with stroke in the UK. Objectives This paper's objectives are to (1) conduct a scoping review of qualitative literature that defines and characterizes participation from the perspective of pwABI of any type, (2) synthesize how pwABI define and categorize participation, and (3) link the themes identified in the qualitative synthesis to the International Classification of Functioning, Disability, and Health (ICF) using standardized linking rules to enhance the comparability of our findings to other types of health information, including standardized outcome measures. Methods We completed a scoping review of qualitative literature. Our search included PubMed, APA PsychInfo, CINAHL, and Embase databases and included articles that (1) had qualitative methodology, (2) had a sample ≥50% pwABI, (3) had aims or research questions related to the meaning, definition, perception, or broader experience of participation, and (4) were in English. Qualitative findings were synthesized using Thomas and Harden's methodology and resultant themes were linked to ICF codes. Results The search identified 2,670 articles with 2,580 articles excluded during initial screening. The remaining 90 article abstracts were screened, and 6 articles met the full inclusion criteria for the qualitative synthesis. Four analytical themes emerged: (1) Essential Elements of Participation (2) How pwABI Approach Participation, (3) Where pwABI Participate, and (4) Outcomes of Participation. Each overarching theme included multiple descriptive themes. Conclusion In this paper, we identified themes that illustrate key components of participation to pwABI. Our results provide insight into the complex perspectives about participation among pwABI and illustrate aspects of participation that should hold elevated importance for clinicians and researchers supporting participation of pwABI.
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Affiliation(s)
- Caitlin Rajala
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Caitlin Rajala
| | - Camden Waterhouse
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Emily Evans
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Kimberly S. Erler
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, United States
| | - Michael J. Bergin
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Sarah M. Bannon
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Mary D. Slavin
- Rehabilitation Outcomes Center, Spaulding Rehabilitation Hospital, Boston University School of Public Health, Boston, MA, United States
| | - Lewis E. Kazis
- Rehabilitation Outcomes Center, Spaulding Rehabilitation Hospital, Harvard Medical School and Boston University School of Public Health, Boston, MA, United States
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7
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Juengst SB, Erler KS, Neumann D, Kew CLN, Goldin Y, O'Neil-Pirozzi TM, Rabinowitz A, Niemeier J, Bushnik T, Dijkers M. Participation importance and satisfaction across the lifespan: A traumatic brain injury model systems study. Rehabil Psychol 2022; 67:344-355. [PMID: 35834205 DOI: 10.1037/rep0000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In rehabilitation research and practice, participation is defined as involvement in life situations and most often measured as frequency of engaging in these life situations. This narrow measurement approach overlooks that individuals perceive importance of and satisfaction with participation in activities in various life areas differently. The purpose of this study was to determine differences in meaningful participation (perceived importance and satisfaction) after moderate to severe traumatic brain injury (TBI) across age groups and to identify predictors of participation satisfaction. METHOD Secondary data analysis of a TBI Model Systems substudy, including the Participation Assessment with Recombined Tools-Subjective (PART-S) that rates participation importance and satisfaction in 11 life areas that we grouped into three domains (i.e., productivity, social relations, out-and-about). We identified differences across age groups (i.e., 16 to 24 years, 25 to 44 years, 45 to 64 years, and 65 + years) and predictors of participation satisfaction. RESULTS Participation satisfaction in and importance of the 11 life areas varied across age groups. In all age groups, participants rated relationships as being of medium or high importance more often than other life areas. Older adults reported the highest participation satisfaction across life areas, despite having the lowest participation frequency. Consistent predictors of participation satisfaction were cognitive functioning and frequency of participation in the domain examined. CONCLUSION Participation importance, satisfaction, and frequency are related, yet distinct, dimensions of participation that should all be measured to adequately evaluate meaningful participation. Future research should explore interventions across the lifespan that target modifiable predictors, like functional cognition and access to frequent participation in important life activities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | | | - Dawn Neumann
- Department of Physical Medicine and Rehabilitation
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8
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Erler KS, Wu R, DiCarlo JA, Petrilli MF, Gochyyev P, Hochberg LR, Kautz SA, Schwamm LH, Cramer SC, Finklestein SP, Lin DJ. Association of Modified Rankin Scale With Recovery Phenotypes in Patients With Upper Extremity Weakness After Stroke. Neurology 2022; 98:e1877-e1885. [PMID: 35277444 PMCID: PMC9109148 DOI: 10.1212/wnl.0000000000200154] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 01/18/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Precise measurement of outcomes is essential for stroke trials and clinical care. Prior research has highlighted conceptual differences between global outcome measures such as the Modified Rankin Scale (mRS) and domain-specific measures (e.g. motor, sensory, language or cognitive function). This study related motor phenotypes to the mRS, specifically aiming to (1) determine whether mRS levels distinguish motor impairment and function phenotypes, and (2) compare mRS