Budget impact analysis of robotic exoskeleton use for locomotor training following spinal cord injury in four SCI Model Systems.

BACKGROUND: We know little about the budget impact of integrating robotic exoskeleton over-ground training into therapy services for locomotor training. The purpose of this study was to estimate the budget impact of adding robotic exoskeleton over-ground training to existing locomotor training strategies in the rehabilitation of people with spinal cord injury. METHODS: A Budget Impact Analysis (BIA) was conducted using data provided by four Spinal Cord Injury (SCI) Model Systems rehabilitation hospitals. Hospitals provided estimates of therapy utilization and costs about people with spinal cord injury who participated in locomotor training in the calendar year 2017. Interventions were standard of care walking training including body-weight supported treadmill training, overground training, stationary robotic systems (i.e., treadmill-based robotic gait orthoses), and overground robotic exoskeleton training. The main outcome measures included device costs, training costs for personnel to use the device, human capital costs of locomotor training, device demand, and the number of training sessions per person with SCI. RESULTS: Robotic exoskeletons for over-ground training decreased hospital costs associated with delivering locomotor training in the base case analysis. This analysis assumed no difference in intervention effectiveness across locomotor training strategies. Providing robotic exoskeleton overground training for 10% of locomotor training sessions over the course of the year (range 226-397 sessions) results in decreased annual locomotor training costs (i.e., net savings) between $1114 to $4784 per annum. The base case shows small savings that are sensitive to parameters of the BIA model which were tested in one-way sensitivity analyses, scenarios analyses, and probability sensitivity analyses. The base case scenario was more sensitive to clinical utilization parameters (e.g., how often devices sit idle and the substitution of high cost training) than device-specific parameters (e.g., robotic exoskeleton device cost or device life). Probabilistic sensitivity analysis simultaneously considered human capital cost, device cost, and locomotor device substitution. With probabilistic sensitivity analysis, the introduction of a robotic exoskeleton only remained cost saving for one facility. CONCLUSIONS: Providing robotic exoskeleton for over-ground training was associated with lower costs for the locomotor training of people with SCI in the base case analyses. The analysis was sensitive to parameter assumptions.

[Results of case evaluations by the medical services of the paying health insurances in neurological early rehabilitation]. / Ergebnisse der MDK-Prüfungen in einer Klinik der neurologischen Frührehabilitation Phase B.

Evaluations of cases of a neurological early rehabilitation clinic carried out by the medical services of health insurances (2018) are described and analyzed. More than a quarter of the 1098 cases were evaluated. Examinations focused on hours of ventilation, unnecessary hospitalization, intensity of nursing and features of the definition of early neurological rehabilitation. Strategies to minimize are errors described.

Telemedicine in Rehabilitation.

Telerehabilitation refers to the virtual delivery of rehabilitation services into the patient's home. This methodology has shown to be advantageous when used to enhance or replace conventional therapy to overcome geographic, physical, and cognitive barriers. The exponential growth of technology has led to the development of new applications that enable health care providers to monitor, educate, treat, and support patients in their own environment. Best practices and well-designed Telerehabilitation studies are needed to build and sustain a strong Telerehabilitation system that is integrated in the current health care structure and is cost-effective.

Economic Evaluation of Activities of Daily Living Retraining During Posttraumatic Amnesia for Inpatient Rehabilitation Following Severe Traumatic Brain Injury.

OBJECTIVE: To evaluate the cost-effectiveness of structured activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) plus treatment as usual (TAU) vs TAU alone for inpatient rehabilitation following severe traumatic brain injury (TBI). DESIGN: Trial-based economic evaluation from a health-system perspective. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Participants (N=104) admitted to rehabilitation and in PTA for >7 days following severe TBI. INTERVENTIONS: Structured ADL retraining during PTA plus TAU vs TAU alone. Structured ADL retraining was manualized to minimize the risk of agitation and maximize functional improvement, following principles of errorless and procedural learning and targeting individualized therapy goals. TAU included physiotherapy and/or speech therapy during PTA plus ADL retraining after PTA emergence. MAIN OUTCOME MEASURES: FIM total scores at baseline, PTA emergence, hospital discharge, or final follow-up (2mo postdischarge) where FIM total scores were calculated as the sum of 5 FIM motor self-care items and a FIM meal-preparation item. RESULTS: Structured ADL retraining during PTA significantly increased functional independence at PTA emergence (mean difference: 4.90, SE: 1.4, 95% confidence interval [CI]: 1.5, 8.3) and hospital discharge (mean difference: 5.22, SE: 1.4, 95% CI: 1.8, 8.7). Even in our most pessimistic scenario, structured ADL retraining was cost-saving as compared to TAU (mean: -$7762; 95% CI: -$8105, -$7419). Together, these results imply that structured ADL retraining dominates (less costly but no less effective) TAU when effectiveness is evaluated at PTA emergence and hospital discharge. CONCLUSIONS: Structured ADL retraining during PTA yields net cost-savings to the health system and offers a cost-effective means of increasing functional independence at PTA emergence and hospital discharge.

