Frances Simmonds

A population-based study comparing traumatic spinal cord injury and non-traumatic spinal cord injury using a national rehabilitation database

Study design:A limitation of many studies of non-traumatic spinal cord injury (NT-SCI) and traumatic spinal cord injury (T-SCI) is potential lack of generalizability because of selection bias. An open cohort study using a national rehabilitation database was planned to address this.Objective:To compare the demographic characteristics and outcomes between NT-SCI and T-SCI patients.Setting:Rehabilitation hospitals in Australia.Methods:The Australasian Rehabilitation Outcomes Centre maintains a national database of information on in-patients admitted to almost all (130/145 as at 2006) public and private rehabilitation hospitals in Australia. It collects a range of demographic and clinical outcomes. Patients were included if they were discharged between 1 January 2002 and 31 December 2006. Patients were excluded if they were admitted for <7 days, only for assessment or were a readmission.Results:There were 3610 patients included (NT-SCI, n=2241, 62.1%; T-SCI, n=1361, 37.7%). There were numerous significant differences between NT-SCI and T-SCI patients. NT-SCI patients were generally older (median age NT-SCI 67 years vs T-SCI 46 years, P=0.000), less likely to be male (male NT-SCI 52.5% vs T-SCI 71.6%, P=0.000) and had a shorter length of stay (median NT-SCI 21 days vs T-SCI 44 days, P=0.000). NT-SCI patients were also less disabled than T-SCI patients, having higher Functional Independence Measure motor subscale score on admission (median NT-SCI 53 vs T-SCI 38, P=0.000) and discharge (median NT-SCI 76 vs T-SCI 74, P=0.000).Conclusion:Previous demographic studies of NT-SCI and T-SCI patients are similar to our population-based results. More population-based research in SCI is required.

Comparison of patients managed in specialised spinal rehabilitation units with those managed in non-specialised rehabilitation units

Study design:Prospective open cohort study.Objective:Compare the demographic characteristics and rehabilitation outcomes for both non-traumatic SCI (NT-SCI) and traumatic SCI (T-SCI) patients admitted into either specialist spinal cord injury rehabilitation units (SCIRUs) or non-specialist rehabilitation units (NSRUs).Setting:Rehabilitation units in Australia.Methods:The Australasian Rehabilitation Outcomes Centre maintains a national database on inpatients admitted to most (130/145) public and private rehabilitation units in Australia. Patients were included if they had a diagnosis of spinal cord injury (SCI) and were discharged between 1 January 2006 and 31 December 2006. Patients were excluded if admitted for <7 days, only for assessment, or were a readmission following a previous SCI.Results:There were 668 patients with confirmed SCI admitted (NT-SCI n=361, 54.0%; T-SCI n=307, 46.0%). NT-SCI patients were much less likely to be admitted into a specialist SCIRU (30.5%) compared with T-SCI patients (70.4%). For both NT-SCI and T-SCI patients, those admitted to a specialist SCIRU tended to be younger (P=0.000), have a longer length of stay in rehabilitation (P=0.000), and lower Functional Independence Measure (FIM) motor subscale score on admission (P=0.000) than those admitted to a NSRU. For NT-SCI patients, after adjusting for covariates, those admitted into specialist SCIRU had greater improvement in their FIM motor score during rehabilitation. This finding was not demonstrated in T-SCI patients.Conclusions:There are differences in the characteristics of SCI patients admitted to SCIRU compared with NSRU. NT-SCI patients admitted to SCIRU have greater functional gain.Sponsorship:This project was made possible by a major research grant from the Victorian Neurotrauma Initiative. A minor research grant was also provided by the Australasian Faculty of Rehabilitation Medicine 2007 Ipsen research scholarship. The authors would like to thank these organisations for their support. These organisations had no role in the design, analysis or preparation of this manuscript.

Multiple sclerosis rehabilitation outcomes: analysis of a national casemix data set from Australia

Objective To examine the outcomes of inpatient rehabilitation for persons with multiple sclerosis (pwMS), using the Australian Rehabilitation Outcomes Centre (AROC) database. Method Deidentified data from the AROC database were analyzed for all rehabilitation admissions during 2003–2007, using four classes for functional level. The outcomes included Functional Independence Measure (FIM) scores and efficiency, hospital length of stay (LOS), and discharge destination. Results Of 1010 case episodes, 70% were women, admitted from home (n = 851) and discharged into the community (n = 890), and 97% (n = 986) were in the higher three classes for functional level (classes 216, 217, and 218). Majority of the more disabled pwMS were treated in the public hospital system, with a longer LOS compared with private facilities (P < 0.001). The FIM for classes 216–218 showed significant functional improvement during the admission (P < 0.001), and those in higher classes showed less change (likely due to higher FIM admission scores). FIM efficiency was significantly higher in class 217 than other classes (P < 0.001). The year-on-year trend was toward reducing hospital LOS and FIM efficiency, but these did not reach significance (P = 0.107, P = 0.634). Conclusion The AROC data set is useful for describing rehabilitation outcomes for pwMS. However, additional information needs to be collected to evaluate nature of services provided and service implications.

