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Objective: To determine if patients' level of effort (LOE) in therapy sessions during traumatic brain injury (TBI) rehabilitation modifies the effect of compliance with the 3-Hour Rule of the Centers for Medicare & Medicaid Services., Design: Propensity score methodology applied to the TBI Practice-Based Evidence database, consisting of multisite, prospective, longitudinal observational data., Setting: Acute inpatient rehabilitation facilities (IRF)., Participants: Patients (N=1820) who received their first IRF admission for TBI in the United States and were enrolled for 3- and 9-month follow-up., Main Outcome Measures: Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9., Results: When the full cohort was examined, no strong main effect of compliance with the 3-Hour Rule was identified and LOE did not modify the effect of compliance with the 3-Hour Rule. In contrast, LOE had a strong positive main effect on all outcomes, except depression. When the sample was stratified by level of disability, LOE modified the effect of compliance, particularly on the outcomes of participants with less severe disability. For these patients, providing 3 hours of therapy for 50% or more of therapy days in the context of low effort resulted in poorer performance on select outcome measures at discharge and up to 9 months postdischarge compared to patients with <50% of 3-hour therapy days., Conclusions: LOE is an active ingredient in inpatient TBI rehabilitation, while compliance with the 3-Hour Rule was not found to have a substantive effect on the outcomes. The results support matching time in therapy during acute TBI rehabilitation to patients' LOE in order to optimize long-term benefits on outcomes., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To use causal inference methods to determine if receipt of a greater proportion of inpatient rehabilitation treatment focused on higher level functions, for example, executive functions, ambulating over uneven surfaces (advanced therapy [AdvTx]), results in better rehabilitation outcomes., Design: A cohort study using propensity score methods applied to the traumatic brain injury practice-based evidence (TBI-PBE) database, a database consisting of multisite, prospective, longitudinal observational data., Setting: Acute inpatient rehabilitation facilities., Participants: Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, receiving their first inpatient rehabilitation facility admission to 1 of 9 sites in the United States, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation., Interventions: Not applicable., Main Outcome Measures: Participation Assessment with Recombined Tools-Objective-17, FIM motor and cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9., Results: Controlling for measured potential confounders, increasing the percentage of AdvTx during inpatient TBI rehabilitation was found to be associated with better community participation, functional independence, life satisfaction, and decreased likelihood of depression during the year after discharge from inpatient rehabilitation. Participants who began rehabilitation with greater disability experienced larger gains on some outcomes than those who began rehabilitation with more intact abilities., Conclusions: Increasing the proportion of treatment targeting higher level functions appears to have no detrimental and a small, beneficial effect on outcome. Caution should be exercised when inferring causality given that a large number of potential confounders could not be completely controlled with propensity score methods. Further, the extent to which unmeasured confounders influenced the findings is not known and could be of particular concern due to the potential for the patient's recovery trajectory to influence therapists' decisions to provide a greater amount of AdvTx., (Copyright © 2018 American Congress of Rehabilitation Medicine. All rights reserved.)

Sound rigorous methods are needed by researchers and providers to address practical questions about risks, benefits, and costs of interventions as they occur in routine clinical practice such as: Are treatments used in daily practice associated with intended outcomes? For whom does an intervention work best? With limited clinical resources, what are the best interventions to use for specific types of patients? Answers to such questions can help clinicians, patients, researchers, and health care administrators learn from, and improve, real-world everyday clinical practice. In this article, we describe existing research designs to demonstrate clinical usefulness and comparative effectiveness of rehabilitation treatments. We compare randomized controlled trials and observational cohort studies of various types, including those that use instrumental variables or propensity scores to control for potential patient or treatment selection effects. We argue that practice-based evidence (PBE) study designs include features that address limitations inherent in both randomized trials and traditional observational studies, and also reduce the need for instrumental variables and propensity scores methods. We give examples of how PBE designs have been used in various rehabilitation areas to determine better treatments for specific types of patients., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

A barrier in outcomes and effectiveness research is the ability to characterize the interventions under review. This has been the case especially in rehabilitation in which interventions are commonly multidisciplinary, customized to the patient, and lack standardization in definition and measurement. This commentary describes how investigators and clinicians, working together, in a major multisite stroke rehabilitation outcome study were able to define and characterize diverse stroke rehabilitation interventions in a comprehensive, yet parsimonious, fashion and thus capture what actually transpires in a hospital-based stroke rehabilitation program. We consider the implications of the study's classification system for a more comprehensive taxonomy of rehabilitation interventions and the potential utility of such a taxonomy in operationalizing practice standards, medical record keeping, and rehabilitation research.

Objective: To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI). Setting: Acute inpatient rehabilitation. Participants: Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. Design: Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data. Main Measures: Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9. Results: When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment. Conclusions: The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment. [ABSTRACT FROM AUTHOR]

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

To evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge. Propensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data. Nine inpatient rehabilitation centers in the United States. Patients (N=1835) admitted for first inpatient rehabilitation after an index TBI. Family attendance during therapy sessions. Participation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Participants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance. Family involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients' families in the rehabilitation process to maximize outcomes. [ABSTRACT FROM AUTHOR]

