Service utilization following traumatic brain injury

Quantifying the amount of physical rehabilitation received by individuals living with neurological conditions in the community: a scoping review

Background

Physical rehabilitation is often prescribed immediately following a neurological event or a neurological diagnosis. However, many individuals require physical rehabilitation after hospital discharge. The purpose of this scoping review was to determine the amount of physical rehabilitation that individuals living in the community with neurological conditions receive to understand current global practices and assess gaps in research and service use.

Methods

This scoping review included observational studies that 1) involved adults living with a neurological condition, and 2) quantified the amount of rehabilitation being received in the community or outpatient hospital setting. Only literature published in English was considered. MEDLINE, EMBASE, AMED, CINAHL, Cochrane Library, and PEDro databases were searched from inception. Two independent reviewers screened titles and abstracts, followed by full texts, and data extraction. Mean annual hours of rehabilitation was estimated based on the amount of rehabilitation reported in the included studies.

Results

Overall, 18 studies were included after screen 14,698 articles. The estimated mean annual hours of rehabilitation varied greatly (4.9 to 155.1 h), with individuals with spinal cord injury and stroke receiving the greatest number of hours. Participants typically received more physical therapy than occupational therapy (difference range: 1 to 22 h/year). Lastly, only one study included individuals with progressive neurological conditions, highlighting a research gap.

Discussion

The amount of rehabilitation received by individuals with neurological conditions living in the community varies greatly. With such a wide range of time spent in rehabilitation, it is likely that the amount of rehabilitation being received by most individuals in the community is insufficient to improve function and quality of life. Future work should identify the barriers to accessing rehabilitation resources in the community and how much rehabilitation is needed to observe functional improvements.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07754-4.

Healthcare Utilization Following Traumatic Brain Injury in a Large National Sample

OBJECTIVE

To evaluate the impact of traumatic brain injury (TBI) on healthcare utilization (HCU) over a 1-year period in a large national sample of individuals diagnosed with TBI across multiple care settings.

SETTING

Commercial insurance enrollees.

PARTICIPANTS

Individuals with and without TBI, 2008-2014.

DESIGN

Retrospective cohort.

MAIN MEASURES

We compared the change in the 12-month sum of inpatient, outpatient, emergency department (ED), and prescription HCU from pre-TBI to post-TBI to the same change among a non-TBI control group. Most rehabilitation visits were not included. We stratified models by age ≥65 and included the month of TBI in subanalysis.

RESULTS

There were 207 354 individuals in the TBI cohort and 414 708 individuals in the non-TBI cohort. Excluding the month of TBI diagnosis, TBI resulted in a slight increase in outpatient visits (rate ratio [RtR] = 1.05; 95% confidence interval [CI], 1.04-1.06) but decrease in inpatient HCU (RtR = 0.86; 95% CI, 0.84-0.88). Including the month of TBI in the models resulted in increased inpatient (RtR = 1.55; 95% CI, 1.52-1.58) and ED HCU (RtR = 1.37; 95% CI, 1.34-1.40).

CONCLUSION

In this population of individuals who maintained insurance coverage following TBI, results suggest that TBI may have a limited impact on nonrehabilitation HCU at the population level.

Care coordination experiences of people with traumatic brain injury and their family members in the 4-years after injury: a qualitative analysis

TITLE

Care coordination experiences of people with traumatic brain injury and their family members 4-years after injury: A qualitative analysis.

AIM

To explore experiences of care coordination in the first 4-years after severe traumatic brain injury (TBI).

METHODS

A qualitative study nested within a population-based longitudinal cohort study. Eighteen semi-structured telephone interviews were conducted 48-months post-injury with six adults living with severe TBI and the family members of 12 other adults living with severe TBI. Participants were identified through purposive sampling from the Victorian State Trauma Registry. A thematic analysis was undertaken.

RESULTS

No person with TBI or their family member reported a case manager or care coordinator were involved in assisting with all aspects of their care. Many people with severe TBI experienced ineffective care coordination resulting in difficulty accessing services, variable quality in the timing, efficiency and appropriateness of services, an absence of regular progress evaluations and collaboratively formulated long-term plans. Some family members attempted to fill gaps in care, often without success. In contrast, effective care coordination was reported by one family member who advocated for services, closely monitored their relative, and effectively facilitated communication between services providers.

CONCLUSION

Given the high cost, complexity and long-term nature of TBI recovery, more effective care coordination is required to consistently meet the needs of people with severe TBI.

Comorbidity and outcomes in traumatic brain injury: protocol for a systematic review on functional status and risk of death

INTRODUCTION

Reports on the association between comorbidity and functional status and risk of death in patients with traumatic brain injury (TBI) have been inconsistent; it is currently unknown which additional clinical entities (comorbidities) have an adverse influence on the evolution of outcomes across the lifespan of men and women with TBI. The current protocol outlines a strategy for a systematic review of the current evidence examining the impact of comorbidity on functional status and early-term and late-term mortality, taking into account known risk factors of these adverse outcomes (ie, demographic (age and sex) and injury-related characteristics).

