Effectiveness of supported employment for veterans with spinal cord injuries: results from a randomized multisite study

The impact of social support at home on health-related quality of life among veterans with spinal cord injury participating in a supported employment program

PURPOSE

To investigate the impact of social support at home on health-related quality of life (HRQOL) as measured by the VR-6D utility index for spinal cord injury (SCI) veterans participating in a program of supported employment (SE).

METHODS

We calculated a preference-based utility index called the VR-6D from the responses from a 36-item instrument called the VR-36. We estimated a growth curve model to examine the change in the VR-6D utility index over time adjusting for social support status, demographics, and chronic comorbidities.

RESULTS

Study participants experienced an increase in HRQOL over time. The initial level and the rate of increase in HRQOL varied by groups based on their support status. The rate of increase in HRQOL diminished over time. Participants reporting no support at home experienced lower initial HRQOL but reached the same level of those who reported having support at home by the ninth month of follow-up. Quality-adjusted life-years, as measured by the area under the curves, were approximately the same for both groups after 2 years.

CONCLUSIONS

Differences in the rate of change in HRQOL by support status have important implications for evaluations of SE programs. Participants in this program of SE experienced improvement in HRQOL beyond 12 months and extending to 2 years. Follow-up times for evaluations should extend beyond 12 months to assess complete improvements in HRQOL. Future comparison groups in comparative effectiveness evaluations of SE need to be balanced carefully on support status in addition to other factors.

Bone marrow mesenchymal stem cells with Nogo-66 receptor gene silencing for repair of spinal cord injury

We hypothesized that RNA interference to silence Nogo-66 receptor gene expression in bone marrow mesenchymal stem cells before transplantation might further improve neurological function in rats with spinal cord transection injury. After 2 weeks, the number of neurons and BrdU-positive cells in the Nogo-66 receptor gene silencing group was higher than in the bone marrow mesenchymal stem cell group, and significantly greater compared with the model group. After 4 weeks, behavioral performance was significantly enhanced in the model group. After 8 weeks, the number of horseradish peroxidase-labeled nerve fibers was higher in the Nogo-66 receptor gene silencing group than in the bone marrow mesenchymal stem cell group, and significantly higher than in the model group. The newly formed nerve fibers and myelinated nerve fibers were detectable in the central transverse plane section in the bone marrow mesenchymal stem cell group and in the Nogo-66 receptor gene silencing group.

Effect of supported employment on vocational rehabilitation outcomes of transition-age youth with intellectual and developmental disabilities: a case control study

The purpose of this study was to examine the effect of supported employment intervention on the employment outcomes of transition-age youth with intellectual and developmental disabilities served by the public vocational rehabilitation system using a case-control study design. Data for this study were extracted from the Rehabilitation Services Administration Case Service Report (RSA-911) database for fiscal year 2009. The sample included 23,298 youth with intellectual and developmental disabilities aged between 16 and 25 years old at the time of application. The classification and regression tree (CART) method was used to estimate propensity scores and to adjust for selection bias on the basis of all prominent covariates relevant to the dependent variable (i.e., competitive employment). Results yielded six homogeneous subgroups, and receipt of supported employment was found to increase the employment rates across all of the groups. The effect of supported employment was especially strong for youth who were Social Security beneficiaries, special education students, and individuals with intellectual disabilities or autism who were high school graduates. These findings suggest that supported employment is an effective service for enhancing the vocational rehabilitation outcomes of young adults and provides valuable information for policy makers, health care providers, rehabilitation counselors, and educators.

Supported employment for persons with serious mental illness: current status and future directions

The individual placement and supported (IPS) model of supported employment is the most empirically validated model of vocational rehabilitation for persons with schizophrenia or another serious mental illness. Over 18 randomized controlled trials have been conducted throughout the world demonstrating the effectiveness of supported employment at improving competitive work compared to other vocational programs: IPS supported employment is defined by the following principles: 1) inclusion of all clients who want to work; 2) integration of vocational and clinical services; 3) focus on competitive employment; 4) rapid job search and no required prevocational skills training; 5) job development by the employment specialist; 6) attention to client preferences about desired work and disclosure of mental illness to prospective employers; 7) benefits counseling; and 8) follow-along supports after a job is obtained. Supported employment has been successfully implemented in a wide range of cultural and clinical populations, although challenges to implementation are also encountered. Common challenges are related to problems such as the failure to access technical assistance, system issues, negative beliefs and attitudes of providers, funding restrictions, and poor leadership. These challenges can be overcome by tapping expertise in IPS supported employment, including standardized and tested models of training and consultation. Efforts are underway to increase the efficiency of training methods for supported employment and the overall program, and to improve its effectiveness for those clients who do not benefit. Progress in IPS supported employment offers people with a serious mental illness realistic hope for achieving their work goals, and taking greater control over their lives.

Ethnography, fidelity, and the evidence that anthropology adds: supplementing the fidelity process in a clinical trial of supported employment

This discussion considers the role and findings of ethnographic research within a clinical trial of supported employment for veterans with spinal cord injury. Contributing to qualitative evaluation research and to debates over anthropological evidence vis-à-vis clinical trials, we demonstrate how enactors of a randomized controlled trial can simultaneously attend to both the trial's evidentiary and procedural requirements and to the lived experiences and needs of patients and clinicians. Three major findings are described: (1) contextual information essential to fidelity efforts within the trial; (2) the role of human interrelationships and idiosyncratic networks in the trial's success; and (3) a mapping of the power and authority structures relevant to the staff's ability to perform the protocol. We emphasize strengths of anthropological ethnography in clinical trials that include the provision of complementary, qualitative data, the capture of otherwise unmeasured parts of the trial, and the realization of important information for the translation of the clinical findings into new settings.

Cost-effectiveness of supported employment for veterans with spinal cord injuries

OBJECTIVE

To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs).

DESIGN

Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI.

SETTING

SCI centers in the Veterans Health Administration.

PARTICIPANTS

Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76).

INTERVENTION

A vocational rehabilitation program of SE for veterans with SCI.

MAIN OUTCOME MEASURES

Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities.

RESULTS

Average cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care.

CONCLUSIONS

An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI.

A prospective examination of the impact of a supported employment program and employment on health-related quality of life, handicap, and disability among Veterans with SCI

PURPOSES

To investigate impact of participation in a supported employment program and impact of employment itself on health-related quality of life (HRQOL), disability, and handicap among Veterans with spinal cord injury (SCI).

METHODS

We used a prospective, randomized, controlled, multi-site trial of supported employment (SE) versus treatment as usual (TAU) for vocational issues. Subjects were 157 Veterans with SCI who received either SE or TAU for vocational issues. Outcomes were examined in terms of type of vocational treatment received and whether competitive employment was obtained. Outcomes investigated were HRQOL as measured by the Veterans RAND 36-item health survey (VR-36), handicap as measured by the Craig Handicap Assessment and Reporting Technique (CHART), and disability as measured by the functional independence measure (FIM). Subjects were assessed at baseline and at 3, 6, 9, and 12 months.

RESULTS

There were no significant differences between Veterans who participated in SE compared to those who received TAU in study measures. Participants obtaining competitive employment demonstrated significantly higher scores on the Social Integration, Mobility, and Occupation dimensions of the CHART. There were no observed differences in VR-36 scores or FIM scores for those obtaining competitive employment.

CONCLUSION(S)

This study suggests that employment has a positive effect on an individual's ability to participate in social relationships, move about their home and community, and spend time in productive and usual roles. Inability to detect differences across other domains of handicap or any changes in HRQOL may have been due to several factors including level and intensity of employment, insufficient follow-up period, or measurement limitations.