outcomes to meaningful changes in impairment and function from acute to subacute recovery after stroke. METHODS Patients with upper extremity weakness after ischemic stroke were assessed with a battery of impairment and functional measures within the first week and at 90-days post-stroke. Impairment and functional outcomes were examined in relation to 90-day mRS scores. Clinically meaningful changes in motor impairment, activities of daily living, and mobility were examined in relation to 90-day mRS. RESULTS In this cohort of n = 73 stroke patients, impairment and functional outcomes were associated with 90-day mRS scores but showed substantial variability within individual mRS levels: within mRS level 2, upper extremity impairment ranged from near hemiplegia (with an upper extremity Fugl-Meyer 8) to no deficits (upper extremity Fugl-Meyer 66). Overall, there were few differences in impairment and functional outcomes between adjacent mRS levels. While some outcome measures were significantly different between mRS levels 3 and 4 (Nine-Hole Peg, Leg Motor, Gait Velocity, Timed Up and Go, National Institutes of Health Stroke Scale, and Barthel Index), none of the outcome measures differed between mRS levels 1 and 2. Fugl-Meyer and Grip Strength were not different between any adjacent mRS levels. A substantial number of patients experienced clinically meaningful changes in impairment and function in the first 90 days post-stroke but did not achieve good mRS outcome (mRS ≤ 2). CONCLUSIONS The mRS broadly relates to domain-specific outcomes after stroke confirming its established value in stroke trials, but it does not precisely distinguish differences in impairment and function nor does it sufficiently capture meaningful clinical changes across impairment, ADL status, and mobility. These findings underscore the potential utility of incorporating detailed phenotypic measures alongside the mRS in future stroke trials.
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Affiliation(s)
- Kimberly S Erler
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA.,Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Rui Wu
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Julie A DiCarlo
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Marina F Petrilli
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA
| | - Perman Gochyyev
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Stroke Service, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,VA RR&D Center for Neurorestoration and Neurotechnology, VA Medical Center, Providence, RI, USA.,School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI, USA
| | - Steven A Kautz
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, USA.,Ralph H Johnson VA Medical Center, Charleston, SC, USA
| | - Lee H Schwamm
- Stroke Service, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven C Cramer
- Department of Neurology University of California, Los Angeles, CA, USA.,California Rehabilitation Institute, Los Angeles, CA, USA
| | - Seth P Finklestein
- Stroke Service, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA.,Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Stroke Service, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,VA RR&D Center for Neurorestoration and Neurotechnology, VA Medical Center, Providence, RI, USA
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9
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DiCarlo JA, Erler KS, Jaywant A, Ranford J, Cramer SC, Lin DJ. Abstract 4: Patient-reported And Performance-based Outcomes Separate Independently And Are Associated With Distinct Patterns Of Neuroanatomical Injury After Stroke. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Patient-reported outcome measures (PROMs) provide valuable insights into health status and function, but their relationships with performance-based outcomes remain incompletely understood. Here we compared these two classes of measures using dimensionality-reduction techniques with longitudinal data and examined their relationships with neuroanatomical injury.
Methods:
Sixty-three adults with hemiparesis were serially assessed (acute, sub-acute, early-chronic, chronic) after stroke using performance-based scales (Upper Extremity Fugl-Meyer, Barthel Index, modified Rankin Scale, Box and Blocks, 9- Hole Peg, Grip Strength) and PROMs (PROMIS-Global Physical, Mental, and General Health, Patient Health Questionnaire-9). Principal component analysis (PCA) was performed at each timepoint to reduce variable dimensionality. Voxel-Based Lesion Symptom Mapping examined the relationship between lesion location and PCA components.
Results:
Two PCA components accounted for more than 70% of the total variance among outcomes. Performance-based variables loaded onto factor 1 while PROMs loaded onto factor 2. Results were consistent at each timepoint. Performance-based measures were related to injury to subcortical brain regions particularly corticospinal tract (figure, top row), while PROMs were related to injury to cortical areas including intraparietal sulcus and parietal operculum (figure, bottom row).
Discussion:
A multidimensional battery of assessments scored across the first year post-stroke separated independently into PCA components related to performance-based measure and PROMs. Each component was associated with injury to brain regions concordant with the content of the assessment. These findings emphasize the distinct behavioral elements and neuroanatomical underpinnings for performance-based measures and PROMs after stroke.
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10
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DiCarlo JA, Petrilli M, Emerson K, Erler KS, Schwamm LH, Lin DJ. Abstract WMP45: Feasibility, Acceptability, And Accuracy Of A Text-messaging Program For Outcomes Data Collection In Patients After Stroke. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wmp45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Robust outcome data collection is critical for stroke care and clinical trials. However, reaching patients after discharge from acute care is challenging. This study examined the feasibility, acceptability, and accuracy of collecting outcomes through a text message-based program after stroke.