METHODS AND ANALYSIS

A comprehensive search strategy for TBI prognosis, functional (cognitive and physical) status and mortality studies has been developed in collaboration with a medical information specialist of the large rehabilitation teaching hospital. All peer-reviewed English language studies with longitudinal design in adults with TBI of any severity, published from May 1997 to April 2017, found through Medline, Central, Embase, Scopus, PsycINFO and bibliographies of identified articles, will be considered eligible. Study quality will be assessed using published guidelines.

ETHICS AND DISSEMINATION

The authors will publish findings from this review in a peer-reviewed scientific journal(s) and present the results at national and international conferences. This work aims to understand how comorbidity may contribute to adverse outcomes in TBI, to inform risk stratification of patients and guide the management of brain injury acutely and at the chronic stages postinjury on a population level.

PROSPERO REGISTRATION NUMBER

CRD42017070033.

Three Year Trends in Veterans Health Administration Utilization and Costs after Traumatic Brain Injury Screening among Veterans with Mild Traumatic Brain Injury

Examination of trends in Veterans Health Administration (VHA) healthcare utilization and costs among veterans with mild traumatic brain injury (mTBI) is needed to inform policy, resource allocation, and treatment planning. The objective of this study was to assess the patterns of VHA healthcare utilization and costs in the 3 years following TBI screening among veterans with mTBI, compared with veterans without TBI. A retrospective cohort study of veterans who underwent TBI screening in fiscal year 2010 was conducted. We used VHA healthcare utilization and associated costs by categories of care to compare veterans diagnosed with mTBI (n = 7318) with those who screened negative (n = 75,294) and those who screened positive but had TBI ruled out (n = 3324). Utilization and costs were greatest in year 1, dropped in year 2, and then leveled off. mTBI diagnosis was associated with high rates of utilization. Each year, healthcare costs for those with mTBI were two to three times higher than for those who screened negative, and 20-25% higher than for those who screened positive but had TBI ruled out. A significant proportion of healthcare use and costs for veterans with mTBI were associated with mental health service utilization. The relatively high rate of VHA utilization and costs associated with mTBI over time demonstrates the importance of long-term planning to meet these veterans' needs. Identifying and engaging patients with mTBI in effective mental health treatments should be considered a critical component of treatment planning.

Identification of hidden health utilization services and costs in adults awaiting tertiary care following mild traumatic brain injury in Toronto, Ontario, Canada

Aim:

The cognitive, emotional, behavioral and physical impairments experienced by adults after mild traumatic brain injury (mTBI) can produce substantial disability, with 15–20% requiring referral to tertiary care (TC) for persistent symptoms.

Methods:

A convenience sample of 201 adult patients referred to TC as a result of mTBI was studied. Self-reported data were collected at first TC visit, on average 10 months postinjury. Patients reported the type and intensity of healthcare provider visit(s) undertaken while awaiting TC.

Results:

On average males reported 37 and females 30 healthcare provider visits, resulting in over $500,000 Canadian dollars spent on potentially excess mTBI care over 1 year.

Discussion:

Based on conservative estimate of 15% of mTBI patients receiving TC, this finding identifies a possible excess in care of $110 million for Ontario. Accurate diagnosis of mTBI and early coordination of follow-up care for those needing TC could increase cost–effectiveness.

Predicting use of case management support services for adolescents and adults living in community following brain injury: A longitudinal Canadian database study with implications for life care planning

OBJECTIVE: To determine factors associated with case management (CM) service use in people with traumatic brain injury (TBI), using a published model for service use.

DESIGN: A retrospective cohort, with nested case-control design. Correlational and logistic regression analyses of questionnaires from a longitudinal community data base.

STUDY SAMPLE: Questionnaires of 203 users of CM services and 273 non-users, complete for all outcome and predictor variables. Individuals with TBI, 15 years of age and older. Out of a dataset of 1,960 questionnaires, 476 met the inclusion criteria.

METHODOLOGY: Eight predictor variables and one outcome variable (use or non-use of the service). Predictor variables considered the framework of the Behaviour Model of Health Service Use (BMHSU); specifically, pre-disposing, need and enabling factor groups as these relate to health service use and access.

RESULTS: Analyses revealed significant differences between users and non-users of CM services. In particular, users were significantly younger than non-users as the older the person the less likely to use the service. Also, users had less education and more severe activity limitations and lower community integration. Persons living alone are less likely to use case management. Funding groups also significantly impact users.

CONCLUSIONS: This study advances an empirical understanding of equity of access to health services usage in the practice of CM for persons living with TBI as a fairly new area of research, and considers direct relevance to Life Care Planning (LCP). Many life care planers are CM and the genesis of LCP is CM. The findings relate to health service use and access, rather than health outcomes. These findings may assist with development of a modified model for prediction of use to advance future cost of care predictions.