The Comparative Effectiveness of Inpatient Rehabilitation Interventions for Traumatic Brain Injury (TBI-CER) project used causal inference methods as an alternative to randomized controlled trials to evaluate rehabilitation practices. The TBI practice-based evidence dataset afforded the opportunity to compare the outcomes of different rehabilitation approaches while controlling for a large set of potential confounders using propensity score methods (PSMs). PSMs rely on 4 assumptions: positivity, exchangeability, consistency, and correct specification of the propensity score model. When these assumptions are met, PSMs provide a transparent means for evaluating potential causal relations between interventions and outcomes using observational data. In combination, the series of studies resulting from the TBI-CER project suggested that the content and approach used in treatment have a stronger effect on outcomes than the amount of time spent in treatment. Further, engagement of the patient and family in treatment is key to optimizing outcomes up to 9 months postdischarge from rehabilitation. [ABSTRACT FROM AUTHOR]

To evaluate the effect of providing a greater percentage of therapy as contextualized treatment on acute traumatic brain injury (TBI) rehabilitation outcomes. Propensity score methods are applied to the TBI Practice-Based Evidence (TBI-PBE) database, a database consisting of multi-site, prospective, longitudinal observational data. Acute inpatient rehabilitation. Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received their first inpatient rehabilitation facility admission in the US, and consented to follow-up 3 and 9 months post discharge from inpatient rehabilitation. Not applicable. Participation Assessment with Recombined Tools-Objective (PART-O)-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Increasing the percentage of contextualized treatment during inpatient TBI rehabilitation leads to better outcomes, specifically in regard to community participation. Increasing the proportion of treatment provided in the context of real-life activities appears to have a beneficial effect on outcome. Although the effect sizes are small, the results are consistent with other studies supporting functional-based interventions effecting better outcomes. Furthermore, any positive findings, regardless of size or strength, are endorsed as important by consumers (survivors of TBI). While the findings do not imply that decontextualized treatment should not be used, when the therapy goal can be addressed with either approach, the findings suggest that better outcomes may result if the contextualized approach is used. [ABSTRACT FROM AUTHOR]

To describe development and testing of a physical therapy treatment code documentation taxonomy. Clinician survey within a practice-based evidence study framework for patients with lymphedema. Outpatient physical therapy clinics within a large public health care service using a central electronic medical record. Certified lymphedema therapists (CLTs) (N=43). Treatment coding of 10 treatment vignettes representing real-life clinical scenarios. The CLTs were asked to accurately select 35 activity-intervention combination codes. The CLT score represented percentage of treatment codes accurately selected by each therapist. The code score represented percentage of CLTs who accurately selected each treatment code. The mean CLT score was 91%, with 72% of CLTs meeting the 90% criterion. Personal feedback was provided to each CLT. The mean code score was also 91%; with 71% of treatment codes meeting the 90% criterion. We identified 9 low-score codes needing additional education or found to be redundant. These codes were either clarified or removed. The proposed treatment code documentation system for lymphedema therapy was found to be clear and accurately used by most CLTs. Specific needs for improvement were identified. Follow-up testing is warranted to ensure ongoing accurate implementation of the treatment documentation system. [ABSTRACT FROM AUTHOR]

To explore the patterns of cognitive and motor recovery at 4 time points from admission to 9 months after discharge from inpatient rehabilitation (IR) and to investigate the association of therapeutic factors and conditions before and after discharge with long-term outcomes. Secondary analysis of traumatic brain injury (TBI) and practice-based evidence dataset. IR in Ontario, Canada. Patients with TBI consecutively admitted for IR between 2008 and 2011 who had data available from admission to 9 months after discharge (N=85). Not applicable. FIM-Rasch cognitive and motor scores at admission, discharge, 3 months after discharge, and 9 months after discharge. Cognitive and motor recovery showed similar patterns of improvement with recovery up to 3 months but no significant change from 3 to 9 months. Having fewer postdischarge health conditions was associated with better long-term cognitive scores (95% confidence interval, -13.06 to -1.2) and added 9.9% to the explanatory power of the model. More therapy time in complex occupational therapy activities (95% confidence interval,.02 to.09) and fewer postdischarge health conditions (95% confidence interval, -19.5 to -3.8) were significant predictors of better long-term motor function and added 14.3% and 7.2% to the explanatory power of the model, respectively. Results of this study inform health care providers about the influence of the timing of IR on cognitive and motor recovery. In addition, it underlines the importance of making patients and families aware of residual health conditions following discharge from IR. [ABSTRACT FROM AUTHOR]

Objective: Minority populations have worse stroke outcomes compared with non-Hispanic whites (NHWs). One possible explanation for this disparity is differential allocation of stroke rehabilitation. We utilized a population-based stroke study to determine the feasibility of studying Mexican American-NHW differences in stroke rehabilitation in a population-based design including identification of community partners, development of standardized data collection instruments, and collection of pilot data. Methods: As part of the Brain Attack Surveillance in Corpus Christi project, we followed 48 patients for the first 90 days after stroke, and attempted to work with community partners to garner information on rehabilitation modalities used. With input from local occupational and physical therapists and speech language pathologists, we created data collection forms to capture rehabilitation activities and time spent on these activities and conducted a 3-month data collection pilot. Results: Of the 79 rehabilitation venues in the community, 63 (80%) agreed to participate. During the pilot, 545 data forms from 20 stroke patients were collected corresponding to ~18% of stroke patients. Forms were used by 13 partners during the pilot including 3 of 4 inpatient rehabilitation facilities, 4 of 13 skilled nursing facilities, 4 of 26 home health agencies, and 2 of 36 outpatient rehabilitation providers. Conclusions: Initial agreement from rehabilitation providers to participate in research was excellent, but completion of study related data collection forms was sub-optimal suggesting this approach is not feasible for a future population-based stroke rehabilitation study. Further methods to study post-stroke rehabilitation disparities in communities are needed. [ABSTRACT FROM AUTHOR]

Background: Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups.Objective: To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission.Design: Multicenter prospective observational cohort, practice-based evidence, study.Setting: Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States.Participants: A total of 226 patients with hip fractures treated with hip arthroplasty.Methods: Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster).Main Outcome Measure(s): Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity).Results: The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group.Conclusions: Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research. [ABSTRACT FROM AUTHOR]

The article summarizes important points on the need for a rehabilitation treatment taxonomy. The features of a proposed conceptual framework to support the development of a rehabilitation treatment taxonomy that can be used by all disciplines are outlined and the immediate and long-term benefits of the proposed framework are discussed. Commentaries by various scholars on the classifications of health interventions and the rehabilitation treatment taxonomy are presented.

