Librada Callender

Comparative effectiveness of traumatic brain injury rehabilitation: Differential outcomes across TBI Model Systems Centers

Objective:To measure patient functional outcomes across rehabilitation centers. Setting:Traumatic Brain Injury Model System (TBIMS) centers. Participants:Patients with traumatic brain injury (TBI) admitted to 21 TBIMS rehabilitation centers (N = 6975, during 1999-2008). Design:Retrospective analysis of prospectively collected data. Main Measures:Center-specific functional outcomes of TBI patients using Functional Independence Measure, Disability Rating Scale, and Glasgow Outcome Scale–Extended. Results:There were large differences in patient characteristics across centers (demographics, TBI severity, and functional deficits at admission to rehabilitation). However, even after taking those factors into account, there were significant differences in functional outcomes of patients treated at different TBIMS centers. Conclusion:There are significant differences in functional outcomes of TBI patients across rehabilitation centers.

Variations in Inpatient Rehabilitation Functional Outcomes Across Centers in the Traumatic Brain Injury Model Systems Study and the Influence of Demographics and Injury Severity on Patient Outcomes

OBJECTIVE To compare patient functional outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers using an enhanced statistical model and to determine factors that influence those outcomes. DESIGN Multicenter observational cohort study. SETTING TBIMS centers. PARTICIPANTS Patients with traumatic brain injury (TBI) admitted to 19 TBIMS rehabilitation centers from 2003-2012 (N=5505). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Functional outcomes of patients with TBI. RESULTS Individuals with lower functional status at the time of admission, longer duration of posttraumatic amnesia, and higher burden of medical comorbidities continued to have worse functional outcomes at discharge from inpatient rehabilitation and at the 1-year follow-up, whereas those who were employed at the time of injury had better outcomes at both time periods. Risk-adjusted patient functional outcomes for patients in most TBIMS centers were consistent with previous research. However, there were wide performance differences for a few centers even after using more recently collected data, improving on the regression models by adding predictors known to influence functional outcomes, and using bootstrapping to eliminate confounds. CONCLUSIONS Specific patient, injury, and clinical factors are associated with differences in functional outcomes within and across TBIMS rehabilitation centers. However, these factors did not explain all the variance in patient outcomes, suggesting a role of some other predictors that remain unknown.

Utilization and access to healthcare services among community-dwelling people living with spinal cord injury

Objective: Describe the utilization, accessibility, and satisfaction of primary and preventative health-care services of community-dwelling individuals with spinal cord injury (SCI). Design: Cross sectional, in-person or telephonic survey, utilizing a convenience sample. Setting: Community. Participants: Individuals with SCI greater than 12-months post injury. Interventions: N/A. Outcome measures: Demographic, injury related, and 34-item questionnaire of healthcare utilization, accessibility, and satisfaction with services. Results: The final sample consisted of 142 participants (50 female, 92 male). Ninety-nine percent of respondents had a healthcare visit in the past 12-months with primary care physicians (79%), with SCI physiatrists (77%) and urologists (50%) being the most utilized. 43% of the sample reported an ER visit within the past 12-months, with 21% reporting multiple visits. People who visited the ER had completed significantly less secondary education (P = 0.0386) and had a lower estimate of socioeconomic status (P = 0.017). The majority of individuals (66%) were satisfied with their primary care physician and 100% were satisfied with their SCI physiatrist. Individuals who did not visit an SCI physiatrist were significantly more likely to live in a rural area (P = 0.0075), not have private insurance (P = 0.0001), and experience a greater decrease in income post injury (P = 0.010). Conclusion: The delivery of care for people with SCI with low socioeconomic status may be remodeled to include patient-centered medical homes where care is directed by an SCI physiatrist. Further increased telehealth efforts would allow for SCI physiatrists to monitor health conditions remotely and focus on preventative treatment.

Effect of Obesity on Motor Functional Outcome of Rehabilitating Traumatic Brain Injury Patients.