Combat-related Mild Traumatic Brain Injury: Association between Baseline Diffusion-Tensor Imaging Findings and Long-term Outcomes

Purpose To determine whether functional outcomes of veterans who sustained combat-related mild traumatic brain injury (TBI) are associated with scalar metrics derived from diffusion-tensor (DT) imaging at their initial postdeployment evaluation. Materials and Methods This HIPAA-compliant retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. From 2010 to 2013, initial postdeployment evaluation, including clinical assessment and brain magnetic resonance (MR) examination with DT imaging, was performed in combat veterans who sustained mild TBI while deployed. Outcomes from chart review encompassed initial postdeployment clinical assessment as well as later functional status, including evaluation of occupational status and health care utilization. Scalar diffusion metrics from the initial postdeployment evaluation were compared with outcomes by using multivariate analysis. Veterans who did and did not return to work were also compared for differences in clinical variables by using t and χ(2) tests. Results Postdeployment evaluation was performed a mean of 3.8 years after injury (range, 0.5-9 years; standard deviation, 2.5 years). After a mean follow-up of 1.4 years (range, 0.5-2.5 years; standard deviation, 0.8 year), 34 of 57 veterans (60%) had returned to work. Return to work was associated with diffusion metrics in multiple regions of white matter, particularly in the left internal capsule and the left frontal lobe (P = .02-.05). Overall, veterans had a mean of 46 health care visits per year during the follow-up period (range, 3-196 visits per year; standard deviation, 41 visits per year). Cumulative health care visits over time were inversely correlated with diffusion anisotropy of the splenium of the corpus callosum and adjacent parietal white matter (P < .05). Clinical measures obtained during initial postdeployment evaluation were not predictive of later functional status (P = .12-.8). Conclusion Differences in white matter microstructure may partially account for the variance in functional outcomes among veterans who sustained combat-related mild TBI. (©) RSNA, 2016.

Rehabilitation Utilization following a Work-Related Traumatic Brain Injury: A Sex-Based Examination of Workers' Compensation Claims in Victoria, Australia

Objectives

To report on and examine differences in the use of four types of rehabilitation services (occupational therapy, physiotherapy, psychology, and speech therapy) by men and women following a work-related traumatic brain injury in Victoria, Australia; and to examine the importance of demographic, need, work-related and geographic factors in explaining these differences.

Methods

A retrospective cohort design was used to analyze 1786 work-related traumatic brain injury workers’ compensation claims lodged between 2004 and 2012 in Victoria, Australia. ZINB regressions were conducted for each type of rehabilitation service to examine the relationship between sex and rehabilitation use. Covariates included demographic, need-related, work-related, and geographic factors.

Results

Out of all claims (63% male, 37% female), 13% used occupational therapy, 23% used physiotherapy, 9% used psychology, and 2% used speech therapy at least once during the first year of service utilization. After controlling for demographic, need-related, work-related, and geographic factors, women were more likely to use physiotherapy compared to men. Men and women were equally likely to use occupational therapy and psychology services. The number of visits in the first year for each type of service did not differ between male and female users.

Conclusions

Our findings support a sex-based approach to studying rehabilitation utilization in work-related populations. Future research is needed to examine other factors associated with rehabilitation utilization and to determine the implications of different rehabilitation utilization patterns on health and return-to-work outcomes.

Utilization and Cost of Health Services in Individuals With Traumatic Brain Injury

Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in the conflicts in Iraq and Afghanistan. TBI is a major burden for both the military and civilian population in the US and worldwide. It is a leading cause of death and disability in the US and a major health services resource burden. We seek to answer two questions. What is the evidence regarding the association of TBI with health services utilization and costs in the US and worldwide? What is the evidence regarding racial/ethnic, gender, geographic, socio-economic and other disparities in health services utilization and cost in the US and worldwide? To attain this goal we searched several databases using key words to perform a systematic review of the literature since 2000. We found 36 articles to be eligible for inclusion in the review. The evidence demonstrates a wide variation in health services utilization and costs depending on population of study and severity of TBI. The evidence also supports the existence of racial/ethnic, gender, insurance, geographic disparities in the US as well as other unique disparities worldwide.

Service utilisation in a public post-acute rehabilitation unit following traumatic brain injury

Traumatic brain injury (TBI) causes disability in a proportion of survivors across the spectrum of injury severity. Previous research suggests physical changes are the primary focus of rehabilitation, although cognitive, emotional and behavioural difficulties cause greater concern in the long-term. There is little information about services accessed by those with mild injuries, who often have no physical disabilities. This study investigated factors determining service utilisation in a population-based sample which included 52% mild injuries (PTA ≤ 24 hours). Chi-squares and t-tests were used to examine the impact of demographic, clinical, psychological and physical variables on referral of 175 TBI patients to clinical disciplines in a public, community-based rehabilitation facility in Hobart, Tasmania. Increased service intensity (total disciplines referred to), was associated with greater injury severity (p = .006) and previous TBI (p = .041). Less traditional rehabilitation services (nursing, psychology) received more referrals than traditional disciplines (physiotherapy, occupational therapy, social work). Referral to physiotherapy and occupational therapy was associated with greater injury severity, functional dependence, hospitalisation and older age. Referral to nursing, psychology and social work was associated with more post-concussion symptoms, younger age, anxiety, depression and assault-related injury. The large number of referrals to psychology strengthens the case for including it as a core rehabilitation discipline.

Self-perceived health care needs and delivery of health care services 5 years after moderate-to-severe traumatic brain injury

OBJECTIVE

To describe the self-perceived health care needs of patients with moderate-to-severe traumatic brain injury (TBI) and to assess the impact of the functional level at 1 year after injury on patients' unmet needs at the 5-year follow-up.