Methods:
Patients discharged between June 8
th
, 2020 and February 1
st
, 2021 from Massachusetts General Hospital with an ICD-10 Code of stroke who consented to receiving messages, were enrolled in a message-based program upon acute stroke discharge. Participants received weekly brain health tips and assessments of the Modified Rankin Scale (mRS) and PROMIS Global-10 at 30, 60, and 90 days post-stroke via text message prompts. Participants were sent a satisfaction survey upon program conclusion. Data from routine 90-day follow-up phone calls were extracted from clinical charts of patients discharged during a representative 3 month period for comparison. Descriptive statistics, group comparisons, and inter-modal reliability (text message versus phone) were performed.
Results:
Of 530 patients with stroke discharged during the study period, 350 enrolled in the message program. Forty-one percent of the patients answered one or more of the assessment prompts. The 90-day mRS collected by messaging was 1[0-3] and the PROMIS Global Physical and Mental Health were 15[12.5-17] and 13[11-16], respectively. We reached 104/169 (61.54%) patients by phone. There were no statistically significant differences on 90-day outcome scores between those who responded via messages or phone. Inter-modal reliability (message versus phone) was moderate for mRS (κ=.521) but poor for PROMIS scores (κ<.1). Nearly all participants (90%) felt it was helpful to receive information about stroke via messages and found the program adequate (63%) and not burdensome (94%).
Discussion:
Post-stroke outcomes data collection via text-messaging is feasible, acceptable, and moderately accurate compared to phone-based methods. Inter-modal reliability was higher for functional outcomes as compared to PROMs. Further validation of specific measures is required; yet, these findings suggest that future programs could use messaging to identify patients at risk for poor outcome.
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11
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Kumar A, Roy I, Karmarkar AM, Erler KS, Rudolph JL, Baldwin JA, Rivera-Hernandez M. Shifting US Patterns of COVID-19 Mortality by Race and Ethnicity From June-December 2020. J Am Med Dir Assoc 2021; 22:966-970.e3. [PMID: 33775597 PMCID: PMC7934694 DOI: 10.1016/j.jamda.2021.02.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The COVID-19 pandemic has disproportionately affected racial and ethnic minorities in the United States and has been devastating for residents of nursing homes (NHs). However, evidence on racial and ethnic disparities in COVID-19-related mortality rates within NHs and how that has changed over time has been limited. This study examines the impact of a high proportion of minority residents in NHs on COVID-19-related mortality rates over a 30-week period. DESIGN Longitudinal study. SETTING AND PARTICIPANTS Centers for Medicare & Medicaid Services Nursing Home COVID-19 Public Use File data from 50 states from June 1, 2020, to December 27, 2020. METHODS We linked data from 11,718 NHs to (1) Nursing Home Compare data, (2) the Long-Term Care: Facts on Care in the U.S., and (3) US county-level data on COVID cases and deaths. Our primary independent variable was proportion of minority residents (blacks and Hispanics) in NHs and its association with mortality rate over time. RESULTS During the first 6 weeks from June 1, 2020, NHs with a higher proportion of black residents reported more COVID-19 deaths per 1000 followed by NHs with a higher proportion of Hispanic residents. Between 7 and 12 weeks, NHs with a higher proportion of Hispanic residents reported more deaths per 1000, followed by NHs with a higher proportion of black residents. However, after 23 weeks (mid-November 2020), NHs serving a higher proportion of white residents reported more deaths per 1000 than NHs serving a high proportion of black and Hispanic residents. CONCLUSIONS AND IMPLICATIONS The disparities in COVID-19-related mortality for nursing homes serving minority residents is evident for the first 12 weeks of our study period. Policy interventions and the equitable distribution of vaccine are required to mitigate the impact of systemic racial injustice on health outcomes of people of color residing in NHs.
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Affiliation(s)
- Amit Kumar
- College of Health and Human Services, Northern Arizona University, Flagstaff, AZ, USA; Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ, USA
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ, USA
| | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA; Sheltering Arms Institute, Richmond, VA, USA
| | - Kimberly S Erler
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA
| | - James L Rudolph
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Julie A Baldwin
- College of Health and Human Services, Northern Arizona University, Flagstaff, AZ, USA; Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ, USA
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
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12
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Lin DJ, Erler KS, Snider SB, Bonkhoff AK, DiCarlo JA, Lam N, Ranford J, Parlman K, Cohen A, Freeburn J, Finklestein SP, Schwamm LH, Hochberg LR, Cramer SC. Cognitive Demands Influence Upper Extremity Motor Performance During Recovery From Acute Stroke. Neurology 2021; 96:e2576-e2586. [PMID: 33858997 DOI: 10.1212/wnl.0000000000011992] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that cognitive demands influence motor performance during recovery from acute stroke, we tested patients with acute stroke on 2 motor tasks with different cognitive demands and related task performance to cognitive impairment and neuroanatomic injury. METHODS We assessed the contralesional and ipsilesional upper extremities of a cohort of 50 patients with weakness after unilateral acute ischemic stroke at 3 time points with 2 tasks: the Box & Blocks Test, a task with greater cognitive demand, and Grip Strength, a simple and ballistic motor task. We compared performance on the 2 tasks, related motor performance to cognitive dysfunction, and used voxel-based lesion symptom mapping to determine neuroanatomic sites associated with motor performance. RESULTS Consistent across contralesional and ipsilesional upper extremities and most pronounced immediately after stroke, Box & Blocks scores were significantly more impaired than Grip Strength scores. The presence of cognitive dysfunction significantly explained up to 33% of variance in Box & Blocks performance but was not associated with Grip Strength performance. While Grip Strength performance was associated with injury largely restricted to sensorimotor regions, Box & Blocks performance was associated with broad injury outside sensorimotor structures, particularly the dorsal anterior insula, a region known to be important for complex cognitive function. CONCLUSIONS Together, these results suggest that cognitive demands influence upper extremity motor performance during recovery from acute stroke. Our findings emphasize the integrated nature of motor and cognitive systems and suggest that it is critical to consider cognitive demands during motor testing and neurorehabilitation after stroke.