Background. The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown. Objective. The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups. Design. This was a prospective observational cohort study. Methods. The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patient's medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities. Results. All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average = 31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average = 65.3 minutes per day), whereas the TBI group received the least physical therapy (average = 38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome. Limitations. The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities. Conclusions. All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes. [ABSTRACT FROM AUTHOR]

Deutscher D, Horn SD, Smout RJ, DeJong G, Putman K. Black-white disparities in motor function outcomes taking into account patient characteristics, nontherapy ancillaries, therapy activities, and therapy interventions. Objective: To assess black-white differences in functional outcomes, controlling for patient characteristics, use of nontherapy ancillaries (NTAs), and use of physical (PT) and occupational therapy (OT) activities and interventions. Design: Multicenter prospective observational cohort study of poststroke rehabilitation. Setting: Six U.S. inpatient rehabilitation facilities. Participants: Patients (N=732) subdivided into case-mix subgroups (CMGs; CMGs 104–107 for moderate strokes [n=397], CMGs 108–114 for severe strokes [n=335]). Interventions: Not applicable. Main Outcome Measure: Discharge Motor FIM. Results: Taking into account patient characteristics, NTAs, and therapy activities, multivariate regressions explained (R 2) 54% and 69% of variation in outcomes between patients with moderate and severe stroke, respectively. Black race was associated with lower outcomes than white race in the severe group. However, race was no longer associated with outcomes after including interventions used within PT and OT activities. Including interventions within therapy activities increased R 2 to 64% and 74% for moderate and severe strokes, respectively. Some PT and OT activities were provided more to blacks than whites and vice versa. Greater intensity sometimes was associated with better and sometimes with poorer functional outcomes. Conclusions: After controlling for interventions within activities, no racial differences were found in functional outcomes at discharge despite racial differences in rehabilitation care, possibly because each racial group received a mixture of interventions that were negatively and positively associated with outcome. Clinicians should provide therapies associated with better outcomes with high and similar intensities for black and white patients poststroke. [Copyright &y& Elsevier]

Horn SD, Deutscher D, Smout RJ, DeJong G, Putman K. Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation. Objective: To describe racial differences in patient characteristics, nontherapy ancillaries, physical therapy (PT), occupational therapy (OT), and functional outcomes at discharge in stroke rehabilitation. Design: Multicenter prospective observational cohort study of poststroke rehabilitation. Setting: Six U.S. inpatient rehabilitation facilities. Participants: Black and white patients (n=732), subdivided in case-mix subgroups (CMGs): CMGs 104 to 107 for moderate strokes (n=397), and CMGs 108 to 114 for severe strokes (n= 335). Interventions: Not applicable. Main Outcome Measure: FIM. Results: Significant black-white differences in multiple patient characteristics and intensity of rehabilitation care were identified. White subjects took longer from stroke onset to rehabilitation admission and were more ambulatory prior to stroke. Black subjects had more diabetes. For patients with moderate stroke, black subjects were younger, were more likely to be women, and had more hypertension and obesity with body mass index greater than or equal to 30. For patients with severe stroke, black subjects were less sick and had higher admission FIM scores. White subjects received more minutes a day of OT, although black subjects had significantly longer median PT and OT session duration. No black-white differences in unadjusted stroke rehabilitation outcomes were found. Conclusions: Reasons for differences in rehabilitation care between black and white subjects should be investigated to understand clinicians' choice of treatments by race. However, we did not find black-white differences in unadjusted stroke rehabilitation outcomes. [Copyright &y& Elsevier]

Abstract: Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ, Gutvirtz M, Ariel I. Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Objective: To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake. Design: Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes. Setting: Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel. Participants: A consecutive sample of 22,019 adult patients (mean age 51.2y, standard deviation=15.7, range 18–96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge. Interventions: Not applicable. Main Outcome Measure: Functional status at discharge. Results: Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs. Conclusions: The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice. [Copyright &y& Elsevier]

