Designing a Fall Prediction Model for Inpatient Rehabilitation Facilities Using Readily Available Data.

OBJECTIVE: To create a fall risk assessment tool for inpatient rehabilitation facilities (IRFs) using available data and compare its predictive accuracy with that of the Morse Fall Scale (MFS). DESIGN: We conducted a secondary analysis from a retrospective cohort study. Using a nomogram that displayed the contributions of QI codes associated with falls in a multivariable logistic regression model, we created a novel fall risk assessment, the Inpatient Rehabilitation Fall Scale (IRF Scale). To compare the predictive accuracy of the IRF Scale and MFS, we used receiver operator characteristic (ROC) curve analysis. SETTING: We included data from 4 IRFs owned and operated by Intermountain Health. PARTICIPANTS: Data came from the medical records of 1699 patients. All participants were over the age of 14 and were admitted and discharged from 1 of the 4 sites between January 1 and December 31, 2020. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): We assigned point values on the IRF Scale based on the adjusted associations of QI codes with falls. Using ROC curve analysis, we discovered an optimal cutoff score, sensitivity, specificity, and overall AUC of the IRF Scale and MFS. RESULTS: ROC curve analysis revealed the optimal IRF Scale cutoff score of 22.4 yielded a sensitivity of 0.74 and a specificity of 0.63. With an AUC of 0.72, the IRF Scale demonstrated acceptable accuracy at identifying patients who fell in our retrospective cohort. CONCLUSIONS: Because the IRF Scale uses readily available data, it minimizes staff assessment and outperforms the MFS at identifying patients who previously fell. Prospective research is needed to investigate if it can adequately identify in advance which patients will fall during their IRF stay.

Using Quality Indicator Codes to Identify Patients' Fall Risk in Inpatient Rehabilitation Facilities.

OBJECTIVE: To discover if quality indicator (QI) codes are associated with patient falls in inpatient rehabilitation facilities (IRFs). DESIGN: This retrospective cohort study explored differences between patients who fell and those who did not fall. We analyzed potential associations between QI codes and falls using univariable and multivariable logistic regression models. SETTING: We collected data from electronic medical records at 4 IRFs. PARTICIPANTS: In 2020, our 4 data collection sites admitted and discharged a total of 1742 patients older than 14 years . We only excluded patients (N=43) from statistical analysis if they were discharged before admission data had been assigned. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Using a data extraction report, we collected age, sex, race and ethnicity, diagnosis, falls, and QI codes for communication, self-care, and mobility performance. Staff documented communication codes on a 1-4 scale and self-care and mobility codes on a 1-6 scale, with higher codes representing greater independence. RESULTS: Ninety-seven patients (5.71%) fell in the 4 IRFs over a 12-month period. The group who fell had lower QI codes for communication, self-care, and mobility. When adjusting for bed mobility, transfer, and stair-climbing ability, low performance with understanding, walking 10 feet, and toileting were significantly associated with falls. Patients with admission QI codes below 4 for understanding had 78% higher odds of falling. If they were assigned admission QI codes below 3 for walking 10 feet or toileting, they had 2 times greater odds of falling. We did not find a significant association between falls and patients' diagnosis, age, sex, or race and ethnicity in our sample. CONCLUSIONS: Communication, self-care, and mobility QI codes appear to be significantly associated with falls. Future research should explore how to use these required codes to better identify patients likely to fall in IRFs.

Family Involvement in Traumatic Brain Injury Inpatient Rehabilitation: A Propensity Score Analysis of Effects on Outcomes During the First Year After Discharge.

OBJECTIVE: To evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge. DESIGN: Propensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data. SETTING: Nine inpatient rehabilitation centers in the United States. PARTICIPANTS: Patients (N=1835) admitted for first inpatient rehabilitation after an index TBI. INTERVENTION: Family attendance during therapy sessions. MAIN OUTCOME MEASURES: Participation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9. RESULTS: Participants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance. CONCLUSIONS: Family involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients' families in the rehabilitation process to maximize outcomes.

Contextualized Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge.