ObjectiveThe aim of this study was to determine the association between obesity and functional motor outcome of patients undergoing inpatient rehabilitation after traumatic brain injury. DesignThis retrospective study at an urban acute inpatient rehabilitation center screened data from 761 subjects in the Traumatic Brain Injury Model System who were admitted from January 2010 to September 2013. Inclusion criteria consisted of age of 18 years or older and an abnormal Functional Independence Measure motor score. Body mass index was used to determine obesity in the study population. Patients with a body mass index of 30.0 kg/m2 or greater were considered obese. ResultsA total of 372 subjects met the criteria for inclusion in the study. Of these, 54 (13.2%) were obese. Both obese and nonobese patients showed similar improvement in Functional Independence Measure motor score (mean [SD], 30.4 [12.8] for the obese patients, P = 0.115, and 27.3 [13.1] for the nonobese patients). The mean (SD) Functional Independence Measure motor scores at discharge for the obese and nonobese patients were 63.0 (12.6) and 62.3 (10.1) (P = 0.6548), respectively. ConclusionsObesity had no adverse impact on motor functional outcomes of the traumatic brain injury patients who underwent inpatient rehabilitation. Therefore, obesity should not be considered an obstacle in inpatient rehabilitation after traumatic brain injury, if patients are able to participate in necessary therapy.

Process for developing rehabilitation practice recommendations for individuals with traumatic brain injury

BackgroundAttempts at measuring quality of rehabilitation care are hampered by a gap in knowledge translation of evidence-based approaches and lack of consensus on best practices. However, adoption of evidence-based best practices is needed to minimize variations and improve quality of care. Therefore, the objective of this project was to describe a process for assessing the quality of evidence of clinical practices in traumatic brain injury (TBI) rehabilitative care.MethodsA multidisciplinary team of clinicians developed discipline-specific clinical questions using the Population, Intervention, Control, Outcome process. A systematic review of the literature was conducted for each question using Pubmed, CINAHL, PsychInfo, and Allied Health Evidence databases. Team members assessed the quality, level, and applicability of evidence utilizing a modified Oxford scale, the Agency for Healthcare Research and Quality Methods Guide, and a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation scale.ResultsDraft recommendations for best-practice were formulated and shared with a Delphi panel of clinical representatives and stakeholders to obtain consensus.ConclusionEvidence-based practice guidelines are essential to improve the quality of TBI rehabilitation care. By using a modified quality of evidence assessment tool, we established a process to gain consensus on practice recommendations for individuals with TBI undergoing rehabilitation.

Sacral examination in spinal cord injury: Is it really needed?

Objective: To determine if a self-report measure of S4-5 motor and sensory function in patients with chronic SCI accurately predicts sacral examination results. Design: Prospective, single-blinded self-report survey compared with sacral exam. Setting: Outpatient SCI clinic. Participants: 116 patients aged 18+ with chronic SCI > 6 months who have undergone sacral exam. Interventions: The survey included demographic/clinical and sacral function information such as light tough (LT), pinprick sensation (PP), deep anal pressure (DAP) and voluntary anal contraction (VAC). Survey results and sacral exam were compared and stratified by the patient’s American Spinal Cord Injury Association Impairment Scale (AIS) category. Outcome Measures: Sacral self-report survey, AIS examination. Results: Mean age was 41.3 ± 14.4 years with majority male (69%) and Caucasian (71.6%). Overall, Positive Predictive Value (PPV) ranged between 48% (VAC) to 73% (DAP) and Negative Predictive Value (NPV) between 92% (VAC) to 100% (LT). AIS-A had NPV of 100% across all categories, and AIS-D had PPV of 100% across all categories. Conclusion: Patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification.

Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry

Objective: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center. Design: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year. Setting: Dallas, TX, USA. Participants: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591. Outcome Measures: Data included demographic and clinical characteristics, charges, and healthcare utilization. Results: Mean age was 46.1 years (±18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use. Conclusion: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Phase 2 Randomized, Placebo-Controlled Clinical Trial of Recombinant Human Growth Hormone (rhGH) During Rehabilitation From Traumatic Brain Injury