Abstract: DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Hsieh C-H, Gassaway J, Smith P. Long-term outcomes of joint replacement rehabilitation patients discharged from skilled nursing and inpatient rehabilitation facilities. Objective: To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). Design: Postdischarge follow-up interview study at 7.5 months after admission. Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs. Participants: Patients (N=856): 561 with knee replacement and 295 with hip replacement. Interventions: None. Main Outcome Measures: FIM and Short-Form 12-Item Health Survey (SF-12). Results: Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12–related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes. Conclusions: At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Smith P, Gassaway J, DaVanzo JE. Use of rehabilitation and other health care services by patients with joint replacement after discharge from skilled nursing and inpatient rehabilitation facilities. Objective: To compare use of rehabilitation and other health services among patients with knee and hip replacement after discharge from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). Design: Follow-up interview study at 7.5 months after discharge. Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs from across the United States. Participants: Patients (N=856): patients with knee replacement (n=561) and patients with hip replacement (n=295). Interventions: No interventions. Main Outcome Measures: Number of home and outpatient therapy visits, physician visits, emergency room visits, rehospitalizations, and medical complications. Results: After discharge from postacute care, the vast majority of patients received home rehabilitation, outpatient rehabilitation, or both. Patients with knee replacement received an average of 19 home and/or outpatient rehabilitation visits; patients with hip replacement received almost 15 visits. There were no statistically significant differences in rates of emergency room use and rehospitalization except that patients with hip replacement discharged from IRFs had higher rates of rehospitalization than those discharged from freestanding SNFs (15.8% vs 3.1%). Multivariate analyses did not find any SNF/IRF effects. Conclusions: Patients with joint replacement from both SNFs and IRFs receive considerable amounts of follow-up rehabilitation care. Study uncovered no setting effects related to rehospitalization or medical complications. Looking only at care rendered in the initial postacute setting provides an incomplete picture of all care received and how it may affect follow-up outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Horn SD, Smout RJ, Tian W, Putman K, Gassaway J. Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities. Objective: To compare functional outcomes at discharge across postacute settings. Design: Prospective observational cohort study. Setting: Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States. Participants: Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751). Interventions: None; examination of existing practice patterns. Main Outcome Measure: FIM discharge motor score. Results: Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome. Conclusions: As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Hsieh C-H, Gassaway J, Horn SD, Smout RJ, Putman K, James R, Brown M, Newman EM, Foley MP. Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities. Objective: To characterize rehabilitation services for patients with knee and hip replacement in 3 types of postacute facilities in the U.S. Design: Multi-site prospective observational cohort study. Setting: Eight freestanding skilled nursing facilities (SNFs), 1 hospital-based SNF, and 11 inpatient rehabilitation facilities (IRFs). Participants: Patients (N=2158) with knee or hip replacement. Interventions: No new interventions. Main Outcome Measures: Length of stay (LOS), amount and intensity of physical therapy (PT) and occupational therapy (OT), types of therapy activities. Results: Average LOS was about 15 days for freestanding SNF patients, and 9 to 10 days for hospital-based SNF and IRF patients. Freestanding SNFs and IRFs provide about the same number of hours of PT and OT; the hospital-based SNF provided 27% fewer hours. Freestanding SNFs and the hospital-based SNF provided fewer hours a day than did IRFs. Joint replacement patients across all 3 types of facilities spent, on average, 70% to 75% of their PT time in just 2 activities—exercise and gait and spent 56% to 66% of their OT time in 3 activities—exercise, functional mobility, and dressing lower body. Conclusions: Both freestanding SNFs and IRFs provided similar amounts of PT with a similar emphasis on exercise and gait activities. IRFs, however, provided more OT than freestanding SNFs. IRFs had shorter LOSs and more intensive therapy services than freestanding SNFs. Study freestanding SNFs exhibited greater variation in LOS and intensity of therapy than IRFs. [Copyright &y& Elsevier]

Abstract: Tian W, DeJong G, Brown M, Hsieh C-H, Zamfirov ZP, Horn SD. Looking upstream: factors shaping the demand for postacute joint replacement rehabilitation. Since 1993, the numbers of hip and knee replacements in the United States have increased 2-fold to 3-fold while lengths of stay in acute care have decreased by about half, leading to a significant growth in the use of postacute rehabilitative care for patients with a joint replacement. To document these trends, this article uses secondary analysis of acute hospital discharge survey data and evaluates projections to 2030. This article uses a market approach to identify 3 sets of factors that influence the use of joint replacements: (1) increasing patient demand, (2) increasing supply of practitioners, and (3) the role of fiscal intermediaries. The article reviews underlying epidemiologic trends, growing numbers of orthopedic surgeons performing the procedure, technologic innovations, changing indications for the procedure, changing payer mix, and the effects of payer attempts to contain joint replacement costs. An unintended effect of Medicare payment policy has been to shift costs from acute care to downstream postacute care. Medicare and private health plan reimbursement policies need to take into account this broader perspective and not examine joint replacement care and payment in isolated care settings. Future research and health policy needs to consider the interdependent features of the health care system by linking changes in postacute care with upstream changes both in society at large and in the organization, delivery, and financing of acute care associated with joint replacement. [Copyright &y& Elsevier]

Abstract: Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Objective: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients. Design: Prospective observational cohort study. Setting: Five U.S. inpatient rehabilitation facilities. Participants: Poststroke rehabilitation patients (N=830; age, >18y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database. Interventions: Not applicable. Main Outcome Measures: Discharge total, motor, and cognitive FIM scores and discharge destination. Results: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes. Conclusions: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes. [Copyright &y& Elsevier]

Abstract: DeJong G, Horn SD, Smout RJ, Ryser DK. The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes. Objective: To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes. Design: Prospective observational cohort study. Setting: Three IRFs in the United States. Participants: Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs. Interventions: Not applicable. Main Outcome Measures: Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination. Results: The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities. Conclusions: For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study’s findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS. [Copyright &y& Elsevier]