DESIGN

A prospective follow-up study.

SETTING

Clinical research.

PARTICIPANTS

A total of 93 patients participated in the 5-year follow-up.

METHODS

We registered demographic and injury-related data at the time of admission and the scores for the Disability Rating Scale, Glasgow Outcome Scale-Extended, and Short Form 36 subscales for physical functioning and mental health at 1 and 5 years. The patients' self-perceived health care needs and use of health care services at 5 years were the main outcome measurements.

RESULTS

At the 5-year follow-up, 70% of patients reported at least 1 perceived need. The self-perceived health care needs were met for 39% of the patients. The patients with unmet needs (n = 29 [31%]) reported frequent needs in emotional (65%), vocational (62%), and cognitive (58%) domains. These patients were significantly more likely to present a less severe disability on the Disability Rating Scale at the 1-year follow-up (odds ratio [OR] 0.11 [95% confidence interval {CI}, 0.02-0.7]; P = .02). Worse mental health at the 1-year follow-up and a younger age (16-29 years) largely predicted unmet needs at the 5-year follow-up (OR 3.28 [95% CI, 1.1-10.04], P = .04; and OR 4.93 [95% CI, 0.16-15.2], P = .005, respectively).

CONCLUSION

Gaps between self-perceived health care needs and health care services received at the 5-year follow-up were found. An important message to clinicians who provide health care services in the late TBI phase is that they should be aware of patients' long-term needs regarding cognitive and emotional difficulties. Of equal importance is an emphasis on long-term vocational rehabilitation services. To ensure the appropriateness of health care service delivery, health care services after TBI should be better targeted at less-severe TBI population as well.

Challenging Behaviours, Co-morbidities, Service Utilisation and Service Access among Community-dwelling Adults with Severe Traumatic Brain Injury: A Multicentre Study

Objective: To examine patterns, predictors and unmet needs of service utilisation and access to mental health and/or drug and alcohol services among community-dwelling adults with severe traumatic brain injury, and compare those who displayed challenging behaviours with those not displaying challenging behaviour.

Design: Retrospective multicentre study.

Subjects: All active clients (n= 507) of the New South Wales (NSW) Brain Injury Rehabilitation Program (BIRP) community rehabilitation teams.

Methods: Clinician-rated data were collected on client challenging behaviours, mental health and functional status, service utilisation and unmet needs. Between-groups analyses (challenging behaviour versus no challenging behaviours) were conducted to examine patterns of service utilisation and unmet needs. Predictors for service utilisation were tested by multiple linear regression.

Results: Challenging behaviours were associated with higher use of BIRP and non-BIRP services and greater levels of unmet needs. Challenging behaviour was an independent predictor of higher levels of service utilisation, in conjunction with pre- and post-injury mental health and drug and alcohol co-morbidities and geographic location. Only 15.3% of the 111 clients with challenging behaviours and co-morbid drug and alcohol problems accessed a drug and alcohol service, while another 32.4% had unmet needs for such services.

Conclusion: Challenging behaviours make an independent contribution to increased levels of service utilisation after severe traumatic brain injury.

Direct cost associated with acquired brain injury in Ontario

BACKGROUND

Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada.

METHODS

A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer's perspective.

RESULTS

Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65% of the total treatment cost in the first year overwhelming all other cost components.

CONCLUSIONS

The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.

Utilization and costs of health care after geriatric traumatic brain injury

Despite the growing number of older adults experiencing traumatic brain injury (TBI), little information exists regarding their utilization and cost of health care services. Identifying patterns in the type of care received and determining their costs is an important first step toward understanding the return on investment and potential areas for improvement. We performed a health care utilization and cost analysis using the National Study on the Costs and Outcomes of Trauma (NSCOT) dataset. Subjects were persons 55-84 years of age with TBI treated in 69 U.S. hospitals located in 14 states (n=414, weighted n=1038). Health outcomes, health care utilization, and 1-year costs of care following TBI in 2005 U.S. dollars were estimated from hospital bills, patient surveys, medical records, and Medicare claims data. The subjects were further analyzed in three subgroups (55-64, 65-74, and 75-84 years of age). Unadjusted cost models were built, followed by a second set of models adjusting for demographic and pre-injury health status. Those in the oldest category (75-84 years) had significantly higher numbers of re-hospitalizations, home health care visits, and hours per week of unpaid care, and significantly lower numbers of physician and mental health professional visits than younger age groups (age 55-64 and 65-74 years). Significant age-related differences were seen in all health outcomes tested at 12 months post-injury except for incidence of depressive symptoms. One-year total treatment costs did not differ significantly across age categories for brain-injured older adults in either the unadjusted or adjusted models. The unadjusted total mean 1-year cost of care was $77,872 in persons aged 55-64 years, $76,903 in persons aged 65-74 years, and $72,733 in persons aged 75-84 years. There were significant differences in cost drivers among the age groups. In the unadjusted model index hospitalization costs and inpatient rehabilitation costs were significantly lower in the oldest age category, while outpatient care costs and nursing home stays were lower in the younger age categories. In the adjusted model, in addition to these cost drivers, re-hospitalization costs were significantly higher among those 75-84 years of age, and receipt of informal care from friends and family was significantly different, being lowest among those aged 65-74 years, and highest among those aged 75-84 years. Identifying variations in care that these patients are receiving and determining the costs versus benefits is an important next step in understanding potential areas for improvement.