OBJECTIVE: To evaluate the effect of providing a greater percentage of therapy as contextualized treatment on acute traumatic brain injury (TBI) rehabilitation outcomes. DESIGN: Propensity score methods are applied to the TBI Practice-Based Evidence (TBI-PBE) database, a database consisting of multi-site, prospective, longitudinal observational data. SETTING: Acute inpatient rehabilitation. PARTICIPANTS: Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received their first inpatient rehabilitation facility admission in the US, and consented to follow-up 3 and 9 months post discharge from inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation Assessment with Recombined Tools-Objective (PART-O)-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. RESULTS: Increasing the percentage of contextualized treatment during inpatient TBI rehabilitation leads to better outcomes, specifically in regard to community participation. CONCLUSIONS: Increasing the proportion of treatment provided in the context of real-life activities appears to have a beneficial effect on outcome. Although the effect sizes are small, the results are consistent with other studies supporting functional-based interventions effecting better outcomes. Furthermore, any positive findings, regardless of size or strength, are endorsed as important by consumers (survivors of TBI). While the findings do not imply that decontextualized treatment should not be used, when the therapy goal can be addressed with either approach, the findings suggest that better outcomes may result if the contextualized approach is used.

Level of Effort and 3 Hour Rule Compliance.

OBJECTIVE: To determine if patients' level of effort (LOE) in therapy sessions during traumatic brain injury (TBI) rehabilitation modifies the effect of compliance with the 3-Hour Rule of the Centers for Medicare & Medicaid Services. DESIGN: Propensity score methodology applied to the TBI Practice-Based Evidence database, consisting of multisite, prospective, longitudinal observational data. SETTING: Acute inpatient rehabilitation facilities (IRF). PARTICIPANTS: Patients (N=1820) who received their first IRF admission for TBI in the United States and were enrolled for 3- and 9-month follow-up. MAIN OUTCOME MEASURES: Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. RESULTS: When the full cohort was examined, no strong main effect of compliance with the 3-Hour Rule was identified and LOE did not modify the effect of compliance with the 3-Hour Rule. In contrast, LOE had a strong positive main effect on all outcomes, except depression. When the sample was stratified by level of disability, LOE modified the effect of compliance, particularly on the outcomes of participants with less severe disability. For these patients, providing 3 hours of therapy for 50% or more of therapy days in the context of low effort resulted in poorer performance on select outcome measures at discharge and up to 9 months postdischarge compared to patients with <50% of 3-hour therapy days. CONCLUSIONS: LOE is an active ingredient in inpatient TBI rehabilitation, while compliance with the 3-Hour Rule was not found to have a substantive effect on the outcomes. The results support matching time in therapy during acute TBI rehabilitation to patients' LOE in order to optimize long-term benefits on outcomes.

Advanced Therapy in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge.

OBJECTIVE: To use causal inference methods to determine if receipt of a greater proportion of inpatient rehabilitation treatment focused on higher level functions, for example, executive functions, ambulating over uneven surfaces (advanced therapy [AdvTx]), results in better rehabilitation outcomes. DESIGN: A cohort study using propensity score methods applied to the traumatic brain injury practice-based evidence (TBI-PBE) database, a database consisting of multisite, prospective, longitudinal observational data. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, receiving their first inpatient rehabilitation facility admission to 1 of 9 sites in the United States, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation Assessment with Recombined Tools-Objective-17, FIM motor and cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. RESULTS: Controlling for measured potential confounders, increasing the percentage of AdvTx during inpatient TBI rehabilitation was found to be associated with better community participation, functional independence, life satisfaction, and decreased likelihood of depression during the year after discharge from inpatient rehabilitation. Participants who began rehabilitation with greater disability experienced larger gains on some outcomes than those who began rehabilitation with more intact abilities. CONCLUSIONS: Increasing the proportion of treatment targeting higher level functions appears to have no detrimental and a small, beneficial effect on outcome. Caution should be exercised when inferring causality given that a large number of potential confounders could not be completely controlled with propensity score methods. Further, the extent to which unmeasured confounders influenced the findings is not known and could be of particular concern due to the potential for the patient's recovery trajectory to influence therapists' decisions to provide a greater amount of AdvTx.

Occupational, Physical, and Speech Therapy Treatment Activities During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury. DESIGN: Multisite prospective observational cohort study. SETTING: Inpatient rehabilitation settings. PARTICIPANTS: Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined. RESULTS: Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay. CONCLUSIONS: The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups.