Functional outcomes in patients with brain tumor after inpatient rehabilitation: comparison with traumatic brain injury

OBJECTIVE: To compare the functional outcome, length of stay, and discharge disposition of individuals with brain tumor versus those with acute traumatic brain injury. DESIGN: In this study, 78 brain tumor patients were one-to-one matched by location of lesion and age with 78 acute traumatic brain injury patients. Outcome was measured by using the Functional Independence Measure (FIM 228) on admission and discharge. The FIM change and FIM efficiency were also calculated. FIM data were analyzed in three subsets, i.e., activities of daily living, mobility, and cognition. Discharge disposition and rehabilitation length of stay were also compared. RESULTS: Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and the traumatic brain injury populations with respect to total admission FIM, total discharge FIM, and FIM efficiency. The brain injury population had a significantly greater change in FIM. The tumor group had a significantly shorter rehabilitation length of stay and a greater discharge to community rate. CONCLUSIONS: Thus, individuals with brain tumor can achieve comparable functional outcome and have a shorter rehabilitation length of stay and greater discharge to community rate than individuals with brain injury.     

Rehabilitation outcomes in patients with brain tumors and acute stroke: comparative study of inpatient rehabilitation

OBJECTIVES: To investigate functional outcomes after hospital rehabilitation of patients surviving craniotomy for primary brain tumor excision compared with post-stroke patients. DESIGN: The database of the Neurological Rehabilitation Department "C" of Loewenstein Rehabilitation Center was used to investigate primary brain tumors and first ischemic and hemorrhagic stroke patients admitted for hospital rehabilitation during an 11-yr period, between January 1993 and August 2004. Particular attention was paid to age and sex distribution, onset-to-admission interval, length of stay, functional status at admission and discharge, functional gain (DeltaFI change) as measured by the FIM instrument. RESULTS: A total of 168 patients with craniotomy for primary brain tumor excision (128 intracranial meningiomas and 40 cerebral gliomas) and 1660 first-stroke patients were admitted to the department for rehabilitation during the study period. Mean patient age was 59.9 yrs in meningioma group, 54.1 yrs in the glioma group, and 60.4 yrs in the stroke group. In the meningioma and stroke groups, male patients were in the majority (62 and 70%); in the glioma group, there was equal sex distribution. On average, patients were admitted to rehabilitation treatment 13 days after meningioma excision, 34 days after glioma operation, and 21.6 days after stroke. Functional variables during inpatient rehabilitation were found to be similar in the all groups. Average FIM rating at admission was 80.07 in the meningioma group, 68.2 in the glioma group, and 70.4 in the stroke group. Average discharge FIM rating was 90.3 for patients with meningiomas, 80.7 for patients with gliomas, and 87.8 for stroke patients. Functional gain was 17.9 for meningioma patients, 17.2 for glioma patients, and 21.8 for stroke patients. Average length of stay was 24 days for the meningioma group, 23 days for the glioma group, and 75.4 days for stroke patients; 88.1% of stroke patients, 91.7% of meningioma patients, and 82.7% of glioma patients were discharged to their homes, and 5.4, 3.4, and 8.6%, respectively, were discharged to nursing homes. CONCLUSIONS: Patients with brain tumors can achieve good functional outcomes with a shorter length of stay.     

Fatigue assessment and rehabilitation outcomes in patients with brain tumors

Objectives  

This study seeks to investigate the fatigue severity and the relationship among fatigue and other associated factors in patients with brain tumors, and to evaluate the rehabilitation outcome on fatigue.     

Access to inpatient rehabilitation after violence-related traumatic brain injury

OBJECTIVES: To examine injury characteristics, demographics, and discharge disposition after traumatic brain injury of violent or nonviolent cause. DESIGN: Cohort study. SETTING: Level I trauma center. PARTICIPANTS: Patients (N=1807) admitted with a Head Abbreviated Injury Score (AIS) of 2 or more over a 2-year period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Injury cause was classified as violent or nonviolent. Discharge disposition was classified as home, inpatient rehabilitation, skilled nursing facility (SNF), and other. RESULTS: The violence group was more likely to be male, to include individuals from diverse racial groups, to have an alcohol level above the legal limit, to have a more severe Head AIS, and to have Medicaid funding and equal access to inpatient rehabilitation compared with the nonviolence group. The violence group, though, was more likely to be discharged to home than to inpatient rehabilitation and more likely to be discharged to inpatient rehabilitation than to an SNF. The nonviolence group had a longer acute care length of stay and a higher rate of injuries to other body systems. CONCLUSIONS: People with violence-related injuries often present unique rehabilitation challenges. After accounting for injury severity and demographics, there was no evidence of bias against the violently injured in gaining access to inpatient rehabilitation services.     

Measuring patient-reported outcomes after discharge from inpatient rehabilitation settings.

OBJECTIVE: To examine the sensitivity of the Short Form Activity Measure for Post-Acute Care (AM-PAC) in comparison to the Functional Independence Measure (FIM) across a 12-month period after discharge from rehabilitation hospital. DESIGN: Prospective longitudinal study. Patients were recruited while receiving inpatient services from facilities in the north-east USA and interviewed 1, 6 and 12 months thereafter. PATIENTS: Convenience sample of 516 patients at baseline (65% retention at the final follow-up) receiving rehabilitation services for neurological, lower extremity orthopedic, or complex medical conditions. Mean age 68.3 years; 47% male. MAIN OUTCOME MEASURES: AM-PAC Physical and Movement, Personal Care and Instrumental, and Applied Cognitive Activity scales; FIM Motor and Cognitive scales. RESULTS: All 3 AM-PAC scales were sensitive to both positive and negative change across the follow-up period. Standardized response means for the AM-PAC were consistently larger than for the FIM across patient and severity groups. A greater percentage of patients showed positive change that exceeded the minimal detectable change on the AM-PAC than on the FIM both 6- and 12-month follow-ups. CONCLUSION: The short-form AM-PAC scales are more sensitive measures of change in functional activity performance over time in the general population of persons who receive inpatient rehabilitation services compared to the FIM. Thus, the AM-PAC offers a short, comprehensive, and sensitive measure of positive and/or negative change in patients' ability to perform important activities of daily life.     

Process and outcome during early inpatient rehabilitation after brain injury

Purpose: To describe aspects of process and outcome during early inpatient rehabilitation of younger adults after single incident brain injury.

Method: Analysis of a database of 290 patients discharged from an inner-city hospital based inpatient unit for younger adults after single incident neurological events, over a 5-year period.

Results: Analysis showed a stable case-mix of patients over the 5 years surveyed with a preponderance of young male patients after traumatic brain injury. Improvements in patients' disability and dependency, measured by the Barthel Index and Functional Independence Measure, were recorded in the majority of patients. The ethnic diversity of the patients, reflecting the multi-cultural nature of the catchment population, did not appear to affect rehabilitation outcome. Failure to record improvement in 15% of patients was related to the floor and ceiling effects of the instruments. A useful regression equation was produced relating length of stay to Barthel score on admission.

Conclusions: These data demonstrate the changes that occur during early inpatient rehabilitation after single incident brain injury. They explore clinical indicators of dependency and outcome, and aspects of resource utilization that characterize our service. Publication of data of this sort, from this and other units, should encourage the development and improvement of current rehabilitation service delivery after brain injury.     

Measuring medical complexity during inpatient rehabilitation after traumatic brain injury

OBJECTIVE: To compare the performance of 3 severity of illness (SOI) indices--the Comprehensive Severity Index (CSI), All Patient Refined Diagnosis Related Groups Severity of Illness, case-mix group (CMG)--and 5 well-known neurologic parameters, as measures of medical complexity. DESIGN: Retrospective chart review. SETTING: Inpatient rehabilitation center within a level I trauma center. PARTICIPANTS: Consecutive traumatic brain injury (TBI) admissions (N=212). INTERVENTION: Acute inpatient TBI rehabilitation. CSI and neurologic parameters were scored by chart extraction. SOI was based on diagnosis codes by using 3M PC Grouper software, version 15. MAIN OUTCOME MEASURES: Adjusted R 2 was used to predict rehabilitation charges as a proxy of medical complexity. RESULTS: The highest adjusted R 2 values for single variables predicting charges were: CMG .349, CSI .293, duration of posttraumatic amnesia .260. Adjusted R 2 values for the CMG combined with the CSI, 5 neurologic parameters, and SOI to predict charges were .446, .431, and .365, respectively. CONCLUSIONS: The CMG was the best single predictor of rehabilitation charges for TBI. Predictive ability was better when the CMG was combined with the CSI or a combination of the 5 neurologic parameters. A severity index based on objective clinical findings rather than diagnostic codes may have distinct advantages for rehabilitation outcome studies and reimbursement methodology.     

Post-acute care referral and inpatient rehabilitation admission criteria for persons with brain injury across two Canadian provinces

Purpose: Investigate health care providers’ perceptions of referral and admission criteria to brain injury inpatient rehabilitation in two Canadian provinces.

Methods: Health care providers (n?=?345) from brain injury programs (13 acute care and 16 rehabilitation facilities) participated in a cross-sectional web-based survey. The participants rated the likelihood of patients (traumatic brain injury and cerebral hypoxia) to be referred/admitted to rehabilitation and the influence of 19 additional factors (e.g., tracheostomy). The participants reported the perceived usefulness of referral/admission policies and assessment tools used.

Results: Ninety-one percent acute care and 98% rehabilitation participants reported the person with traumatic brain injury would likely or very likely be referred/admitted to rehabilitation compared to respectively 43% and 53% for the patient with hypoxia. Two additional factors significantly decreased the likelihood of referral/admission: older age and the combined presence of minimal learning ability, memory impairment and physical aggression. Some significant inter-provincial variations in the perceived referral/admission procedure were observed. Most participants reported policies were helpful. Similar assessment tools were used in acute care and rehabilitation.

Conclusions: Health care providers appear to consider various factors when making decisions regarding referral and admission to rehabilitation. Variations in the perceived likelihood of referral/admission suggest a need for standardized referral/admission practices.

• Implications for Rehabilitation

• Various patient characteristics influence clinicians’ decisions when selecting appropriate candidates for inpatient rehabilitation.

• In this study, acute care clinicians were less likely to refer patients that their rehabilitation counter parts would likely have admitted and a patient with hypoxic brain injury was less likely to be referred or admitted in rehabilitation than a patient with a traumatic brain injury.

• Such discrepancies suggest that policy-makers, managers and clinicians should work together to develop and implement more standardized referral practices and more specific admission criteria in order to ensure equitable access to brain injury rehabilitation services.

     

Change in inpatient rehabilitation admissions for individuals with traumatic brain injury after implementation of the medicare inpatient rehabilitation facility prospective payment system

Hoffman JM, Donoso Brown E, Chan L, Dikmen S, Temkin N, Bell KR. Change in inpatient rehabilitation admissions for individuals with traumatic brain injury after implementation of the Medicare inpatient rehabilitation facility prospective payment system.ObjectiveTo evaluate the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on use of inpatient rehabilitation for individuals with traumatic brain injury (TBI).DesignRetrospective cohort study of patients with TBI.SettingOne hundred twenty-three level I and II trauma centers across the U.S. who contributed data to the National Trauma Data Bank.ParticipantsPatients (N=135,842) with TBI and an Abbreviated Injury Score of the head of 2 or greater admitted to trauma centers between 1995 and 2004.InterventionsNone.Main Outcome MeasureDischarge location: IRF, skilled nursing facility, home, and other hospitals.ResultsCompared with inpatient rehabilitation admissions before IRF PPS came into effect, demographic characteristics of admitted patients changed. Those admitted to acute care trauma centers after PPS was enacted (January 2002) were older and nonwhite. No differences were found in rates of injury between men and women. Over time, there was a significant drop in the percent of patients being discharged to inpatient rehabilitation, which varied by region, but was found across all insurance types. In a logistic regression, after controlling for patient characteristics (age, sex, race), injury characteristics (cause, severity), insurance type, and facility, the odds of being discharged to an IRF after a TBI decreased 16% after Medicare's IRF PPS system was enacted.ConclusionsThe enactment of the Medicare PPS appears to be associated with a reduction in the chance that patients receive inpatient rehabilitation treatment after a TBI. The impact of these changes on the cost, quality of care, and patient outcome is unknown and should be addressed in future studies.     

Racial disparities in outcomes of inpatient stroke rehabilitation

OBJECTIVE: To determine whether race is associated with outcomes of inpatient stroke rehabilitation. DESIGN: Retrospective cohort study. SETTING: A community-based inpatient rehabilitation facility. PARTICIPANTS: Poststroke patients (N=1002) admitted to a community-based inpatient rehabilitation facility between 1995 and 2001. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional improvement at discharge from the rehabilitation facility, discharge disposition, and functional improvement at 3 months after discharge. Inpatient and follow-up data were collected from the facility's electronic patient database. We used the FIM instrument to assess functional status at admission, discharge, and follow-up. RESULTS: In multivariable models, blacks achieved less functional improvement at discharge (-1.9 FIM points, P=.02) compared with whites and, despite worse FIM scores, were more likely to be discharged to home (adjusted odds ratio=1.7; 95% confidence interval, 1.1-2.5). Although Asian-American patients did not differ from whites in terms of functional improvement at discharge or disposition, they had less improvement at 3 months following discharge (-6.3 FIM points, P=.005). CONCLUSIONS: We identified racial disparities in poststroke outcomes in a community-based inpatient rehabilitation facility. Future research in stroke rehabilitation should explore the consistency of these findings across settings and if they are confirmed, identify explanatory mediators to better inform efforts to eliminate racial disparities.     

Use of the Barthel Index and the Functional Independence Measure during early inpatient rehabilitation after single incident brain injury

OBJECTIVE: To compare the appropriateness and responsiveness of the Barthel Index and the Functional Independence Measure (FIM) during early inpatient rehabilitation after single incident brain injury. DESIGN: Cohort study. SETTING: A regional neurological rehabilitation unit. PATIENTS: Two hundred and fifty-nine consecutive patients undergoing inpatient comprehensive neurological rehabilitation following a vascular brain injury due to single cerebral infarction (n = 75), spontaneous intracerebral haemorrhage (n = 34) and subarachnoid haemorrhage (n = 43), and 107 patients who had sustained traumatic brain injury. MEASUREMENTS: Admission and discharge FIM total, physical and cognitive scores and the Barthel Index were recorded. Appropriateness and responsiveness in the study samples were determined by examining score distributions and floor and ceiling effects, and by an effect size calculation respectively. Non-parametric statistical analysis was used to calculate the significance of the change in scores. RESULTS: In all patient groups there was a significant improvement (Wilcoxon's rank sum, P<0.0001) in the Barthel Index (mean change score: vascular 3.9, traumatic 3.95) and FIM (mean change score: vascular 17.3, traumatic 17.4) scores during rehabilitation, and similar effect sizes were found for the Barthel Index (effect size: vascular 0.65, traumatic 0.55) and FIM total (effect size: vascular 0.59, traumatic 0.48) and physical scores in all patient groups. In each patient group the cognitive component of the FIM had the smallest effect size (0.35-0.43). CONCLUSIONS: All measures were appropriate for younger (less than 65 years of age) patients undergoing early inpatient rehabilitation after single incident vascular or traumatic brain injury. The Barthel Index and the total and physical FIM scores showed similar responsiveness, whilst the cognitive FIM score was least responsive. These findings suggest that none of the FIM scores have any advantage over the Barthel Index in evaluating change in these circumstances.     

Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation

OBJECTIVE: To retrospectively examine the effects of sex and age on the inpatient rehabilitation outcomes of patients after total hip arthroplasty (THA). DESIGN: Exploratory, retrospective study. SETTING: A university-affiliated rehabilitation hospital. PARTICIPANTS: Male and female THA patients (N=332) were stratified into age brackets (<65y, 65-84y, >or=85y). All patients completed interdisciplinary inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), FIM instrument scores, FIM efficiency (FIM/LOS), hospital costs, and discharge disposition location were collected by chart review. RESULTS: Regardless of age, women had lower FIM scores at admission and discharge than men (P<.05). FIM efficiency was 22% to 53% lower for women in primary THA and 16% to 85% lower in revision THA than men (P=.001). Women accrued higher total hospital charges than men (13,099 dollars vs 11,141 dollars; P<.05), and were discharged home less frequently than men (84.4% vs 90.9%; P<.05). Admission FIM scores were 10.6% and 8.9% lower and discharge FIM scores were 7.3% and 9.2% lower in patients 85 years or older than those less than 65 or 65 to 84 years (P<.01). FIM efficiency was 25% to 38% higher in patients less than 85 years than those 85 years and older (P=.015), and 37% higher in men than women (P=.001). Patients 85 years and older were discharged less frequently to home than patients less than 85 years (P<.05). CONCLUSIONS: All patients made functional improvement after inpatient rehabilitation, but women and patients 85 years and older had longer LOS and lower FIM efficiency, incurred greater hospital charges, and were less likely to be discharged to home than men and younger counterparts.     

Use of outcomes information in acute inpatient rehabilitation

OBJECTIVE: To describe the ways in which rehabilitation outcomes information is used in the acute inpatient rehabilitation industry and the industry's views on the topic of public disclosure of rehabilitation outcomes information. DESIGN: A mixed-methods approach, featuring data from 39 informational telephone interviews with rehabilitation industry stakeholders followed by a survey of 95 randomly sampled acute inpatient rehabilitation provider organizations. RESULTS: Both the informational interviews and survey findings revealed that there is currently little stakeholder demand for functional outcomes information. Outcomes information is primarily used within provider organizations to track the effectiveness of rehabilitation services. There is general consensus among rehabilitation provider organizations in favor of public disclosure of outcomes information. CONCLUSIONS: Outcomes information is not routinely shared with rehabilitation stakeholders (i.e., payers and consumers). Rehabilitation providers and industry stakeholders generally express favorable attitudes toward public disclosure of outcomes information. Stakeholders' perceptions of current barriers and facilitators of outcomes information provide insight into the steps that can be taken toward greater transparency in the rehabilitation industry.     