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Affiliation(s)
- David J Lin
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles.
| | - Kimberly S Erler
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Samuel B Snider
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Anna K Bonkhoff
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Julie A DiCarlo
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Nicole Lam
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Jessica Ranford
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Kristin Parlman
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Audrey Cohen
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Jennifer Freeburn
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Seth P Finklestein
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Lee H Schwamm
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Leigh R Hochberg
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
| | - Steven C Cramer
- From the Center for Neurotechnology and Neurorecovery (D.J.L., J.A.D., N.L., J.R., K.P., A.C., J.F., L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurocritical Care (D.J.L., L.R.H.), Department of Neurology, Stroke Service (D.J.L., S.P.F., L.H.S., L.R.H.), Department of Neurology, J. Philip Kistler Stroke Research Center (A.K.B.), Department of Neurology, Department of Occupational Therapy (J.R.), Department of Physical Therapy (K.P.), and Department of Speech, Language, and Swallowing Disorders (A.C., J.F.), Massachusetts General Hospital, Boston; VA RR&D Center for Neurorestoration and Neurotechnology (D.J.L., L.R.H.), Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI; Department of Occupational Therapy (K.S.E., N.L.), MGH Institute of Health Professions, Boston, MA; Division of Neurocritical Care (S.B.S.), Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; School of Engineering (L.R.H.), Brown University, Providence, RI; Department of Neurology (S.C.C.), University of California, Los Angeles; and California Rehabilitation Hospital (S.C.C.), Los Angeles
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13
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Keeney T, Kumar A, Erler KS, Karmarkar AM. Making the Case for Patient-Reported Outcome Measures in Big-Data Rehabilitation Research: Implications for Optimizing Patient-Centered Care. Arch Phys Med Rehabil 2021; 103:S140-S145. [PMID: 33548207 DOI: 10.1016/j.apmr.2020.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 11/02/2022]
Abstract
Advances in data science and timely access to health informatics provide a pathway to integrate patient-reported outcome measures (PROMs) into clinical workflows and optimize rehabilitation service delivery. With the shift toward value-based care in the United States health care system, as highlighted by the recent Centers for Medicare and Medicaid Services incentive and penalty programs, it is critical for rehabilitation providers to systematically collect and effectively use PROMs to facilitate evaluation of quality and outcomes within and across health systems. This editorial discusses the potential of PROMs to transform clinical practice, provides examples of health systems using PROMs to guide care, and identifies barriers to aggregating data from PROMs to conduct health services research. The article proposes 2 priority areas to help advance rehabilitation health services research: (1) standardization of collecting PROMs data in electronic health records to facilitate comparing health system performance and quality and (2) increased partnerships between rehabilitation providers, researchers, and payors to accelerate health system learning. As health care reform continues to emphasize value-based payment strategies, it is essential for the field of physical medicine and rehabilitation to be at the forefront of demonstrating its value in the care continuum.
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Affiliation(s)
- Tamra Keeney
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI; Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.
| | - Amit Kumar
- Department of Physical Therapy, Northern Arizona University, Flagstaff, AZ
| | - Kimberly S Erler
- Department of Occupation Therapy, MGH Institute of Health Professions, Boston, MA
| | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA; Sheltering Arms Institute, Richmond, VA
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14
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Courtwright AM, Rubin E, Erler KS, Bandini JI, Zwirner M, Cremens MC, McCoy TH, Robinson EM. Experience with a Revised Hospital Policy on Not Offering Cardiopulmonary Resuscitation. HEC Forum 2020; 34:73-88. [PMID: 33136221 DOI: 10.1007/s10730-020-09429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate (DNR) status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation (CPR) despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics consult outcomes were analyzed. In 42 of the 116 cases (36.2%), the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 (97.3%) of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 (79.2%) of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying (p = 0.007). The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants' recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients.