Self-care after traumatic injury and the use of the therapeutic self care scale in trauma populations

AIMS

To report a correlational study of the relationship between gender, age, severity of injury, length of hospital stay and self-care behaviour in patients with traumatic injuries.

BACKGROUND

This study may provide a foundation for targeted nursing intervention and education programmes to help patients better recover from their injury, which is a fundamental aspect of nursing.

DESIGN

A longitudinal cohort study.

METHOD

This study of patients hospitalized for traumatic injury was conducted from May 2006-November 2007. The Therapeutic Self Care Scale along with demographic and clinical data, were completed at 3 and 6 months after hospital discharge. Using data from the 3-month survey, the validity and reliability of the scale was calculated. Multiple regression was used to identify predictors of self-care at 3 and 6 months.

FINDING

Participants (n = 125) completed the questionnaire at 3 months and 103 participants completed it at 6 months. Self-care was high on both occasions and high self-care at 3 months was related to high self-care at 6 months. Older participants reported higher self-care at 3 months compared with younger patients. Factor analysis of the scale revealed three clear components; taking medication, recognition and managing symptoms and managing changes in health conditions, which explained a total of 59·8% of the variance. The 10-item revised scale was reliable.

CONCLUSION

The findings indicate that self-care remains fairly high and stable in the first 6 months after trauma. The revised Therapeutic Self Care Scale was valid and reliable in the trauma population.

The Clinical Practice of a Community Rehabilitation Team for People with Acquired Brain Injury

The aim of this study was to examine the clinical practice of a community team that is one component of the statewide, government-funded, specialist Brain Injury Rehabilitation Program for New South Wales, Australia. The 467 clients served by the community team of the Brain Injury Rehabilitation Service at Liverpool Hospital, Sydney during the calendar year 2000 were identified and their use of clinical services described. A random sample of 50 clients from this group was studied in further detail, with specific reference to the type of therapy interventions they received. This was compared with the therapy interventions received 2 years later, in 2002. A total of 8046 occasions of service (OoS) were recorded for the 467 clients during 2000, with a median number of 8 OoS per client. All disciplines contributed to this number, with case managers providing the largest number of OoS (n = 2734). Between 65–75% of clients attended medical clinics and received services from case managers, with between 15–30% of clients receiving services from allied health disciplines. The random sample received a median of 9 OoS during 2000, and a median of 3 therapy interventions per client. Therapy interventions pertaining to living skills were addressed in 66% of the group, interpersonal relationships in 54%, and occupational activity in 44%. Although the community team continued to provide a comparable number of OoS in 2000 and 2002, 56% of the random sample had been discharged by 2002. There were significant group differences between those who were discharged and those who remained in the service. Additionally, for those who remained in the service, there was a significant reduction of OoS and therapy interventions between 2000 and 2002. The data were used to draw together a model of clinical practice of the community team.

Supporting the Needs of Young Adults With Acquired Brain Injury During Transition From Hospital to Home: The Queensland Service Provider Perspective

Objective: To explore the availability and perceived adequacy of service support for younger people with ABI and their families in Queensland during the transition phase from the perspective of service providers. Research Design: A qualitative research design utilising survey-based open-ended questioning. Methods and Procedures: Participants were service provider organisations in Queensland for younger people with aquired brain injury (ABI). A two-part survey was developed for the purpose of the study. The first part of the survey obtained general information regarding client base and service characteristics for each organisation, while the second part was designed to identify gaps in, and barriers and facilitators to service provision. Snowballing recruitment was used with the initial seed point an existing Brain Injury Network. Results: A response rate of 20% was obtained with a total of 12 surveys returned representing seven service providers. Services currently available included rehabilitation, consultancy, education and training, and practical and emotional supports. Existing gaps in, and barriers to service provision were clustered under three key themes: service infrastructure, transition support, and transition context. Some of the facilitators to service provision identified included interagency linkages and financial compensation for injury. Conclusions: Gaps in, and barriers to service provision during the transition phase were identified that could be utilised to develop models of service delivery to improve short- and long-term outcomes for younger people with ABI.

Acceptance rates in state-federal vocational rehabilitation of clients with brain injury: Is racial disparity an issue?

PRIMARY OBJECTIVE

To utilize Aday and Andersen's Framework for the Study of Access to examine racial disparity within the State-Federal vocational rehabilitation system, among clients with brain injury. Research questions included: Do pre-disposing characteristics such as age, race, ethnicity, gender, marital status and education influence vocational rehabilitation acceptance rates in the US? Do enabling characteristics such as referral source, insurance coverage and primary source of support at application influence vocational rehabilitation acceptance rates in the US? Is there a difference, based on race, in the reason for case closure for vocational rehabilitation services?