Use of goal attainment scaling in inpatient rehabilitation for persons with multiple sclerosis

Khan F, Pallant JF, Turner-Stokes L. Use of goal attainment scaling in inpatient rehabilitation for persons with multiple sclerosis.

Objectives

To use goal attainment scaling (GAS) to measure clinically important functional change in persons with multiple sclerosis (MS) and to assess its responsiveness compared with standard measures used to evaluate progress in rehabilitation.

Design

Prospective, observational cohort study.

Setting

Tertiary inpatient rehabilitation unit in Victoria, Australia.

Participants

Consecutive sample of 24 persons with MS admitted for comprehensive rehabilitation program. The male-to-female ratio was 10:14, and the mean age ± standard deviation was 52.0±8.3 years (range, 37−62y). Over half (n=14 [58.3%]) had secondary progressive MS.

Interventions

Not applicable.

Main Outcome Measures

GAS scores were calculated for 5 to 10 priority goals set prospectively by each patient in agreement with the multidisciplinary treating team and compared with standard outcome measures—the FIM instrument and Barthel Index—rated on admission and discharge from the program. Patients were categorized into responders and nonresponders based on an overall clinical global impression.

Results

Of 203 selected goals, 167 were achieved at the predicted level. GAS recorded outcomes for 105 individualized goals not measured by the FIM and Barthel Index. Although all 3 measures showed statistically significant change from admission to discharge (P<.001), only GAS scores strongly correlated with the Clinical Global Impression scale (ρ=−.86, P<.001). GAS discharge scores differed significantly between the responder and nonresponder groups (Mann-Whitney, z=−3.78, P<.001). Different measures of effect size gave different results, but GAS was consistently more responsive than either the FIM or Barthel Index.

Conclusions

This preliminary study suggests that GAS is a responsive and useful outcome measure for the rehabilitation of persons with MS, providing added value to standardized outcome measurement.     

Comparison of costs-of-illness in a year before and after inpatient and outpatient rehabilitation in persons with spinal disorders

The present economic analyses of orthopaedic inpatient and outpatient rehabilitation (IPR resp. OPR) focus but on the evaluation of the expenses from the cost carrier's perspective. Lower intervention costs were related to OPR, whereas comparable social and clinical outcome was achieved. Comprehensive assessment of the economic consequences (resource utilization and lost productivity) of low back pain have not been performed up to now. Therefore, as part of a prospective follow-up study (1) a comparison of overall cost-of-illness and cost components 12 months prior and after IPR and OPR, respectively, was carried out in patients with low back pain and (2) the relative changes of these cost components were compared in a full-cost-analysis from a societal perspective. A total of 150 matched pairs (SR and AR) were followed prospectively over 12 months. Disease related costs in the year prior to the intervention were evaluated retrospectively. Prior to IPR and OPR overall costs amounted to 7010 and 7710 Euro, respectively, per person and year in patients with low back pain. As the main cost component of overall costs, sick leave (SL) periods account for 74% (IPR) and 76% (OPR), respectively. Inpatient costs represent the main component of direct costs. In the year after the intervention the costs due to sick leave periods still represent the major cost component (46 and 52%, resp.) of overall costs (3370 and 3600 Euro, resp.). Disease related cessation of work including work disability accounts for about 10% of productivity costs after IPR and OPR. Indirect costs still make up for the major part of overall costs (58 and 62%, resp.). No differences of cost components and their relative changes can be seen between patients participating in IPR and OPR, respectively, within both time frames. The comparison of overall costs in the 12 months before and after IPR and OPR reveals a cost reduction of 52% (IPR) and 53% (OPR), resp. This decrease of costs is mainly related to the reduction of SL periods, though costs due to inpatient treatment decrease as well. Summarizing, the present full-cost-analysis from a societal perspective shows no differences of cost components and cost changes between orthopaedic IPR and OPR in the 12 months prior to and after the intervention. Comprehensive cost-analyses reveal no obstacles for further implementation of OPR in the treatment of low back pain. Future development and diversification of rehabilitation measures should aim at evaluating real resource consumption during the intervention in detail as a basis for further allocational decision making.