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Affiliation(s)
- Andrew M Courtwright
- Department of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Rubin
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kimberly S Erler
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA
| | | | - Mary Zwirner
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Social Services, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Departments of Psychiatry and Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Ellen M Robinson
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA. .,Patient Care Services, Massachusetts General Hospital, Boston, MA, 02114, USA.
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15
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Affiliation(s)
- Emily M. Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kimberly S. Erler
- School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - David Fleming
- Center for Health Ethics, University of Missouri, Columbia, Missouri, USA
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16
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Lin DJ, Cloutier AM, Erler KS, Cassidy JM, Snider SB, Ranford J, Parlman K, Giatsidis F, Burke JF, Schwamm L, Finklestein SP, Hochberg L, CRAMER SC. Abstract 13: Corticospinal Tract Injury Estimated From Acute Stroke Imaging Predicts Upper Extremity Motor Recovery After Stroke. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Injury to the corticospinal tract (CST) has been shown to have a major effect on upper extremity motor recovery after stroke. This study aimed to examine how well CST injury, measured from neuroimaging acquired during the acute stroke workup, predicts upper extremity motor recovery.
Methods:
Patients (N = 48) with upper extremity weakness after ischemic stroke were assessed using the upper extremity Fugl-Meyer (FM) during the acute stroke hospitalization and again at 3-month follow-up. CST injury was quantified and compared, using four different methods, from images obtained as part of the stroke standard-of-care workup. Logistic and linear regression were performed using CST injury to predict delta FM. Injury to primary motor and premotor cortices were included as potential modifiers of the effect of CST injury on recovery.
Results:
48 patients were enrolled 4.2 ± 2.7 days post-stroke and completed this study. CST injury distinguished patients who reached their recovery potential (as predicted from initial impairment) from those who did not, with AUC values ranging from 0.75 to 0.8. In addition, CST injury explained ~20% of the variance in the magnitude of upper extremity recovery, even after controlling for the severity of initial impairment. Results were consistent when comparing four different methods of measuring CST injury. Extent of injury to primary motor and premotor cortices did not significantly influence the predictive value that CST injury had for recovery.
Conclusions:
Structural injury to the CST, as estimated from standard-of-care imaging available during the acute stroke hospitalization, is a robust way to distinguish patients who achieve their predicted recovery potential and explains a significant amount of the variance in post-stroke upper extremity motor recovery.
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Affiliation(s)
- David J Lin
- Neurology, Massachusetts General Hosp, Boston, MA
| | | | - Kimberly S Erler
- Occupational Therapy, MGH Institute of Health Professions, Boston, MA
| | | | | | - Jessica Ranford
- Occupational Therapy, Massachusetts General Hosp, Boston, MA
| | | | | | | | - Lee Schwamm
- Neurology, Massachusetts General Hosp, Boston, MA
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17
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Abstract
Participation restrictions, including restrictions in employment, recreational activities, and social interactions, and depression are common after traumatic brain injury (TBI) and can profoundly affect individuals. Participation and depression demonstrate complex relationships with each other and over time as individuals age. This study (1) identified differences in participation between different age groups; (2) determined if participation differed between those with and without clinically significant depressive symptoms within each age group; and (3) determined the effect of the interaction between age groups and the presence or absence of clinically significant depressive symptoms on participation in community-dwelling adults with a moderate-to-severe TBI. Results indicate that, among community-dwelling adults 5 years post-TBI, there are significant differences in participation between age groups across the lifespan, with younger adults generally having higher levels of participation. Individuals with clinically significant depressive symptoms participate less than individuals without it within the same age group, except for adults over 65 years-old. For the productivity domain, age interacted with depressive symptoms, such that the presence of clinically significant depressive symptoms was associated with a larger difference in productivity in early-to-middle adulthood. Based on these findings, depression should be considered when providing interventions for participation and vice versa.