Abstract: James R, Gines D, Menlove A, Horn SD, Gassaway J, Smout RJ. Nutrition support (tube feeding) as a rehabilitation intervention. Objective: To describe site variation in use of enteral feeding and its association with stroke rehabilitation outcomes, controlling for a variety of confounding variables. Design: Prospective observational cohort study. Setting: Six inpatient rehabilitation facilities in the United States. Participants: Patients (N=919) from the Post-Stroke Rehabilitation Outcomes Project database with moderate or severe stroke who were discharged to home, community, or skilled nursing facility. Interventions: Not applicable. Main Outcome Measures: Change in total, motor, and cognitive FIM instrument scores and change in severity of illness. Results: Monitoring of nutritional status and the frequency of tube-feeding interventions for patients with moderate and severe stroke varied significantly among sites. Patients with tube feeding had higher severity of illness and lower functioning on admission compared with patients who did not receive tube feeding. However, when we controlled for severity of illness, admission FIM score, and other important covariates, we found that patients with severe strokes who were tube fed for more than 25% of their stay had greater increases in total, motor, and cognitive FIM scores and greater improvement in severity of illness by discharge. Conclusions: Nutrition support (tube feeding) is an effective therapy in rehabilitation service for patients with severe strokes and is associated with greater motor and cognitive improvements, even in patients with the most severe strokes. [Copyright &y& Elsevier]

Abstract: Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An exploration of central nervous system medication use and outcomes in stroke rehabilitation. Objective: To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables. Design: Observational cohort study of poststroke rehabilitation. Setting: Six inpatient rehabilitation hospitals in the United States. Participants: Patients with moderate or severe strokes (N=919). Interventions: Not applicable. Main Outcome Measures: Discharge disposition, FIM score change, and rehabilitation length of stay (LOS). Results: Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neurostimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counterintuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation. Conclusions: There are many opportunities to enhance a stroke survivor’s ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups. [Copyright &y& Elsevier]

Abstract: Latham NK, Jette DU, Slavin M, Richards LG, Procino A, Smout RJ, Horn SD. Physical therapy during stroke rehabilitation for people with different walking abilities. Objective: To describe how physical therapy (PT) activities during poststroke inpatient rehabilitation vary by admission walking ability and over time. Design: Observational cohort study. Setting: Six inpatient rehabilitation hospitals in the United States. Participants: People receiving poststroke PT (N=715) who were classified as walking at admission. Interventions: Not applicable. Main Outcome Measures: Percentage of time spent in 11 activities, percentage of patients who participated in each activity, and the FIM instrument scores. Results: The majority of PT time was spent in gait activities. Even people with the most limited mobility spent 25% to 38% of PT time in gait activities during the first 6-hour treatment block. Treatment progression was evident, and a shift to more advanced activities occurred over time (eg, less bed mobility and more advanced gait). However, even in the final 6-hour block, a small proportion of time was spent on community mobility activities (1.2%–5.2%), and most people received no community mobility training. Conclusions: PT activities focused on specific functional tasks at the ability level of each individual patient and provided higher-level activities as patients improved their function. However, although there is increasing recognition that the environment influences task performance, little time was spent in community mobility activities before discharge. [Copyright &y& Elsevier]

Abstract: Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke. Objective: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables. Design: Observational cohort study of 200 consecutive poststroke rehabilitation patients in each of 6 inpatient rehabilitation facilities. Setting: Six U.S. inpatient rehabilitation hospitals. Participants: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records. Interventions: Not applicable. Main Outcome Measures: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS). Results: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108–114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104–107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS. Conclusions: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS. [Copyright &y& Elsevier]

Abstract: Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results. Objectives: To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP). Design: Prospective observational cohort study. Setting: Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand. Participants: Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs). Interventions: Not applicable. Main Outcome Measures: Change in FIM score, change in severity of illness, and discharge destination. Results: For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4. Conclusions: This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability. [Copyright &y& Elsevier]

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

Abstract: DeJong G, Horn SD, Conroy B, Nichols D, Healton EB. Opening the black box of poststroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. This article introduces the journal’s supplement devoted to the methods and findings of the 7-site Post-Stroke Rehabilitation Outcomes Project (PSROP), a study designed to provide a very granular in-depth understanding of stroke rehabilitation practice and how practice is related to outcomes. The article summarizes current knowledge about the effectiveness of poststroke rehabilitation, outlines where the PSROP fits into the broader traditions of stroke rehabilitation outcomes research, underscores the study’s methodologic innovations, and summarizes the scope of the articles that follow. [Copyright &y& Elsevier]

Abstract: Ryser DK, Egger MJ, Horn SD, Handrahan D, Gandhi P, Bigler ED. Measuring medical complexity during inpatient rehabilitation after traumatic brain injury. Arch Phys Med Rehabil 2005;86:1108–17. 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. [Copyright &y& Elsevier]

Background and Purpose. The purpose of this study was to describe physical therapy provided to patients with stroke in inpatient rehabilitation facilities. Subjects and Methods. Data were collected from 972 patients with stroke receiving physical therapy services at 6 rehabilitation facilities in the United States. Descriptive statistics were derived to describe physical therapy sessions, including proportion of therapy time spent in specific functional activities and proportion of those activities that included any of 59 interventions. Results. Mean length of stay was 18.7 days (SD=10.3), and patients received physical therapy, on average, 13.6 days (SD=7.8). Patients attended, on average, 1.5 (SD=0.3) physical therapy sessions per day, with each session lasting 38.1 minutes (SD=17.1). Gait and prefunctional activities were performed most frequently (31.3% and 19.7% of total treatment time, respectively). For gait activity, physical therapists used balance and postural awareness training in more than 50% of sessions and used strength training for more than 50% of sessions of prefunctional activities. Eighty-six percent of the patients received evaluation, and 84% of the patients and families received education. Discussion and Conclusion. Therapists selected an eclectic approach to intervention rather than specific intervention techniques. The approach to patients' care included interventions to remediate impairments and to compensate for functional limitations. Therapists also reported frequently using motor control and motor learning approaches to facilitate all activities. This approach to care is largely consistent with existing stroke care guidelines and advances in the scientific theories of motor control and motor learning. [Jette DU, Latham NK, Smout RJ, et al. Physical therapy interventions for patients with stroke in inpatient rehabilitation facilities. [ABSTRACT FROM AUTHOR]