METHODS AND PROCEDURES

Exhaustive CHAID analysis was conducted with acceptance for rehabilitation as the criterion variable and pre-disposing characteristics as predictor variables. Chi-square analysis was calculated with regard to reason for closure.

MAIN OUTCOMES AND RESULTS

Descriptive findings are presented. Of the pre-disposing factors, the most significant predictor of acceptance rate was education level. Pearson Chi-square analyses revealed significant differences between White and non-White clients with brain injury with regard to reason for closure.

CONCLUSIONS

The data indicate that racial differences were only a small part of the overall equation and again that distinct disparity by race is not evidenced in the RSA-911 data for persons with a primary or secondary diagnosis of brain injury.

Validity and responsiveness of the care and needs scale for assessing support needs after traumatic brain injury

OBJECTIVE

To investigate the validity and responsiveness of the Care and Needs Scale (CANS), which was designed to assess support needs of people with traumatic brain injury (TBI).

DESIGN

Two samples of community clients (n=38, n=30) were recruited to examine concurrent, convergent/divergent, and discriminant validity. The ability of the CANS to detect change over a 6-month period from the time of inpatient rehabilitation discharge (predictive validity and responsiveness) was investigated in a third sample of 40 rehabilitation inpatients.

SETTING

Two Brain Injury Rehabilitation Units in Sydney, Australia.

PARTICIPANTS

People (N=108) aged between 16 and 70 years admitted for rehabilitation after TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The CANS, Supervision Rating Scale, FIM, Sydney Psychosocial Reintegration Scale, and Disability Rating Scale.

RESULTS

Evidence for concurrent validity was shown with fair to moderate correlation coefficients between the CANS and measures of supervision, functional independence, and psychosocial functioning (absolute value, r(s)=.43-.68; P<.01). Support for convergent and divergent validity was provided by correlation coefficients that were higher for measures tapping similar constructs (absolute value, r(s)=46; P<.01) but lower for measures of dissimilar constructs (absolute value, r(s)=.07-.26; not significant). In addition, the CANS discriminated between levels of injury severity, functional independence, and overall functioning (P<.01). In terms of predictive validity and responsiveness, CANS scores at inpatient rehabilitation discharge predicted the participant's functioning 6 months later.

CONCLUSIONS

These results show the CANS is a valid and responsive tool and, together with its previously shown reliability, is suitable for routine application in clinical and research practice.

Experiences of care reported by adults with traumatic brain injury

This paper investigates the continuum of care experienced by adults and their significant others following a moderate to severe traumatic brain injury (TBI) in Victoria, Australia. Clinical care guidelines exist defining best practice in TBI rehabilitation, but little is currently known about the experiences of those who sustain a TBI, their needs and the barriers they encounter when attempting to access services. This paper presents the journeys of 202 Victorians admitted for acute care following a moderate to severe TBI over 4 years. Results of this study indicate very few participants report receiving services in line with recommendations made in clinical care guidelines. In addition reported access to services was noted to vary according to allocated healthcare funding (i.e., compensable vs. private vs. public). Clinicians' consideration of healthcare consumers' experiences are essential if services provided are to match consumers' needs.

Assessing support needs for people with traumatic brain injury: the care and needs scale (CANS)

BACKGROUND

After traumatic brain injury (TBI), many individuals have support needs, but the variety, frequency and intensity of such needs vary widely. Currently available scales do not assess all facets of required supports and the eight-category Care and Needs Scale (CANS) was developed in order to capture the range of support needs. The aim of the present study was to examine the sensitivity and validity of the CANS.

METHOD

Using a sample of 67 people who sustained severe TBI 20-26 years previously, the CANS was compared with the Supervision Rating Scale (SRS), five scales from the Craig Handicap Assessment and Reporting Technique (CHART) and the Sydney Psychosocial Reintegration Scale (SPRS).

RESULTS

The data showed a spread across all CANS categories: 28.4% of participants were fully independent, 46.3% had support needs on less than a daily basis (25.4% intermittently, 13.4% at least weekly and 7.5% every few days) and the remaining 25.4% had needs on a daily basis (ranging from 11.9% for up to 11 hours per day to 4.5% for 24 hours per day). By contrast, the 13-category SRS classified 61.2% in the best category and five categories did not contain any individuals. The CANS showed strong correlation with the SRS (r(s) = 0.75), as well as CHART and SPRS scores (range r(s) = -0.46 to -0.85) and statistically significant differences were found among participant sub-groups. Logistic regression analyses, using variables collected at the time of discharge from rehabilitation, were able to predict independence on the CANS with classification accuracy of 77% and presence of neuropsychological disability was an individual predictor.

CONCLUSION

These results suggest that the CANS shows promise as a sensitive and valid instrument to measure care and support needs after TBI, particularly in the longer term, and further examination of its psychometric properties is warranted.

Adults with acquired traumatic brain injury: experiences of a changeover process and consequences in everyday life

The purpose of this study is to illuminate the changeover process, support, and consequences experienced by adults who acquired traumatic brain injury (TBI). Fifteen persons were in-depth interviewed using a semi-structured interview guide. Data were analyzed by latent-content analysis and structured into six themes. Consequences were negative as well as positive. Significant others were important as a driving force for training and life-situation. The informants were initially satisfied with social supports but in the longer term became more critical regarding accessibility to such supports. The majority had difficulties in returning to working life after injury. The outcomes seemed to be a prolonged process, probably never-ending, which gradually became integrated as a part of life.

