The Foundation to Advance Brain Rehabilitation: Organization, History, and Collaborative Database.

OBJECTIVE: To describe the history, organization, goals, and data management procedures of the Foundation to Advance Brain Rehabilitation (FABR). SETTING: Postacute brain injury rehabilitation following acute inpatient care. KEY POINTS: FABR was incorporated in 2019 with a primary mission to advance brain rehabilitation through scientific and strategic analysis of industry-wide data. Contributing FABR member organizations include Bancroft NeuroRehab, Collage Rehabilitation Partners, On With Life, Pate NeuroRehabilitation, and Shepherd Center. These organizations contribute demographic, admission, discharge, and follow-up data on persons served in 5 types of intensive posthospital brain injury rehabilitation programs (neurobehavioral residential, neurorehabilitation residential, home and community neurorehabilitation, day treatment, and outpatient) and 3 types of supported living programs (neurobehavioral residential, residential, and community-based) to a collaborative database managed by Inventive Software Solutions. Inventive Software Solutions provides FABR researchers with a dataset that is de-identified both for participant and organizational identifying information.

Evaluation of Posthospital Brain Injury Rehabilitation Outcomes With Quasi-Experimental Controls.

OBJECTIVE: To further evaluate, using quasi-experimental methodologies, posthospital brain injury rehabilitation outcomes described in an accompanying report of a large observational study (n = 2120). SETTING: Data from Intensive Rehabilitation (IR: Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation) and Supported Living (SL) programs serving individuals with acquired brain injury (ABI). PARTICIPANTS: Two hundred twenty-eight individuals with traumatic brain injury, stroke, or other ABI in propensity score analysis; 1344 in analysis by extent of recommended treatment completed (TC) rating. MAIN MEASURES: Sex, age, time since injury, Mayo-Portland Adaptability Inventory-4th edition (MPAI-4) Rasch-derived T-scores, and TC rating. DESIGN: Analyses of covariance (1) of discharge MPAI-4 Total, index, and subscale T-scores on propensity score-matched samples of IR and SL participants controlling for admission scores and (2) of MPAI-4 T-scores by TC rating and diagnostic category. RESULTS: Propensity score-matched groups showed superior outcomes for IR participants compared to SL participants on MPAI-4 Total T-score (F = 77.21, P < .001; partial η2 = 0.257) and all MPAI-4 index and subscale T-scores controlling for sex, age, and baseline scores. Participants with traumatic brain injury and stroke who completed the recommended course of rehabilitation had superior outcomes on all MPAI-4 T-scores compared to those who completed less than or much less than the recommended treatment. No additional benefit was apparent for those who completed more than the recommended course. The association between TC rating and outcome was not significant for the other ABI group. CONCLUSIONS: These analyses using quasi-experimental controls provide more scientifically rigorous evidence of the benefit of IR provided through posthospital brain injury rehabilitation programs after acute inpatient care, consistent with the results of numerous observational studies. However, improved internal validity limits external validity and generalization. The absence of a significant association between TC rating and outcomes for the other ABI group most likely reflects the difficulty prescribing rehabilitation for this highly heterogeneous group.

Role and Outcomes of Supported Community Living Programs in Post-Hospital Brain Injury Rehabilitation Programs.

OBJECTIVES: (1) To determine the proportion of participants admitted to supported community living (SCL) programs over the course of 5 years who improve, decline, or maintain functioning and community integration and (2) to examine the associations of time since injury, time in program, and age to their functional trajectory. SETTING: Data from SCL programs serving individuals with acquired brain injury (ABI). PARTICIPANTS: 104 individuals with traumatic brain injury (TBI), stroke, or other ABI. MAIN MEASURES: Sex, age, time since injury, Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). DESIGN: Retrospective analyses of MPAI-4 total and MPAI-4 indices using Linear Mixed Models (LMM) of Rasch-derived T-scores from admission to 5 years into service delivery. RESULTS: MPAI-4 total, index, and subscale scores for yearly intervals of SCL services from admission to 5 years showed a high degree of stability in function (defined using the standard error of measurement (SEM) for the MPAI-4, defined as change ≥3 T-score points) with all intervals showing at least 89% of patients with improved scores or no change. The rate of change over time did not significantly vary by time since injury, time in the program, or age. CONCLUSIONS: The expectations for services in the SCL portion of the care continuum for ABI are unique. Unlike intensive rehabilitation programs which focus on improvement often earlier in the course of recovery, the goal of SCL services is sustained functioning over the long term. Analyses reported here indicate this can be achieved for at least 5 years, potentially mitigating the increased risk for rehospitalization and increased care needs in the ABI population. This study highlights a key finding of MPAI-4 stability within these understudied brain injury service lines. Additional exploration of comorbidities and more nuanced delineation of diagnostic information could further clarify factors influencing outcome stability over time.

Distinguishing Characteristics of Admissions to Various Types of Posthospital Brain Injury Rehabilitation Programs.

OBJECTIVE: Describe and compare the demographic characteristics and disability profiles of individuals admitted to 6 types of posthospital brain injury rehabilitation (PHBIR) programs. SETTING: Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and Supported Living programs serving individuals with acquired brain injury (ABI). PARTICIPANTS: Two thousand twenty-eight individuals with traumatic brain injury (TBI), stroke, or other ABI. MAIN MEASURES: Sex, age, time since injury, and Mayo-Portland Adaptability Inventory, 4th edition (MPAI-4). DESIGN: Retrospective analyses of demographic variables and MPAI-4 Total, Index, and subscale Rasch-derived T-scores on admission comparing diagnostic categories and program types within diagnostic categories. RESULTS: Participants with TBI were predominantly male, and those with stroke were generally older. Admissions to more intensive and supervised programs (residential neurobehavioral and residential neurorehabilitation) generally showed greater disability than admissions to home and community programs who were more disabled than participants in day treatment and outpatient programs. Residential neurobehavioral and supported living program participants generally were male and had TBI. Home and community admissions tended to be more delayed than residential neurorehabilitation admissions. The majority of those with other ABI were admitted to outpatient rather than more intensive programs. Additional analyses demonstrated significant differences in MPAI-4 profiles among the various program types. CONCLUSIONS: Admissions with TBI, stroke, and other ABI to PHBIR differ in demographic factors and disability profiles. When examined within each diagnostic category, demographic features and disability profiles also distinguish among admissions to the various program types. Results provide insights about decision-making in referral patterns to various types of PHBIR programs, although other factors not available for analysis (eg, participant/family preference, program, and funding availability) likely also contribute to admission patterns.

Outcomes of Six Specific Types of Post-Hospital Brain Injury Rehabilitation Programs.

OBJECTIVE: Evaluate outcomes of intensive posthospital brain injury rehabilitation programs compared to supported living (SL) programs; explore variations in outcome by diagnostic category (traumatic brain injury, stroke, and other acquired brain injury [ABI]) and specific program type. SETTING: Data were obtained from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and SL programs serving individuals with ABI. PARTICIPANTS: A total of 2120 individuals with traumatic brain injury, stroke, or other ABI participated in this study. MAIN MEASURES: The main measures are sex, age, time since injury, and Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). DESIGN: Retrospective analyses of demographic variables and MPAI-4 Total, index, and subscale Rasch-derived T-scores on admission and discharge. RESULTS: Gains on MPAI-4  Total T-scores were significantly greater for the intensive rehabilitation (IR) group in comparison to stable functioning in the SL group (F = 236.69, P < .001, partial η2 = .101) while controlling for admission/time 1 scores; similar results were found for MPAI-4 indices and subscales. For the IR cohort, discharge scores differed by diagnostic category after controlling for admission scores for the Total MPAI-4 T-score (F = 22.65, P < .001, partial η2 = .025), as well as all indices and subscales. A statistically significant interaction between program type and diagnostic group on discharge MPAI-4 Total T-scores (F = 2.55, P = .018, partial η2 = .01) after controlling for admission scores indicated that differing outcomes across diagnoses also varied by program type. Varying significant main effects and interactions were apparent for MPAI-4 indices and subscales with generally small effect sizes. CONCLUSIONS: Significant gains on MPAI-4 variables across IR program types compared to no change over a comparable period of time for SL programs supports the effectiveness of posthospital brain injury rehabilitation. This finding in the presence of small effect sizes on outcome variables for program type and for significant interactions between program type and diagnostic category suggests that participants generally were appropriately matched to program type and benefited from interventions provided through specific program types.

Response to the COVID-19 Pandemic Among Posthospital Brain Injury Rehabilitation Providers.

Rehabilitation after significant acquired brain injury (ABI) to address complex independent activities of daily living and return to family and community life is offered primarily after initial hospitalization in outpatient day treatment, group home, skilled nursing, and residential settings and in the home and community of the person served. The coronavirus 2019 pandemic threatened access to care and the health and safety of staff, persons served, and families in these settings. This article describes steps taken to contain this threat by 7 leading posthospital ABI rehabilitation organizations. Outpatient and day treatment facilities were temporarily suspended. In other settings, procedures for isolation, transportation, cleaning, exposure control, infection control, and use of personal protective equipment (PPE) were reinforced with staff. Visitation and community activities were restricted. Staff and others required to enter facilities were screened with symptom checklists and temperature checks. Individuals showing symptoms of infection were quarantined and tested, as possible. New admissions were carefully screened for infection and often initially quarantined. Telehealth played a major role in reducing direct interpersonal contact while continuing to provide services both to outpatients and within facilities. Salary, benefits, training, and managerial support were enhanced for staff. Despite early outbreaks, these procedures were generally effective, with preliminary initial infections rates of only 1.1% for persons served and 2.1% for staff. Reductions in admissions, services, and unanticipated expenses (eg, PPE, more frequent and thorough cleaning) had a major negative financial effect. Providers continue to be challenged to adapt rehabilitative approaches and to reopen services.

Hospital-Based Health Care After Traumatic Brain Injury.

OBJECTIVE: To investigate trends of hospital-based health care utilization after admission to a level I trauma center after acute traumatic brain injury (TBI). DESIGN: Retrospective review. SETTING: Large urban trauma hospital and a hospital council data registry consisting of 88 member institutions (>150 hospitals) covering 15,000 square miles. PARTICIPANTS: All patients (N=5291) admitted to a level I trauma center between January 1, 2006, and June 30, 2014, who experienced an acute TBI based on International Classification of Diseases, Ninth Revision coding. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Included the incidence and type of select hospital-based services received. Analyses were also categorized based on demographic and injury-related information. RESULTS: Of the 5291 patients with newly acquired TBI who were admitted, 512 died, leaving 4779 patients for inclusion in the final analysis. Additional health care utilization from January 1, 2006, and June 30, 2014, was recorded for 3158 patients (66%), totaling 12,307 encounters, with a median of 3 encounters (interquartile range, 1-5) and a maximum of 102 encounters. Most nonadmission urgent or procedural visits (96%) and inpatient encounters (93%) occurred in the first year. Of all the additional encounters, 9769 visits were nonadmission urgent or procedural visits (79%) with a median charge of $1955. The most common type of encounter was elective (46%), followed by medical emergency (29%). Of the remaining 2538 inpatient encounters (21%), the mean length of stay was 6 days with a median charge of $28,450. Medical emergency (39%) and elective admissions (33%) again were the most common encounter type. CONCLUSIONS: This analysis encompasses health care utilization across the range of TBI severity and numerous hospital systems, allowing for a more comprehensive and objective identification of reasons for readmission. This represents an initial step to developing a preventive intervention to manage secondary complications postinjury.

Recognizing European cancer nursing: Protocol for a systematic review and meta-analysis of the evidence of effectiveness and value of cancer nursing.

AIM: To identify, appraise and synthesize the available evidence relating to the value and impact of cancer nursing on patient experience and outcomes. BACKGROUND: There is a growing body of literature that recognizes the importance and contribution of cancer nurses, however, a comprehensive review examining how cancer nurses have an impact on care quality, patient outcomes and overall experience of cancer, as well as cost of services across the entire cancer spectrum is lacking. DESIGN: A systematic review and meta-analysis using Cochrane methods. METHODS: We will systematically search 10 electronic databases from 2000, with pre-determined search terms. No language restrictions will be applied. We will include all randomized and controlled before-and-after studies that compare cancer nursing interventions to a standard care or no intervention. Two reviewers will independently assess the eligibility of the studies and appraise methodological quality using the Cochrane Risk of Bias tool. Disagreements will be resolved by discussion and may involve a third reviewer if necessary. Data from included studies will be extracted in accordance with the Template for intervention Description and Replication reporting guidelines. Missing data will be actively sought from all trialists. Data will be synthesized in evidence tables and narrative to answer three key questions. If sufficient data are available, we will perform meta-analyses. DISCUSSION: This review will allow us to systematically assess the impact of cancer nursing on patient care and experience. This evidence will be used to determine implications for clinical practice and used to inform future programme and policy decisions in Europe.

Knowing the scope of meningococcal disease in Latin America.

Opportunities for strengthening surveillance of meningococcal disease exist between and within countries in Latin America. In August of 2015, a workshop was convened in the city of São Paulo, Brazil, to address the following objectives: 1) to review meningococcal disease burden and vaccine use in Latin America; 2) to evaluate the effectiveness of current meningococcal surveillance practices in the region; 3) to identify challenges to meningococcal surveillance in the region; and 4) to outline steps for strengthening meningococcal surveillance and disease control in the region. Based on the workshop's discussions, recommendations for strengthening surveillance and controlling meningococcal disease in Latin America focus on improving: a) laboratory capabilities for diagnostic testing; b) communication regarding epidemiologic- and laboratory-based analyses; c) communication during outbreaks; d) monitoring of long-term disease outcomes; e) knowledge of vaccines against serogroup B disease; and f) criteria for defining and controlling meningococcal outbreaks. Overall, improving surveillance will help guide strategies for meningococcal disease prevention and control in Latin America.

Existen distintas oportunidades para reforzar los procedimientos de vigilancia de la enfermedad meningocócica entre los países de América Latina y dentro de ellos. En agosto del 2015, se llevó a cabo un taller en la ciudad de São Paulo (Brasil) en el que se trataron los siguientes puntos: 1) examen de la carga de la enfermedad meningocócica y el uso de la vacuna en América Latina; 2) evaluación de la eficacia de los actuales procedimientos de vigilancia de la enfermedad meningocócica en la región; 3) especificación de los retos para la vigilancia de la enfermedad meningocócica en la región; y 4) definición de los pasos para fortalecer los procedimientos de vigilancia de la enfermedad meningocócica y el control de esta enfermedad en la región. Como resultado del taller se formularon recomendaciones para reforzar los procedimientos de vigilancia y control de la enfermedad meningocócica en América Latina que hacían hincapié en mejorar: a) las capacidades de laboratorio con respecto a las pruebas diagnósticas; b) la comunicación sobre los análisis epidemiológicos y de laboratorio; c) la comunicación durante los brotes; d) el seguimiento de las consecuencias de la enfermedad a largo plazo; e) el conocimiento sobre las vacunas contra la enfermedad causada por el serogrupo B; y f) los criterios para definir y controlar los brotes meningocócicos. En términos generales, la mejora de los procedimientos de vigilancia ayudará a delinear las estrategias para la prevención y el control de la enfermedad meningocócica en América Latina.

Existem oportunidades para o reforço da vigilância da doença meningocócica entre os países e em cada país na América Latina. Em agosto de 2015, foi realizado um seminário na cidade de São Paulo, Brasil, com os seguintes objetivos: 1) avaliar a carga da doença meningocócica e o uso da vacina na América Latina; 2) avaliar a eficácia das atuais práticas de vigilância da doença meningocócica na Região; 3) identificar os desafios para a vigilância meningocócica na Região e 4) definir medidas para reforçar a vigilância da doença meningocócica e o controle da doença na Região. Partindo dos debates realizados durante o seminário, foram feitas as seguintes recomendações para reforçar a vigilância e o controle da doença meningocócica na América Latina, dando-se ênfase a melhorar: a) a infraestrutura laboratorial para exames diagnósticos; b) a comunicação das análises epidemiológicas e laboratoriais; c) a comunicação nos surtos; d) o monitoramento dos desfechos da doença a longo prazo; e) o conhecimento sobre as vacinas contra o meningococo do sorogrupo B e f) os critérios para definir e controlar os surtos de doença meningocócica. Em geral, a melhoria da vigilância contribuirá para orientar as estratégias para prevenção e controle da doença meningocócica na América Latina.

Simulation exercises to strengthen polio outbreak preparedness: experience of the World Health Organization European Region.

BACKGROUND: Poliovirus importations and related outbreaks continue to occur in polio-free countries, including those in the World Health Organization (WHO) European Region. National preparedness plans for responding to poliovirus introduction are insufficient in many countries of the European Region. We describe a series of polio outbreak simulation exercises that were implemented to formally test polio outbreak preparedness plans in the European Region. METHODS: We designed and implemented the exercises, reviewed the results, made recommendations, and assessed the role of outbreak simulation exercises in maintaining regional polio-free status. In addition, we performed a comprehensive review of the national plans of all WHO Member States in the European Region. RESULTS: Three exercises, delivered during 2011-2013 (for the Balkans, United Kingdom, and the Caucasus and Ukraine), revealed that participating countries were generally prepared for poliovirus introduction, but the level of preparedness needed improvement. The areas in particular need of strengthening were national preparedness plans, initial response, plans for securing vaccine supply, and communications. CONCLUSIONS: Polio outbreak simulation exercises can be valuable tools to help maintain polio-free status and should be extended to other high-risk countries and subnational areas in the European Region and elsewhere.

Capturing the Value of Vaccination within Health Technology Assessment and Health Economics-Practical Considerations for Expanding Valuation by Including Key Concepts.

Following the development of a value of vaccination (VoV) framework for health technology assessment/cost-effectiveness analysis (HTA/CEA), and identification of three vaccination benefits for near-term inclusion in HTA/CEA, this final paper provides decision makers with methods and examples to consider benefits of health systems strengthening (HSS), equity, and macroeconomic gains. Expert working groups, targeted literature reviews, and case studies were used. Opportunity cost methods were applied for HSS benefits of rotavirus vaccination. Vaccination, with HSS benefits included, reduced the incremental cost-effectiveness ratio (ICER) by 1.4-50.5% (to GBP 11,552-GBP 23,016) depending on alternative conditions considered. Distributional CEA was applied for health equity benefits of meningococcal vaccination. Nearly 80% of prevented cases were among the three most deprived groups. Vaccination, with equity benefits included, reduced the ICER by 22-56% (to GBP 7014-GBP 12,460), depending on equity parameters. Macroeconomic models may inform HTA deliberative processes (e.g., disease impact on the labour force and the wider economy), or macroeconomic outcomes may be assessed for individuals in CEAs (e.g., impact on non-health consumption, leisure time, and income). These case studies show how to assess broader vaccination benefits in current HTA/CEA, providing decision makers with more accurate and complete VoV assessments. More work is needed to refine inputs and methods, especially for macroeconomic gains.

Immunization technologies: Time to consider new preventative solutions for respiratory syncytial virus infections.

New technologies for the prevention of infectious diseases are emerging to address unmet medical needs, in particular, the use of long-acting monoclonal antibodies (mAb) to prevent Respiratory Syncytial Virus (RSV) lower respiratory tract disease in infants during their first RSV season. The lack of precedent for mAbs for broad population protection creates challenges in the assessment of upcoming prophylactic long-acting mAbs for RSV, with associated consequences in legislative and registration categorization, as well as in recommendation, funding, and implementation pathways. We suggest that the legislative and regulatory categorization of preventative solutions should be decided by the effect of the product in terms of its impact on the population and health-care systems rather than by the technology used or its mechanism of action. Immunization can be passive and active, both having the same objective of prevention of infectious diseases. Long-acting prophylactic mAbs work as passive immunization, as such, their recommendations for use should fall under the remit of National Immunization Technical Advisory Groups or other relevant recommending bodies for inclusion into National Immunization Programs. Current regulations, policy, and legislative frameworks need to evolve to embrace such innovative preventative technologies and acknowledge them as one of key immunization and public health tools.

Rule of Prevention: a potential framework to evaluate preventive interventions for rare diseases.

Background: The benefits of preventive interventions lack comprehensive evaluation in standard health technology assessments (HTA), particularly for rare and transmissible diseases. Objective: To identify possible considerations for future HTA using analogies between the treatment and prevention of rare diseases. Study design: An Expert panel meeting assessed whether one HTA assessment framework can be applied to assess both rare disease treatments and preventive interventions. Experts also evaluated the range of value elements currently included in HTAs and their applicability to rare, transmissible, and/or preventable diseases. Results: A broad range of value should be considered when assessing rare, transmissible disease prevention. Although standard HTA can be applied to transmissible diseases, the risk of local outbreaks and the need for large-scale prevention programs suggest a modified assessment framework, capable of incorporating prevention-specific value elements in HTAs. A 'Rule of Prevention' framework was proposed to allow broader value considerations anchored to severity, equity, and prevention benefits in decision-making for preventive interventions for rare transmissible diseases. Conclusion: The proposed prevention framework introduces an explicit initial approach to consistently assess rare transmissible diseases, and to incorporate the broader value of preventive interventions compared with treatment.

Meningococcal Disease in the Post-COVID-19 Era: A Time to Prepare.

The global invasive meningococcal disease (IMD) landscape changed considerably during the COVID-19 pandemic, as evidenced by decreased incidence rates due to COVID-19 mitigation measures, such as limited social contact, physical distancing, mask wearing, and hand washing. Vaccination rates were also lower during the pandemic relative to pre-pandemic levels. Although policymakers may have shifted their focus away from IMD vaccination programs to COVID-19 vaccination programs, strong arguments support implementation and prioritization of IMD vaccination programs; IMD cases have increased in some countries and IMD rates may even have exceeded pre-pandemic levels. Additional concerns include increased susceptibility due to vaccination coverage gaps, increased incidence of other respiratory pathogens, immunity debt from lockdown restrictions, and increased IMD epidemiologic variability. The full range of benefits of widely available and effective meningococcal vaccines needs to be considered, especially in health technology assessments, where the broad benefits of these vaccines are neither accurately quantified nor captured in implementation policy decisions. Importantly, implementation of meningococcal vaccination programs in the current IMD climate also appeals to broader healthcare principles, including preparedness rather than reactive approaches, generally accepted benefit-risk approaches to vaccination, historical precedent, and the World Health Organization's goal of defeating meningitis by 2030. Countries should therefore act swiftly to bolster existing meningococcal vaccination strategies to provide broad coverage across age groups and serogroups given the recent increases in IMD incidence.

The Societal Value of Vaccines: Expert-Based Conceptual Framework and Methods Using COVID-19 Vaccines as a Case Study.

Health technology assessments (HTAs) of vaccines typically focus on the direct health benefits to individuals and healthcare systems. COVID-19 highlighted the widespread societal impact of infectious diseases and the value of vaccines in averting adverse clinical consequences and in maintaining or resuming social and economic activities. Using COVID-19 as a case study, this research work aimed to set forth a conceptual framework capturing the broader value elements of vaccines and to identify appropriate methods to quantify value elements not routinely considered in HTAs. A two-step approach was adopted, combining a targeted literature review and three rounds of expert elicitation based on a modified Delphi method, leading to a conceptual framework of 30 value elements related to broader health effects, societal and economic impact, public finances, and uncertainty value. When applying the framework to COVID-19 vaccines in post-pandemic settings, 13 value elements were consensually rated highly important by the experts for consideration in HTAs. The experts reviewed over 10 methods that could be leveraged to quantify broader value elements and provided technical forward-looking recommendations. Limitations of the framework and the identified methods were discussed. This study supplements ongoing efforts aimed towards a broader recognition of the full societal value of vaccines.

Vaccines for a sustainable planet.

The health of the planet is one objective of the United Nations' Sustainable Development Goals. Vaccines can affect not only human health but also planet health by reducing poverty, preserving microbial diversity, reducing antimicrobial resistance, and preventing an increase in pandemics that is fueled partly by climate change.