Objective To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort. Design Prospective, multicenter, longitudinal cohort study. Setting Acute TBI rehabilitation programs. Participants Patients (N=1946) receiving 138,555 therapy sessions. Interventions Not applicable. Main Outcome Measures Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS). Results The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week ( P <.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings ( P <.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort ( P <.0001). Conclusions Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies. [ABSTRACT FROM AUTHOR]

Objective To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury. Design Multisite prospective observational cohort study. Setting Inpatient rehabilitation settings. Participants Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups. Interventions Not applicable. Main Outcome Measures Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined. Results Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay. Conclusions The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups. [ABSTRACT FROM AUTHOR]

Objective To describe institutional variation in traumatic brain injury (TBI) inpatient rehabilitation program characteristics and evaluate to what extent patient factors and center effects explain how TBI inpatient rehabilitation services are delivered. Design Secondary analysis of a prospective, multicenter, cohort database. Setting TBI inpatient rehabilitation programs. Participants Patients with complicated mild, moderate, or severe TBI (N=2130). Interventions Not applicable. Main Outcome Measures Mean minutes; number of treatment activities; use of groups in occupational therapy, physical therapy, speech therapy, therapeutic recreation, and psychology inpatient rehabilitation sessions; and weekly hours of treatment. Results A wide variation was observed between the 10 TBI programs, including census size, referral flow, payer mix, number of dedicated beds, clinician experience, and patient characteristics. At the centers with the longest weekday therapy sessions, the average session durations were 41.5 to 52.2 minutes. At centers with the shortest weekday sessions, the average session durations were approximately 30 minutes. The centers with the highest mean total weekday hours of occupational, physical, and speech therapies delivered twice as much therapy as the lowest center. Ordinary least-squares regression modeling found that center effects explained substantially more variance than patient factors for duration of therapy sessions, number of activities administered per session, use of group therapy, and amount of psychological services provided. Conclusions This study provides preliminary evidence that there is significant institutional variation in rehabilitation practice and that center effects play a stronger role than patient factors in determining how TBI inpatient rehabilitation is delivered. [ABSTRACT FROM AUTHOR]

Objective To determine the association of enteral nutrition (EN) with patient preinjury and injury characteristics and outcomes for patients receiving inpatient rehabilitation after traumatic brain injury (TBI). Design Prospective observational study. Setting Nine rehabilitation centers. Participants Patients (N=1701) admitted for first full inpatient rehabilitation after TBI. Interventions Not applicable. Main Outcome Measures FIM at rehabilitation discharge, length of stay, weight loss, and various infections. Results There were many significant differences in preinjury and injury characteristics between patients who received EN and patients who did not. After matching patients with a propensity score of >40% for the likely use of EN, patients receiving EN with either a standard or a high-protein formula (>20% of calories coming from protein) for >25% of their rehabilitation stay had higher FIM motor and cognitive scores at rehabilitation discharge and less weight loss than did patients with similar characteristics not receiving EN. Conclusions For patients receiving inpatient rehabilitation after TBI and matched on a propensity score of >40% for the likely use of EN, clinicians should strongly consider, when possible, EN for ≥25% of the rehabilitation stay and especially with a formula that contains at least 20% protein rather than a standard formula. [ABSTRACT FROM AUTHOR]

Objective To describe psychotropic medication administration patterns during inpatient rehabilitation for traumatic brain injury (TBI) and their relation to patient preinjury and injury characteristics. Design Prospective observational cohort. Setting Multiple acute inpatient rehabilitation units or hospitals. Participants Individuals with TBI (N=2130; complicated mild, moderate, or severe) admitted for inpatient rehabilitation. Interventions Not applicable. Main Outcome Measures Not applicable. Results Most frequently administered were narcotic analgesics (72% of sample), followed by antidepressants (67%), anticonvulsants (47%), anxiolytics (33%), hypnotics (30%), stimulants (28%), antipsychotics (25%), antiparkinson agents (25%), and miscellaneous psychotropics (18%). The psychotropic agents studied were administered to 95% of the sample, with 8.5% receiving only 1 and 31.8% receiving ≥6. Degree of psychotropic medication administration varied widely between sites. Univariate analyses indicated younger patients were more likely to receive anxiolytics, antidepressants, antiparkinson agents, stimulants, antipsychotics, and narcotic analgesics, whereas those older were more likely to receive anticonvulsants and miscellaneous psychotropics. Men were more likely to receive antipsychotics. All medication classes were less likely administered to Asians and more likely administered to those with more severe functional impairment. Use of anticonvulsants was associated with having seizures at some point during acute care or rehabilitation stays. Narcotic analgesics were more likely for those with history of drug abuse, history of anxiety and depression (premorbid or during acute care), and severe pain during rehabilitation. Psychotropic medication administration increased rather than decreased during the course of inpatient rehabilitation in each of the medication categories except for narcotics. This observation was also true for medication administration within admission functional levels (defined by cognitive FIM scores), except for those with higher admission FIM cognitive scores. Conclusions Many psychotropic medications are used during inpatient rehabilitation. In general, lower admission FIM cognitive score groups were administered more of the medications under investigation compared with those with higher cognitive function at admission. Considerable site variation existed regarding medications administered. The current investigation provides baseline data for future studies of effectiveness. [ABSTRACT FROM AUTHOR]

Objective To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). Design Prospective, longitudinal observational study. Setting Inpatient rehabilitation centers. Participants Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury. Interventions Not applicable. Main Outcome Measures Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. Results The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained. Conclusions At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes. [ABSTRACT FROM AUTHOR]

This supplement of the Archives of Physical Medicine and Rehabilitation is devoted to the Traumatic Brain Injury–Practice Based Evidence study, the first practice-based evidence study, to our knowledge, of traumatic brain injury rehabilitation. The purpose of this preface is to place this study in the broader context of comparative effectiveness research and introduce the articles in the supplement. [ABSTRACT FROM AUTHOR]

Objective To identify predictors of the severity of agitated behavior during inpatient traumatic brain injury (TBI) rehabilitation. Design Prospective, longitudinal observational study. Setting Inpatient rehabilitation centers. Participants Consecutive patients enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, who exhibited agitation during their stay (n=555, N=2130). Interventions Not applicable. Main Outcome Measure Daytime Agitated Behavior Scale scores. Results Infection and lower FIM cognitive scores predicted more severe agitation. The medication classes associated with more severe agitation included sodium channel antagonist anticonvulsants, second-generation antipsychotics, and gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated with less severe agitation included antiasthmatics, statins, and norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants. Conclusions Further support is provided for the importance of careful serial monitoring of both agitation and cognition to provide early indicators of possible beneficial or adverse effects of pharmacologic interventions used for any purpose and for giving careful consideration to the effects of any intervention on underlying cognition when attempting to control agitation. Cognitive functioning was found to predict agitation, medications that have been found in previous studies to enhance cognition were associated with less agitation, and medications that can potentially suppress cognition were associated with more agitation. There could be factors other than the interventions that account for these relations. In addition, the study provides support for treatment of underlying disorders as a possible first step in management of agitation. Although the results of this study cannot be used to draw causal inferences, the associations that were found can be used to generate hypotheses about the most viable interventions that should be tested in future controlled trials. [ABSTRACT FROM AUTHOR]

Objectives To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population. Design Prospective, longitudinal, observational study. Setting Ten inpatient rehabilitation centers. Participants Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury. Interventions Not applicable. Main Outcome Measures Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being. Results The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations. Conclusions This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail. [ABSTRACT FROM AUTHOR]

Objective To assess the incidence of, causes for, and factors associated with readmission to an acute care hospital (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). Design Prospective observational cohort. Setting Inpatient rehabilitation. Participants Individuals with TBI admitted consecutively for inpatient rehabilitation (N=2130). Interventions Not applicable. Main Outcome Measures RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. Results A total of 183 participants (9%) experienced RTAC for a total of 210 episodes. Of 183 participants, 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. The mean time from rehabilitation admission to first RTAC was 22±22 days. The mean duration in acute care during RTAC was 7±8 days. Eighty-four participants (46%) had ≥1 RTAC episodes for medical reasons, 102 (56%) had ≥1 RTAC episodes for surgical reasons, and 6 (3%) participants had RTAC episodes for unknown reasons. Most common surgical RTAC reasons were neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurological (23%), and cardiac (12%). Any RTAC was predicted as more likely for patients with older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission. RTAC was less likely for patients with higher admission FIM motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. Conclusions Approximately 9% of patients with TBI experienced RTAC episodes during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation for RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting. [ABSTRACT FROM AUTHOR]

Objectives To describe the amount and content of group therapies provided during inpatient rehabilitation for traumatic brain injury (TBI), and to assess the relations of group therapy with patient, injury, and treatment factors and outcomes. Design Prospective observational cohort. Setting Inpatient rehabilitation. Participants Consecutive admissions (N=2130) for initial TBI rehabilitation at 10 inpatient rehabilitation facilities (9 in the United States, 1 in Canada) from October 2008 to September 2011. Interventions Not applicable. Main Outcome Measures Proportion of sessions that were group therapy (≥2 patients were treated simultaneously by ≥1 clinician); proportion of patients receiving group therapy; type of activity performed and amount of time spent in group therapy, by discipline; rehabilitation length of stay; discharge location; and FIM cognitive and motor scores at discharge. Results Of the patients, 79% received at least 1 session of group therapy, with group therapy accounting for 13.7% of all therapy sessions and 15.8% of therapy hours. On average, patients spent 2.9h/wk in group therapy. The greatest proportion of treatment time in group format was in therapeutic recreation (25.6%), followed by speech therapy (16.2%), occupational therapy (10.4%), psychology (8.1%), and physical therapy (7.9%). Group therapy time and type of treatment activities varied among admission FIM cognitive subgroups and treatment sites. Several factors appear to be predictive of receiving group therapy, with the treatment site being a major influence. However, group therapy as a whole offered little explanation of differences in the outcomes studied. Conclusions Group therapy is commonly used in TBI rehabilitation, to varying degrees among disciplines, sites, and cognitive impairment subgroups. Various therapeutic activities take place in group therapy, indicating its perceived value in addressing many domains of functioning. Variation in outcomes is not explained well by overall percentage of therapy time delivered in groups. [ABSTRACT FROM AUTHOR]