[Integrated neurorehabilitation improves efficacy of treatment]. / Integrierte Neurorehabilitation verbessert Versorgungseffizienz.

Neurorehabilitation comprises medical and functional treatment. If patients in the post-hospital phase need acute medical interventions but these cannot be provided by the rehabilitation center, patients must be referred to suitable acute care hospitals; however, such referrals incur additional costs, are fraught with medical risks and delay further rehabilitation. We evaluated how integrating non-neurological medical specialties and a hospital unit into a neurorehabilitation center affects the rate of acute hospital referrals. The special situation in North-Rhine Westfalia, which was the last state in Germany to grant restricted hospital certification to neurorehabilitation centers, enabled a longitudinal assessment over 10 years. We analyzed the referral rate at one of the first hospitals in the state, which in addition to rehabilitation treatment (according to § 40 of the Social Security Code V, SGB V) now also provide hospital treatment (according to § 39 SGB V) and have reorganized in preparation for integrated treatment structures. In the center investigated (St. Mauritius Therapy Hospital Meerbusch) the average patient age increased between 2007 and 2017 from 69 years to 72 years and the proportion of severely ill patients on admission by 70%. Starting in 2012 integrated structures were established in a stepwise fashion with the inclusion of specialists in intensive care, cardiology and neurosurgery, extension of the diagnostic and interventional spectrum and establishment of a 24/7 emergency team with back-up from a new intensive care and mechanical ventilation unit. As a result referrals to hospitals dropped by more than 50% in all categories of disease severity despite the increase in age and morbidity. In view of the savings in costs of hospital treatment, reduced risks due to transfer and less interruption of rehabilitation, it is concluded that the efficacy of patient treatment is improved by discipline and sector integrated neurorehabilitation compared to isolated structures.

The Health Economics of the spinal cord injury or disease among veterans of war: A systematic review.

CONTEXT: Information on health-care utilization and the economic burden of disease are essential to understanding service demands, service accessibility, and practice patterns. This information may also be used to enhance the quality of care through altered resource allocation. Thus, a systematic review of literature on the economic impact of caring for SCI/D veterans would be of great value. OBJECTIVE: To systematically review and critically appraise the literature on the economics of the management of veterans with SCI/D. METHODS: Medline, EMBASE and PsycINFO databases were searched for articles on economic impact of management of SCI/D veterans, published from 1946 to September/2016. The STROBE statement was used to determine publication quality. RESULTS: The search identified 1,573 publications of which 13 articles fulfilled the inclusion/exclusion criteria with 12 articles focused on costs of management of SCI/D veterans; and, one cost-effectiveness analysis. Overall, the health care costs for the management of SCI/D veterans are substantial ($30,770 to $62,563 in 2016 USD per year) and, generally, greater than the costs of caring for patients with other chronic diseases. The most significant determinants of the higher total health-care costs are cervical level injury, complete injury, time period (i.e. first year post-injury and end-of-life year), and presence of pressure ulcers. CONCLUSIONS: There is growing evidence for the economic burden of SCI/D and its determinants among veterans, whereas there is a paucity of comparative studies on interventions including cost-effectiveness analyses. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for veterans with SCI/D.

[Costs associated with multiresistant bacteria in neurorehabilitation]. / Mehrkosten durch multiresistente Erreger in der Neurorehabilitation.

BACKGROUND AND OBJECTIVES: The number of patients with multiresistant bacteria (MRB) in rehabilitation facilities is increasing. The increasing costs of hygienic isolation measures reduce resources available for core rehabilitation services. In addition to the existing lack of care, patients with MRB are at further risk of being given lower priority for admission to rehabilitation facilities. Therefore, the Hygiene Commission of the German Society for Neurorehabilitation (DGNR) attempted to quantify the overall risk for deterioration of rehabilitation care due to the financial burden of MRB. MATERIALS AND METHODS: To analyze the added costs associated with the rehabilitation of patients with MBR, the DGNR Hygiene Commission identified criteria for a cost assessment. Direct (consumables, personnel and miscellaneous costs) and indirect costs of loss of opportunity were evaluated in seven neurorehabilitation centers in different states across Germany. RESULTS: On average, hygienic isolation measures amounted to direct costs of 144 € per day (47 € consumables, 92 € personnel, 5 € for other costs such as extra transportation expenditure) and indirect costs of 274 €, totaling 418 € per patient with MRB per day. Given that approximately 10% of patients had MRB, the added costs of hygienic isolation measures equaled about one tenth of the overall budget of a rehabilitation center and can be expected to rise with the increasing numbers of patients with MRB. CONCLUSIONS: Admission of patients carrying MRB to neurorehabilitation centers triggers added costs that critically diminish the overall capacity for centers to provide their core rehabilitation services.

Health Care Costs of Spontaneous Aneurysmal Subarachnoid Hemorrhage for Rehabilitation, Home Care, and In-Hospital Treatment for the First Year.

BACKGROUND: Given the young age of onset and high probability of long-term disability after subarachnoid hemorrhage (SAH), the financial impact is expected to be substantial. Our primary objective was to highlight subsequent treatment costs after the acute in-hospital stay, including rehabilitation and home care, compared with costs for ischemic stroke. METHODS: The study included 101 patients (median age 52 years, 70 women) with aneurysmal SAH treated from July 2007 to April 2009. In-hospital costs were calculated using German diagnosis related groups. Rehabilitation costs depended on rehabilitation phase/grade and daily rate. Level of severity of care requirements determined the costs for home care. RESULTS: Of patients, 54% received coiling and 46% received clipping. The clipping group included more poor-grade patients than the coiling group (P = 0.039); 23 patients died. Of 78 surviving patients, 70 received rehabilitation treatment (68 in Germany). Mean rehabilitation costs were €16,030 per patient. Patients in the clipping group generated higher rehabilitation costs and longer treatment periods in rehabilitation facilities (P = 0.001 for costs [€20,290 vs. €11,771] and P = 0.011 for duration (54.4 days vs. 40.5 days). Of surviving patients, 32% needed home care, of whom 52% required constant care. Multivariate regression analysis identified longer intensive care unit stay and poor Hunt and Hess grade as independent predictors of higher costs. CONCLUSIONS: Aneurysmal SAH prevalently affects working individuals with long-term occupational disability necessitating long-term medical rehabilitation for most patients and subsequent nursing care in one third of survivors. Overall, SAH treatment generates far higher costs than reported for ischemic stroke.

[Parkinsonian Syndromes: Direct Costs of Inpatient Neurological Rehabilitation]. / Parkinson-Syndrome: Direkte Kosten der stationären Neurorehabilitation.

BACKGROUND: The Parkinsonian syndromes (PS) belong to the frequent chronic neurological disorders that, due to their progressive character and complex therapeutic options, pose a large economic burden. MATERIAL AND METHODS: In a retrospective health economic study on the treatment of Parkinson's disease, various socioeconomic and clinical parameters were examined. In the years 2011-2012, a total of 29 patients with the diagnosis of a Parkinsonian syndrome who underwent an inpatient rehabilitation in the Department of Neurology of the Rehabilitation MediClin Center Bad Orb were recruited. For this group of patients, we calculated the direct treatment cost and also analyzed the treatment cost based on the German diagnosis-related groups (G-DRG, version 2012). RESULTS: The direct medical costs amounted to € 113.47±13.10 per patient per day. Furthermore, cost simulation and comparison revealed significantly higher cost per day for those patients insured via the German statutory health insurance who undergo inpatient care service based on the DRG-based payment (€ 241.77 vs. 171.74; p≤0.015). CONCLUSION: This study contributes to the achievement of transparency of the direct medical costs of Parkinson's disease treatment in the inpatient setting and emphasizes the cost differences compared to the G-DRG-based payment.

Work process related to cerebral palsy of neurological rehabilitation centers.

OBJECTIVE: To evaluate the work process for CP cases in different rehabilitation centers according to Brazilian health policies and recommendations from the "World Report on Disability". METHODS: A questionnaire - Evaluation Process of Rehabilitation of Children with CP was applied to the Coordinators of 13 services. This instrument has a maximum score of 108 points. RESULTS: The results of the questionnaire varied from 28 to 64 points. The mean and SD were 43.5 and 10.9, respectively. The main administrative difficulties were: (a) presence of unmet demand, (b) patient absenteeism, (c) referral to primary care services, (d) inadequate physical facilities, (e) the scarce provision of prosthetics and orthotics, (f) insufficient financial resources, (g) human resources training, (h) difficulties with the use of the information system and (i) transportation difficulties for patients. CONCLUSION: Administrative and clinical guidelines are needed for uniformity of the work process of the rehabilitation centers.

Low cost implementation of a Motor Imagery experiment with BCI system and its use in neurorehabilitation.

The application of rehabilitation programs based on videogames with brain-computer interfaces (BCI) allows to provide feedback to the user with the expectation of stimulate the brain plasticity that will restore the motor control. The use of specific mental strategies such as Motor Imagery (MI) in neuroscientific experiments with BCI systems often requires the acquisition of sophisticated interfaces and specialized software for execution, which usually have a high implementation costs. We present a combination of low-cost hardware and open-source software for the implementation of videogame based on virtual reality with MI and its potential use as neurotherapy for stroke patients. Three machine learning algorithms for the BCI signals classification are shown: LDA (Linear Discriminant Analysis) and two Support Vector Machines (SVM) in order to determine which task of MI is being performed by the user in a particular moment of the experiment. All classification algorithms was evaluated in 8 healthy subjects, the average accuracy of the best classifier was 96.7%, which shows that it is possible to carry out serious neuroscientific experiments with MI using low-cost BCI systems and achieve comparable accuracies with more sophisticated and expensive devices.