Measuring Post-Acute Rehabilitation Outcomes

Why Outcomes Measurement is Important

Accurately and objectively measuring rehabilitation outcomes and thoroughly reporting that information is important for a number of reasons. Measurement prior to the initiation of treatment objectively describes a patient’s current status and provides a baseline from which future comparisons can be made. Measurement at the completion of rehabilitation is indicative of the impact of rehabilitation on patient function, (i.e., response to treatment), and measurement at regular time points following discharge provides data regarding the durability of treatment. Proper outcomes measurement and reporting allows for objective comparison against normative samples, or across similar programs in a particular state or region. From a broader perspective, measuring and reporting rehabilitation outcomes provides support to the effectiveness and efficiency of post-acute brain injury rehabilitation and may assist in advocating for access to post-acute treatment. Additionally, many state licensing agencies and accreditation organization require the collection, analysis and reporting of outcomes data.

Challenges in Measuring Outcomes

Collecting, analyzing and reporting outcomes data can be a complex undertaking. Injury etiology and severity vary significantly. Brain injuries can be caused by trauma, vascular conditions, infections, metabolic disorders, blast exposure and oxygen deprivation to list a few. The severity and various etiologies of injury present a wide range of clinical features, treatment requirements, and possible recovery trajectories. Additionally, individuals with brain injury are an extremely heterogeneous group and a broad range of rehabilitation outcomes are possible. Demographic variables (i.e., age, gender, level of education, marital status, socioeconomic status, vocational history, amount of family support, etc.), and co-occurring medical diagnoses (i.e., psychiatric illness, substance abuse, and co-morbidities such as diabetes, etc.) can influence rehabilitation outcomes.

Unlike other injuries or diseases that require rehabilitation (i.e., orthopedic injuries, cardiac disease), a brain injury often results in physical, cognitive, communicative, emotional, and behavioral deficits that must be addressed simultaneously, necessitating the participation and coordination of multiple medical and allied health professionals. Additionally, treatment settings and rehabilitation programs vary significantly in terms of intensity of treatment (i.e., hours of therapy per day), duration of treatment (length of time in active rehabilitation), treatment expertise (i.e., quality, training and experience of professional staff), and in treatment approach (i.e., best practice, use of evidenced-based guidelines, interdisciplinary treatment).

Therefore, injury severity, injury etiology, and important demographics and medical information, along with treatment variables such as intensity, duration, and approach must be collected and reported to more fully understand the impact of these variables on treatment outcomes and identify who benefits from what “dose” of treatment.[1]

Determining what outcome measurement tool(s) to employ can also be challenging. The Interagency Traumatic Brain Injury (TBI) Outcomes workgroup recommended the use of multiple measures for outcomes research that demonstrate sound psychometric properties and good utility with the brain injury population.[2] At a minimum, the Interagency TBI Outcomes workgroup recommended that measures selected should assess: global level of function, neuropsychological impairment, psychological status, activity limitations and participation restrictions, and perceived health-related quality of life. A similar strategy should be undertaken for choosing outcomes measurement tools in rehabilitation settings.

While some progress has been made regarding what to measure and how often to measure (i.e., admission, discharge, significant transitions during rehabilitation, and at certain time points post-discharge), there is still little consensus regarding what measurement tools to use. Indeed, in a recent survey of community-based brain injury rehabilitation programs, the Community-Based Treatment Task Force of the Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine (ACRM) found that a large percentage (59.4%) of rehabilitation programs used the Mayo-Portland Adaptability Inventory; however, a surprising 31.3% of programs surveyed were using “home grown” measures that had not been evaluated psychometrically, nor shown utility with the brain injury population.[3]

What’s needed?

The required use of a set of appropriate outcome measurement tools from the point of discharge from an acute hospital setting through the post-acute continuum of treatment, as well as mandatory reporting of important injury characteristics, patient demographics, and treatment variables, would support understanding of recovery from brain injury and variables that contribute to good outcomes. This is needed to demonstrate the value of post-acute rehabilitation and provide evidence to ensure access to and funding for treatment.

References

1. Cioe N., Seale G.S., Marquez de la Plata C., et al. Brain injury rehabilitation outcomes. Vienna, VA: Brain Injury Association of America, 2016.
2. Wilde E.A., Whiteneck G.G., Bogner J., et al. Recommendations for the use of common outcome measures in traumatic brain injury research. Archives of Physical Medicine and Rehabilitation. 2010; 91: 1650-1660.
3. McLaughlin A.M., Clark A., Geier N., Murphy M.P., et al. Current practices and perceived needs of community-based brain injury rehabilitation programs. American Congress of Rehabilitation Medicine Meeting, 2015.

This article was contributed by:

Gary S. Seale, Ph.D., LPA, LCDC, Regional Director of Clinical Services, Centre for Neuro Skills

Gary S. Seale is Regional Director of Clinical Services for the Centre for Neuro Skills. He received his doctoral degree in Rehabilitation Science from the University of Texas Medical Branch (UTMB) in Galveston, Texas. He is licensed in Texas as a Chemical Dependency Counselor, Psychological Associate with Independent Practice, and holds a clinical appointment at UTMB in the School of Health Professions – Department of Rehabilitation Science. He has worked exclusively in post-acute brain injury rehabilitation for over 27 years and has conducted research and published peer-reviewed articles on topics including rehabilitation outcomes, the relationship between positive emotion and recovery of functional status following stroke, and emergency preparedness for disabled populations.