Objective To examine associations of patient and injury characteristics with outcomes at inpatient rehabilitation discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). Design Prospective, longitudinal observational study. Setting Inpatient rehabilitation centers. Participants Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, and divided into 5 subgroups based on rehabilitation admission FIM cognitive score. Interventions Not applicable. Main Outcome Measures Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. Results Severity indices increased explained variation in outcomes beyond that accounted for by patient characteristics. FIM motor scores were generally the most predictable. Higher functioning subgroups had more predictable outcomes then subgroups with lower cognitive function at admission. Age at injury, time from injury to rehabilitation admission, and functional independence at rehabilitation admission were the most consistent predictors across all outcomes and subgroups. Conclusions Findings from previous studies of the relations among patient and injury characteristics and rehabilitation outcomes were largely replicated. Discharge outcomes were most strongly associated with injury severity characteristics, whereas predictors of functional independence at 9 months postdischarge included both patient and injury characteristics. [ABSTRACT FROM AUTHOR]

Objective To assess the frequency of, causes for, and factors associated with acute rehospitalization during 9 months after discharge from inpatient rehabilitation for traumatic brain injury (TBI). Design Multicenter observational cohort. Setting Community. Participants Individuals with TBI (N=1850) admitted for inpatient rehabilitation. Interventions Not applicable. Main Outcome Measures Occurrences of proxy or self-report of postrehabilitation acute care rehospitalization, as well as length of and causes for rehospitalizations. Results A total of 510 participants (28%) had experienced 775 acute rehospitalizations. All experienced 1 admission (510 participants [66%]), whereas 154 (20%) had 2 admissions, 60 (8%) had 3, 23 (3%) had 4, 27 had between 5 and 11, and 1 had 12. The most common rehospitalization causes were infection (15%), neurological (13%), neurosurgical (11%), injury (7%), psychiatric (7%), and orthopedic (7%). The mean time from rehabilitation discharge to first rehospitalization was 113 days. The mean rehospitalization duration was 6.5 days. Logistic regression analyses revealed that older age, history of seizures before injury or during acute care or rehabilitation, history of brain injuries, and non–brain injury medical severity increased the risk of rehospitalization. Injury etiology of motor vehicle collision and high motor functioning at discharge decreased rehospitalization risk. Conclusions Approximately 28% of patients with TBI were rehospitalized within 9 months of TBI rehabilitation discharge owing to various medical and surgical reasons. Future research should evaluate whether some of these occurrences may be preventable (such as infections, injuries, and psychiatric disorders) and should evaluate the extent to which persons at risk may benefit from additional screening, surveillance, and treatment protocols. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine the association between inpatient and postdischarge rehabilitation services and function, life satisfaction, and community participation 1 year after spinal cord injury (SCI). Design: Prospective, observational. Setting: Six rehabilitation facilities. Participants: Patients with SCI (N=1376). Interventions: None. Main Outcome Measures: Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART), motor FIM (mFIM), and return to work/school at 1 year post-SCI. Results: Demographic and injury characteristics explained 49% of the variance in mFIM and 9% to 25% of the variance in SWLS and CHART social integration, mobility, and occupation scores. Inpatient rehabilitation services explained an additional 2% of the variance for mFIM and 1% to 3% of the variance for SWLS and CHART scores. More time in inpatient physical therapy (PT) was associated with higher mFIM scores; more time in inpatient therapeutic recreation (TR) and social work and more postdischarge nursing (NSG) were associated with lower mFIM scores. More inpatient PT and TR and more postdischarge PT were associated with higher mobility scores; more inpatient psychology (PSY) was associated with lower mobility scores. More postdischarge TR was associated with higher SWLS; more postdischarge PSY services was associated with lower SWLS. Inpatient TR was positively associated with social integration scores; postdischarge PSY was negatively associated with social integration scores. More postdischarge vocational counseling was associated with higher occupation scores. Differences between centers did not explain additional variability in the outcomes studied. Conclusions: Inpatient and postdischarge rehabilitation services are weakly associated with life satisfaction and societal participation 1 year after SCI. Further study of the type and intensity of postdischarge services, and the association with outcomes, is needed to ascertain the most effective use of therapy services after SCI. [Copyright &y& Elsevier]

Abstract: Objective: To compare patient and injury characteristics, rehabilitation services, and outcomes between people incurring traumatic spinal cord injury (SCI) at younger and older ages. Design: Multisite prospective observational cohort study. Setting: Six acute rehabilitation facilities. Participants: Patients (N=866) aged ≥16 years admitted to participating centers for their initial rehabilitation after SCI. Interventions: Not applicable. Main Outcome Measures: Motor FIM scores at discharge and 1 year postinjury, discharge location, and postacute clinical pathways. Results: Patients were divided into 4 age-at-injury groups: 16 to 29, 30 to 44, 45 to 60, and >60 years of age. Older adults (>60y) incurring SCI were more likely to be married, retired/unemployed, on Medicare, and to have attained more education. Their injuries mostly resulted from falls and were incomplete in nature. The oldest group had the highest severity of illness, lowest admission and discharge motor FIM scores, and longer rehabilitation stay. They received relatively less rehabilitation than younger groups. They spent proportionately more time in occupational therapy working on preparatory activities and less time on self-care activities during inpatient rehabilitation. In the aged >60 years group, 80% went home at discharge; 17.2% were discharged to a nursing home. Younger groups were less likely to go to a nursing home. Admission motor FIM was the most significant predictor of motor FIM at discharge and 1-year anniversary across age groups. But the age groups differed significantly in patient and treatment factors that explained their respective outcomes. Conclusions: Older injured individuals experienced a different clinical pathway from younger patients. The present study suggests the need for development of a rehabilitation program tailored specifically to older adults. [Copyright &y& Elsevier]