Traumatic brain injury (TBI) is a major cause of death and disability, but there are currently no therapies with proven efficacy for optimizing regeneration of repair during rehabilitation. Using standard stimulation tests, as many as 40–50% of survivors of severe TBI have deficiency of one or more pituitary hormones. Of these, the somatotropic axis is the most commonly affected, with Growth Hormone (GH) deficiency affecting ~20% of persons with severe TBI. Treatment with recombinant human Growth Hormone (rhGH) is generally effective in reversing the effects of acquired GH deficiency, but there is no evidence documenting functional or neurocognitive improvement after GH replacement in TBI patients. As a consequence, screening for GH deficiency and GH replacement when deficiency is found is not routinely performed as part of the rehabilitation of TBI survivors. Given that most of the recovery after TBI occurs within the first 6–12 months after injury and IGF-1 and GH are part of a coordinated restorative neurotrophic system, we hypothesized that patients will optimally benefit from GH therapy during the window of maximal neuroregenerative activity. We performed a Phase IIa, randomized, double-blind, placebo-controlled feasibility trial of recombinant human Growth Hormone (rhGH), starting at discharge from an inpatient rehabilitation unit, with follow up at 6 and 12 months. Our primary hypothesis was that treatment with rhGH in the subacute period would result in improved functional outcomes 6 months after injury. Our secondary hypothesis proposed that treatment with rhGH would increase IGF-1 levels and be well tolerated. Sixty-three subjects were randomized, and 40 completed the trial. At baseline, there was no correlation between IGF-1 levels and peak GH levels after L-arginine stimulation. IGF-1 levels increased after rhGH treatment, but it took longer than 1 month for levels to be higher than for placebo-treated patients. rhGH therapy was well-tolerated. The rhGH group was no different from placebo in the Disability Rating Scale, Glasgow Outcome Scale-Extended, or neuropsychological function. However, a trend toward greater improvement from baseline in Functional Independence Measure (FIM) was noted in the rhGH treated group. Future studies should include longer treatment periods, faster titration of rhGH, and larger sample sizes.

Inconsistencies with Screening for Traumatic Brain Injury in Spinal Cord Injury across the Continuum of Care

Abstract Objective: Explore how traumatic brain injury (TBI) is screened among spinal cord injury (SCI) patients across the continuum of care. Design: Retrospective chart review Setting: Emergency department, trauma, inpatient rehabilitation Participants: 325 patients with SCI from inpatient rehabilitation facility (IRF) between March 1, 2011 and December 31, 2014 were screened. 49 eligible subjects had traumatic SCI and received care in adjoining acute care (AC) hospital. Outcome Measures: Demographic characteristics and variables that capture diagnosis of TBI/SCI included documentation from ambulance, emergency department, AC, and IRF including ICD-9 codes, altered mental status, loss of consciousness (LOC), Glasgow Coma Score, Post Traumatic Amnesia (PTA), neuroimaging, and cognitive assessments. Results: Participants were male (81%), white (55%), privately insured (49%), and aged 39.3±18.0 years with 51% paraplegic and 49% tetraplegic. Mechanisms of injury were gunshot wound (31%), fall (29%), and motor vehicle accident (20%). TBI occurred in 65% of SCI individuals, however documentation of identification of TBI, LOC, and CT imaging results varied in H&P, discharge notes, and ICD-9 codes across the continuum. Cognitive assessments were performed on 16% of subjects. Conclusions: Documentation showed variability between AC and IRF and among disciplines. Imaging and GCS were more consistently documented than LOC and PTA. It is necessary to standardize screening processes between AC and IRF to identify dual diagnosis.

Seizure Prophylaxis Guidelines Following Traumatic Brain Injury: An Evaluation of Compliance.

Objective: To determine degree of adherence to guidelines for seizure prophylaxis following traumatic brain injury (TBI). Setting: Tertiary care level 1 trauma center and affiliated inpatient rehabilitation facility. Participants: A total of 173 individuals with TBI who required inpatient rehabilitation from January 1, 2007, to December 31, 2013. Design: Retrospective medical record review. Main Measures: Overutilization rate of prophylactic antiepileptic drugs (AEDs); failure to stop rate of AED utilization upon admission to and during inpatient rehabilitation; and duration of overutilization. Results: Of the 173 participants included, 77 were started on seizure prophylaxis at hospital presentation and 96 were not. Of the 77 participants, 11 had a posttraumatic seizure. Of the 66 remaining, 18 participants (10.4%) were continued on AEDs for more than 7 days after injury. Of these 18 participants, 12 were continued on AEDs without indication upon admission to inpatient rehabilitation. Finally, 8 of the 12 were continued on AEDs at discharge from rehabilitation, resulting in a failure to stop rate of 66.67%. Conclusion: Despite existing guidelines for stopping seizure prophylaxis after TBI, some patients remain on AEDs and may be inappropriately exposed to possible medication side effects. These findings highlight the importance of communication at the time of rehabilitation transfer and the need for ongoing education about AED guidelines.