Development and validation of the Paediatric Care and Needs Scale (PCANS) for assessing support needs of children and youth with acquired brain injury

AIM

The Paediatric Care and Needs Scale (PCANS) is a newly developed scale that assesses support needs following childhood acquired brain injury (ABI). It yields three measures of support: overall, extent and intensity. The developmental process of the PCANS is described and concurrent and construct validity examined.

METHOD

In the validation study, 32 parents/caregivers of children with ABI aged 5-18 years completed the PCANS and other validating measures: Vineland Adaptive Behavior Scales (VABS), Functional Independence Measure for Children (Wee-FIM) and King's Outcome Scale of Childhood Head Injury (KOSCHI). VABS and Wee-FIM sub-scales examining similar and dissimilar domains to the PCANS were used to investigate convergent and divergent validity, respectively. Discriminant validity analysis used sub-groups dichotomized by VABS and KOSCHI data.

RESULTS

Statistically significant correlation coefficients of moderate-to-strong magnitude were found between the PCANS support intensity score and most of the VABS, Wee-FIM and KOSCHI variables (r(s) = -0.46 to r(s) = -0.77, p < 0.01). Some evidence for convergent and divergent validity was also found. Correlation coefficients between similar domains of the PCANS and other scales were moderately high (e.g. VABS socialization vs PCANS psychosocial items, r(s) = -0.64, p < 0.01). Conversely, correlation coefficients between dissimilar domains were low (e.g. Wee-FIM self-care vs PCANS psychosocial items, r(s) = -0.29). In terms of discriminant group differences, PCANS support extent and intensity scores were able to distinguish between sub-groups dichotomized by VABS and KOSCHI scores.

CONCLUSIONS

These findings provide preliminary evidence for the validity of the PCANS for assessing support needs after paediatric ABI.

A comparison of challenges faced by parents of children with ABI with and without access to third party funding

BACKGROUND

In Canada, allocation of rehabilitation services is often based on the assumption that families who have third party insurance funding are well served by the private sector system and are not in need of publicly funded rehabilitation services. However, there has been little research comparing the experiences of caregivers with and without access to third party insurance funding; data that could inform service planning and provision.

METHOD

The current study compared the stresses, resources and psychological health of caregivers of children with Acquired Brain Injury (ABI) with and without third party funding.

RESULTS

Caregivers with third party funding (MVA) reported a similar level of stress in comparison to caregivers without funding (non-MVA); however there were differences in what these families perceived as stressful.

CONCLUSIONS

Although results indicated significant psychological distress and depressive symptoms for both groups, parents in both groups reported high availability of and satisfaction with services, although they used very few services. Implications for clinical services are discussed.

Achieving a successful and sustainable return to the workforce after ABI: a client-centred approach

PRIMARY OBJECTIVE

This paper describes the approach used by the Victorian Acquired Brain Injury (ABI) specialist team of CRS Australia (formerly Commonwealth Rehabilitation Service) to facilitate participation in the workforce for its clients. The approach and results achieved are compared and contrasted with other models nationally and internationally.

METHOD AND PROCEDURES

This two part study involves a survey of the specialist team members regarding use and efficacy of assessment and intervention strategies and data mining of closed case files to identify predictors of sustainable employment outcomes for people with ABI.

MAIN OUTCOMES AND RESULTS

CRS Australia's results compare favourably with other published results (50% achieved a minimum of 13 weeks open employment compared to population estimates of 38-46.5%). Results were achieved with people with mild, moderate and severe injury. Assessments and interventions that correlate with successful employment outcome are described.

CONCLUSIONS

A client-centred approach, combining specialist ABI expertise, skilled assessment and practical workplace-based interventions results in favourable employment outcome rates.

Preventing suicide after traumatic brain injury: implications for general practice

People with traumatic brain injury (TBI) have an increased risk of suicide, suicide attempts and suicide ideation compared with the general population. Most suicide deaths and attempts involve self-poisoning. General practitioners are strategically placed to make a significant contribution to preventing suicide in this group. Assessment approaches need to take into account the chronic nature of suicide risk in people with TBI. The assessment of post-TBI depression is complicated by the confounding effect of post-TBI motor-sensory and cognitive impairments, but psychological symptoms (feelings of hopelessness, worthlessness, and anhedonia, in particular) suggest the diagnosis of depression after TBI. Management includes close attention to how medications are prescribed, dispensed and administered. Family and community brain injury agencies can be enlisted to provide emotional support and monitoring of people with TBI. GPs can facilitate access to needed mental health services for people with TBI during times of suicidal crisis. Clinical practice guidelines for the care of people living with traumatic brain injury in the community, recently published for general practice, may be of use in managing people with TBI.

Reliability of the Care and Needs Scale for Assessing Support Needs After Traumatic Brain Injury

OBJECTIVE

To investigate the reliability of the Care and Needs Scale (CANS) for measuring the level and types of support needs of people with traumatic brain injury (TBI).