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Affiliation(s)
- Kimberly S Erler
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, USA
| | - Chung Lin Kew
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shannon B Juengst
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
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18
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Malone C, Erler KS, Giacino JT, Hammond FM, Juengst SB, Locascio JJ, Nakase-Richardson R, Verduzco-Gutierrez M, Whyte J, Zasler N, Bodien YG. Participation Following Inpatient Rehabilitation for Traumatic Disorders of Consciousness: A TBI Model Systems Study. Front Neurol 2019; 10:1314. [PMID: 31920935 PMCID: PMC6930171 DOI: 10.3389/fneur.2019.01314] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/27/2019] [Indexed: 11/13/2022] Open
Abstract
Severe traumatic brain injury (TBI) may result in a disorder of consciousness (DoC) and lead to substantial long-term disability. While level of independence with activities of daily living, especially for persons who recover consciousness during inpatient rehabilitation, generally improves over time, the degree of change in participation remains unknown. We determined level of participation among persons with TBI between 2005 and 2017 who were admitted to inpatient rehabilitation unable to follow commands and subsequently enrolled in the TBI Model Systems National Database. Participation on the Participation Assessment with Recombined Tools-Objective (PART-O) Productivity, Social Relations, and Out and About subscales was evaluated at 1-5 years post-injury. We used a mixed-effects model to longitudinally compare participation between persons who did and did not regain command-following during inpatient rehabilitation. We further explored the level of participation associated with increasing levels of functional independence (FIM). The analysis included 333 persons (229 recovered command-following during rehabilitation, mean age = 35.46 years, 74.9% male). Participation across groups, at all follow-up time points, on all PART-O subscales, was remarkably low (mean range = 0.021-1.91, maximum possible score = 5). Performance was highest on the Social Relations subscale and lowest on the Productivity subscale. Longitudinal analyses revealed no difference in level of participation or change in participation across time for persons who regained command-following during rehabilitation compared to those who did not. While productivity increased over time, social participation did not and participation outside the home increased more for younger than for older persons. Across all three PART-O subscales, FIM Motor scores positively predicted participation. FIM Cognitive scores positively predicted level of participation on the Productivity and Social Relations subscales. Exploratory analyses revealed that even persons who achieved independence on the FIM Motor and Cognitive subscales had low levels of participation across domains and follow-up years. In summary, persons with severe TBI who were admitted to inpatient rehabilitation unable to follow commands were found to be unlikely to participate in productive tasks, social endeavors, or activities outside of the home up to 5 years post-injury, even if functional independence was recovered.
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Affiliation(s)
- Christopher Malone
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Neurorehabilitation Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Kimberly S Erler
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, United States
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Neurorehabilitation Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Shannon B Juengst
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joseph J Locascio
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Science, Defense and Veterans Brain Injury Center, James A. Haley Veterans Hospital, Tampa, FL, United States.,Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, FL, United States
| | - Monica Verduzco-Gutierrez
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center at Houston, and TIRR Memorial Hermann, Houston, TX, United States
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, United States
| | - Nathan Zasler
- Department of Physical Medicine and Rehabilitation, Concussion Care Centre of Virginia, Ltd. and Tree of Life Services, Virginia Commonwealth University, Richmond, VA, United States
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Neurorehabilitation Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
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19
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Ranford J, Asiello J, Cloutier A, Cortina K, Thorne H, Erler KS, Frazier N, Sadlak C, Rude A, Lin DJ. Interdisciplinary Stroke Recovery Research: The Perspective of Occupational Therapists in Acute Care. Front Neurol 2019; 10:1327. [PMID: 31920947 PMCID: PMC6928199 DOI: 10.3389/fneur.2019.01327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 12/02/2019] [Indexed: 01/14/2023] Open
Abstract
As acute stroke treatments advance, more people survive the initial stroke event and live with long-term neurological impairments that impact functional outcomes and quality of life. In accordance with International Classification of Functioning (ICF), living with long-term neurological impairments can limit survivors' activity performance and restrict participation in valued life roles and routines. Research focused on longitudinal analysis of functional measures and outcomes after stroke are critical for determining early indicators of long-term participation and quality of life and guiding rehabilitation resource allocation. As core members of the interdisciplinary stroke recovery treatment team throughout the post-acute care continuum, occupational therapists (OTs) directly address stroke survivors' ability to participate in meaningful daily activities to promote function and quality of life. Just as in clinical care in which multidisciplinary, team-based perspectives are vital, OTs provide invaluable perspectives for stroke recovery research. Here we describe OTs' role in a collaborative, interdisciplinary research study aimed at comprehensively understanding upper extremity motor recovery after stroke and its impact on individuals across the post-acute care continuum. This article discusses the importance of the OTs' perspectives in conducting interdisciplinary, longitudinal stroke recovery research. The challenges, strategies and recommendations for future directions of advancing the role of OTs in multidisciplinary stroke recovery research are highlighted. We use this perspective as a call to action to the stroke recovery field to incorporate OTs as members of the research team and for OTs to provide their perspectives on ongoing stroke recovery research.