Lower-limb amputee rehabilitation in Australia: analysis of a national data set 2004–10

OBJECTIVE Examine demographics, clinical characteristics and rehabilitation outcomes of lower-limb amputees, using the Australasian Rehabilitation Outcomes Centre (AROC) database. METHODS Lower-limb amputee rehabilitation separations between 2004 and 2010 were identified using AROC impairment codes 5.3-5.7.(1) Analysis was conducted by year, impairment code, Australian National Sub-acute and Non-Acute Patient (AN-SNAP) classification (S2-224, Functional Independence Measure (FIM) motor(Mot) score 72-91; S2-225, FIM (Mot) score 14-71) and states of Australia. RESULTS Mean length of stay (LOS) for all lower-limb amputee episodes was 36.1 days (95% confidence interval (CI): 35.4-36.9). Majority of episodes were unilateral below knee (63.6%), males (71.8%) with a mean age of 67.9 years (95% CI: 67.6-68.3). Year-on-year analysis revealed a trend for increasing LOS and decreasing age. Analysis by impairment code demonstrated no significant difference in rehabilitation outcomes. Analysis by AN-SNAP found that LOS was 16.2 days longer for S2-225 than for S2-224 (95% CI: 14.7-17.8, P<0.001), and FIM (Mot) change was 12.0 points higher for S2-225 than for S2-224 (95% CI: 11.5-12.6, P<0.001). Analysis by states revealed significant variation in LOS, FIM (Mot) change and FIM (Mot) efficiency which may be associated with variations in organisation of rehabilitation services across states. CONCLUSION Although amputees represented a comparatively small proportion of all rehabilitation episodes in Australia, their LOS was significant. Unlike many other rehabilitation conditions, there was no evidence of decreasing LOS over time. AN-SNAP classes were effective in distinguishing rehabilitation outcomes, and could potentially be used more effectively in planning rehabilitation programs.

Comparison of Rehabilitation Outcomes for Long Term Neurological Conditions: A Cohort Analysis of the Australian Rehabilitation Outcomes Centre Dataset for Adults of Working Age

Objective To describe and compare outcomes from in-patient rehabilitation (IPR) in working-aged adults across different groups of long-term neurological conditions, as defined by the UK National Service Framework. Design Analysis of a large Australian prospectively collected dataset for completed IPR episodes (n = 28,596) from 2003-2012. Methods De-identified data for adults (16–65 years) with specified neurological impairment codes were extracted, cleaned and divided into ‘Sudden-onset’ conditions: (Stroke (n = 12527), brain injury (n = 7565), spinal cord injury (SCI) (n = 3753), Guillain-Barré syndrome (GBS) (n = 805)) and ‘Progressive/stable’ conditions (Progressive (n = 3750) and Cerebral palsy (n = 196)). Key outcomes included Functional Independence Measure (FIM) scores, length of stay (LOS), and discharge destination. Results Mean LOS ranged from 21–57 days with significant group differences in gender, source of admission and discharge destination. All six groups showed significant change (p<0.001) between admission and discharge that was likely to be clinically important across a range of items. Significant between-group differences were observed for FIM Motor and Cognitive change scores (Kruskal-Wallis p<0.001), and item-by-item analysis confirmed distinct patterns for each of the six groups. SCI and GBS patients were generally at the ceiling of the cognitive subscale. The ‘Progressive/stable’ conditions made smaller improvements in FIM score than the ‘Sudden-onset conditions’, but also had shorter LOS. Conclusion All groups made gains in independence during admission, although pattern of change varied between conditions, and ceiling effects were observed in the FIM-cognitive subscale. Relative cost-efficiency between groups can only be indirectly inferred. Limitations of the current dataset are discussed, together with opportunities for expansion and further development.

The psychometric properties of a modified client-centred rehabilitation questionnaire in an Australian population

Abstract Purpose: To identify the face validity of the Client-Centred Rehabilitation Questionnaire (CCRQ) and to determine the internal consistency reliability and factorial validity of a modified CCRQ. Materials and methods: This study was conducted in 2 phases. Phase 1 consisted of 5 focus groups to examine the face validity of the CCRQ, resulting in the development of a modified CCRQ. Phase 2 consisted of a multi-site cross sectional survey, involving 408 rehabilitation inpatients, to examine the internal consistency reliability and factorial validity of the modified CCRQ. Chronbach’s coefficient alpha, composite reliability coefficients, and single factor congeneric models with maximum likelihood confirmatory factor analysis were used. Results: Based on feedback from the focus groups the CCRQ was modified with the word ‘rehabilitation’ replacing ’program’ throughout. The three negatively worded items had poor item-to-total correlations of <0.3. Removing these items resulted in subscale alphas of 0.74–0.86 and composite reliability coefficients of 0.66–0.87. Six of the seven sub-scales had good model fit and the other one had moderate fit following removal of the negatively worded item. Conclusions: This study supports the underlying structure and internal consistency of the modified CCRQ. Implications for Rehabilitation Person-centredness is an important characteristic of effective rehabilitation service delivery that warrants measurement. A modified Client-Centered Rehabilitation Questionnaire has been found to have good face validity, internal consistency reliability and construct validity in an Australian sample of inpatient rehabilitation patients. Use of a modified Client-Centered Rehabilitation Questionnaire incorporating the 7 sub-scales in the original Client-Centered Rehabilitation Questionnaire is supported for use in inpatient rehabilitation. Both sub-scale and item level responses to the modified Client-Centered Rehabilitation Questionnaire provide detailed feedback to rehabilitation service providers looking for opportunities to make their services more person-centred.