METHOD

Interrater reliability was examined in a cohort of 30 community clients with TBI by comparing CANS ratings completed by 2 occupational therapists (OTs) and a case manager. CANS ratings on the same clients were also completed 1 week later to examine test-retest reliability. Reliability of proxy ratings was investigated in a cohort of 40 community clients with TBI by comparing CANS ratings completed by a clinical researcher, multidisciplinary team, relative, and client.

RESULTS

Level of support need as measured by the CANS showed excellent interrater reliability both within and across disciplines: ICC = 0.95 between 2 OTs and ICC = 0.93 and 0.96 between OTs and case manager. Test-retest reliability of the CANS over a 1-week period was also excellent (ICC = 0.98). Although the agreement between the clinical researcher and multidisciplinary team was excellent (ICC = 0.92), ICCs with relative and client ratings were variable, ranging from 0.37 to 0.72.

CONCLUSIONS

The excellent inter-rater and test-retest reliability findings from this present study, together with the evidence for validity reported previously, indicate that the CANS is a reliable and valid instrument for application in clinical practice.

Carers' perspective on respite for persons with acquired brain injury

Persons with acquired brain injury require continuing care and support in various aspects of their lives. Although the care and support are predominantly provided by family members, little is known about the respite that these carers require to continue the care on a daily basis. This study aims to address the lack of data on respite care and people with acquired brain injury from the perspective of carers. Survey methodology was used to gather information from carers who were members of a peak brain injury association in New South Wales, Australia. The responses of 85 carers were analysed using logistic regression and frequency counts. The characteristics of carers were consistent with the research literature on respite and acquired brain injury, with carers being mainly female and there being a reliance on an informal network to assist in the care. Carers also reported that caring prevented them from obtaining gainful employment. Several factors were significantly associated with the use of respite, these were carers' single marital status; and the person with acquired brain injury's severity of disability, high level of dependency and number of days spent in coma. Carers also reported other factors that might influence them to use respite and they identified their expectations of respite. This study highlights carers' perspective on respite that is an under-researched area in acquired brain injury and reiterates ongoing need for respite.

Unmet Service Needs of Persons With Traumatic Brain Injury

OBJECTIVES

Assess unmet needs of persons with traumatic brain injury (TBI) 1 year after hospital discharge; compare perceived need with needs based on deficits (unrecognized need); determine major barriers to services; evaluate association of needs with satisfaction with life.

PARTICIPANTS

Representative sample of 1830 community-dwelling persons with TBI aged 15 years and older.

MEASURES

Perceived and unrecognized unmet needs, barriers to receiving services, and satisfaction with life as a function of met service needs.

RESULTS

35.2% of participants reported at least 1 unmet need, 51.5% had unrecognized needs, 47% reported at least 1 barrier to receiving help. Receipt of services significantly increased satisfaction with life.

CONCLUSIONS

Many persons experiencing TBI report having unmet service needs 1 year after hospital discharge.

Measuring High-Level Mobility After Traumatic Brain Injury

High-level mobility is important for participation in many pre-accident activities after traumatic brain injury (TBI). This review examined which measures are used to quantify physical status and mobility after TBI to determine their appropriateness for measuring high-level mobility. Electronic databases, hand searching of several TBI journals, and citation tracking from retrieved articles were used to identify all TBI outcome studies from 1990 through to May 2004. Preliminary screening identified articles that either reported on physical outcome or mobility after TBI or utilized measurement tools with a physical component. Studies were selected for detailed analysis if they reported on mobility or physical outcomes after TBI. The search identified 175 studies that met the inclusion criteria for further analysis. The FIM instrument is the most frequently used outcome measure, highlighting a trend toward using inpatient measures to evaluate long-term outcomes. Only one study used a measurement tool that incorporated a mobility item beyond independent walking and stairs. High-level mobility is seldom measured using standardized outcome measures after TBI, despite independent mobility being one of the major goals of rehabilitation. A high-level mobility scale is needed to address the ceiling effect of outcome scales currently used in TBI rehabilitation and to extend mobility to age-appropriate levels for return to leisure and sporting activities.

Severity of injury and service utilization following traumatic brain injury: the first 3 months

OBJECTIVE

To describe the medical and rehabilitation service use of model systems by brain injured participants 1 to 3 months postdischarge from inpatient rehabilitation.

DESIGN

Prospective follow-up study.

SETTING

Georgia Model Brain Injury System (GAMBIS).

PARTICIPANTS

Seventy-three GAMBIS subjects consenting to participate in the utilization substudy.

MAIN OUTCOME MEASURES

Receipt of services and intensity of service use.

ANALYSIS

Chi-square analysis of receipt of services by severity of injury.

RESULTS

The likelihood of service use did not vary with severity of injury. Data suggest that intensity of service use was a function of injury severity.

CONCLUSIONS

Subjects with mild and moderate injuries were as likely to use a range of medical and rehabilitation services during the 3-month postdischarge period as those with severe injuries. Traditional rehabilitation services, such as physical therapy, were far more likely to be used, than nontraditional services, such as psychological counseling, in spite of the high level of cognitive and social disability associated with traumatic brain injury.