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Affiliation(s)
- Jessica Ranford
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States
| | - Jessica Asiello
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States
| | - Alison Cloutier
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Kimberly Cortina
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States
| | - Helena Thorne
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States
| | - Kimberly S Erler
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States.,Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, United States
| | - Natasha Frazier
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States
| | - Caitlin Sadlak
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States
| | - Abigail Rude
- Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, United States
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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20
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Bandini JI, Courtwright AM, Rubin E, Erler KS, Zwirner M, Cremens MC, McCoy TH, Robinson EM. Ethics Consultations Related to Opioid Use Disorder. Psychosomatics 2019; 61:161-170. [PMID: 31812218 DOI: 10.1016/j.psym.2019.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The opioid epidemic has resulted in an increased number of patients with opioid use disorder (OUD) hospitalized for serious medical conditions. The intersection between hospital ethics consultations and the opioid crisis has not received significant attention. OBJECTIVE The aim of this study was to characterize ethics consult questions among inpatients with OUD at our institution, Massachusetts General Hospital. METHODS We conducted a single-center retrospective cohort study of ethics consultations from January 1, 1993 to December 31, 2017 at Massachusetts General Hospital. RESULTS Between 1993 and 2017, OUD played a central role in ethics consultations in 43 of 1061 (4.0%) cases. There was an increase in these requests beginning in 2009, rising from 1.4% to 6.8% of consults by 2017. Compared with other ethics cases, individuals with OUD were significantly younger (P < 0.001), more likely to be uninsured or underinsured (P < 0.001), and more likely to have a comorbid mental health diagnosis (P = 0.001). The most common reason for consultation involved continuation of life-sustaining treatment in the setting of overdose with neurological injury or severe infection. Additional reasons included discharge planning, challenges with pain management and behavior, and the appropriateness of surgical intervention, such as repeat valve replacement or organ transplant. Health care professionals struggled with their ethical obligations to patients with OUD, including when to treat pain with narcotics and how to provide longitudinal care for patients with limited resources outside of the hospital. CONCLUSION The growing opioid epidemic corresponds with a rise in ethics consultations for patients with OUD. Similar factors associated with OUD itself, including comorbid mental health diagnoses and concerns about relapse, contributed to the ethical complexities of these consults.
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Affiliation(s)
- Julia I Bandini
- Department of Sociology, Brandeis University, Waltham, MA; RAND Corporation, Boston, MA
| | - Andrew M Courtwright
- Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA; Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA
| | - Emily Rubin
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Kimberly S Erler
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Occupational Therapy, MGH Institute of Health Professions, Boston, MA
| | - Mary Zwirner
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Social Service, Massachusetts General Hospital, Boston, MA
| | - M Cornelia Cremens
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Department of Psychiatry and Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Thomas H McCoy
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Ellen M Robinson
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Patient Care Services, Massachusetts General Hospital, Boston, MA.
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21
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Lin DJ, Cloutier AM, Erler KS, Cassidy JM, Snider SB, Ranford J, Parlman K, Giatsidis F, Burke JF, Schwamm LH, Finklestein SP, Hochberg LR, Cramer SC. Corticospinal Tract Injury Estimated From Acute Stroke Imaging Predicts Upper Extremity Motor Recovery After Stroke. Stroke 2019; 50:3569-3577. [PMID: 31648631 DOI: 10.1161/strokeaha.119.025898] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Injury to the corticospinal tract (CST) has been shown to have a major effect on upper extremity motor recovery after stroke. This study aimed to examine how well CST injury, measured from neuroimaging acquired during the acute stroke workup, predicts upper extremity motor recovery. Methods- Patients with upper extremity weakness after ischemic stroke were assessed using the upper extremity Fugl-Meyer during the acute stroke hospitalization and again at 3-month follow-up. CST injury was quantified and compared, using 4 different methods, from images obtained as part of the stroke standard-of-care workup. Logistic and linear regression were performed using CST injury to predict ΔFugl-Meyer. Injury to primary motor and premotor cortices were included as potential modifiers of the effect of CST injury on recovery. Results- N=48 patients were enrolled 4.2±2.7 days poststroke and completed 3-month follow-up (median 90-day modified Rankin Scale score, 3; interquartile range, 1.5). CST injury distinguished patients who reached their recovery potential (as predicted from initial impairment) from those who did not, with area under the curve values ranging from 0.70 to 0.8. In addition, CST injury explained ≈20% of the variance in the magnitude of upper extremity recovery, even after controlling for the severity of initial impairment. Results were consistent when comparing 4 different methods of measuring CST injury. Extent of injury to primary motor and premotor cortices did not significantly influence the predictive value that CST injury had for recovery. Conclusions- Structural injury to the CST, as estimated from standard-of-care imaging available during the acute stroke hospitalization, is a robust way to distinguish patients who achieve their predicted recovery potential and explains a significant amount of the variance in poststroke upper extremity motor recovery.
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Affiliation(s)
- David J Lin
- From the Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.L., A.M.C., F.G., L.R.H.).,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (D.J.L., S.B.S., L.R.H.), Massachusetts General Hospital, Boston
| | - Alison M Cloutier
- From the Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.L., A.M.C., F.G., L.R.H.)
| | - Kimberly S Erler
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA (K.S.E.)
| | - Jessica M Cassidy
- Division of Physical Therapy, Department of Allied Health Sciences, University of North Carolina at Chapel Hill (J.M.C.)
| | - Samuel B Snider
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology (D.J.L., S.B.S., L.R.H.), Massachusetts General Hospital, Boston
| | - Jessica Ranford
- Department of Occupational Therapy (J.R.), Massachusetts General Hospital, Boston
| | - Kristin Parlman
- Department of Physical Therapy (K.P.), Massachusetts General Hospital, Boston
| | - Fabio Giatsidis
- From the Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.L., A.M.C., F.G., L.R.H.).,Department of Neurology, University of Rome Tor Vergata, Italy (F.G.)
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor (J.F.B.)
| | - Lee H Schwamm
- Stroke Service, Department of Neurology (L.H.S., S.P.F.), Massachusetts General Hospital, Boston
| | - Seth P Finklestein
- Stroke Service, Department of Neurology (L.H.S., S.P.F.), Massachusetts General Hospital, Boston
| | - Leigh R Hochberg
- From the Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.L., A.M.C., F.G., L.R.H.).,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (D.J.L., S.B.S., L.R.H.), Massachusetts General Hospital, Boston.,VA RR&D Center for Neurorestoration and Neurotechnology, Rehabilitation R&D Service, VA Medical Center, Providence, RI (L.R.H.).,School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI (L.R.H.)
| | - Steven C Cramer
- Department of Neurology, University of California, Irvine (S.C.C.)
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22
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Erler KS, Sullivan V, Mckinnon S, Inzana R. Social Support as a Predictor of Community Participation After Stroke. Front Neurol 2019; 10:1013. [PMID: 31616364 PMCID: PMC6763952 DOI: 10.3389/fneur.2019.01013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/05/2019] [Indexed: 01/06/2023] Open
Abstract
Participation is a primary goal of neurorehabilitation; however, most individuals post stroke experience significant restrictions in participation as they attempt to resume their everyday roles and routines. Despite this emphasis on participation, there is a paucity of evidence-based interventions for optimizing this outcome and a limited understanding of factors that contribute to poor participation outcomes. Caregiver support at discharge from inpatient rehabilitation positively influences physical and psychological outcomes after stroke but more research is needed to understand the association between social support and participation. This study aimed to examine the independent contribution of perceived social support to participation 3 months post discharge from inpatient stroke rehabilitation. This study was a secondary analysis of the Stroke Recovery in Underserved Populations 2005–2006 data. Participants were adults ≥55 years old, living in the community 3 months post discharge from inpatient rehabilitation for ischemic stroke (n = 422). Hierarchical linear regressions were performed. The primary variables of interest were the PAR-PRO Measure of Home and Community Participation and the Duke–University of North Carolina Functional Social Support Questionnaire. Perceived social support at discharge from inpatient rehabilitation for ischemic stroke contributed uniquely to the variance in participation 3 months later (β = 0.396, P < 0.001) after controlling for race, sex, age, years of education, comorbidities, stroke symptoms, depression, FIM Motor, and FIM Cognitive. Social support accounted for 12.2% of the variance in participation and was the strongest predictor of participation relative to the other independently significant predictors in the model including FIM Motor and depression. There is already a focus on caregiver training during inpatient rehabilitation related to basic self-care, transfers, and medical management. These findings suggest the need for rehabilitation professionals to also address social support during discharge planning in the context of promoting participation. Given the findings, expanding caregiver training is necessary but novel interventions and programs must be carefully developed to avoid increasing caregiver burden.
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Affiliation(s)
- Kimberly S Erler
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, United States
| | - Virginia Sullivan
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, United States
| | - Sarah Mckinnon
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, United States
| | - Rebecca Inzana
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA, United States
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23
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Erler KS, Juengst SB, Smith DL, O'Neil-Pirozzi TM, Novack TA, Bogner JA, Kaminski J, Giacino JT, Whiteneck GG. Examining Driving and Participation 5 Years After Traumatic Brain Injury. OTJR (Thorofare N J) 2018; 38:143-150. [PMID: 29457535 DOI: 10.1177/1539449218757739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Participation is often considered a primary goal of traumatic brain injury (TBI) rehabilitation, but little is known about the influence of driving on participation after TBI. The objective of this study was to examine the independent contribution of driving status to participation at 5 years post TBI, after controlling for demographic, psychosocial, and functional factors. Participants ( N = 2,456) were community-dwelling individuals with moderate to severe TBI, age 18 to 65 at time of injury, and enrolled in the TBI Model Systems (TBIMS) National Database (NDB). Hierarchical linear regressions for the dependent variable of participation at 5 years post TBI were performed. Findings showed that driving was a highly significant independent predictor of participation and was a stronger relative predictor of participation than FIM® Cognitive, FIM® Motor, and depression. The independent contribution of driving to participation suggests the need to develop evidenced-based occupational therapy assessments and interventions that facilitate safe engagement in the occupation of driving to address the long-term goal of improved participation.
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Affiliation(s)
| | | | - Diane L Smith
- 3 MGH Institute of Health Professions, Boston, MA, USA
| | - Therese M O'Neil-Pirozzi
- 1 Spaulding Rehabilitation Hospital, Boston, MA, USA.,4 Northeastern University, Boston, MA, USA
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