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.

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.

Outcome prediction in home- and community-based brain injury rehabilitation using the Mayo-Portland Adaptability Inventory.

The objective of the study was to develop statistical formulas to predict levels of community participation on discharge from post-hospital brain injury rehabilitation using retrospective data analysis. Data were collected from seven geographically distinct programmes in a home- and community-based brain injury rehabilitation provider network. Participants were 642 individuals with post-traumatic brain injury. Interventions consisted of home- and community-based brain injury rehabilitation. The main outcome measure was the Mayo-Portland Adaptability Inventory (MPAI-4) Participation Index. Linear discriminant models using admission MPAI-4 Participation Index score and log chronicity correctly predicted excellent (no to minimal participation limitations), very good (very mild participation limitations), good (mild participation limitations), and limited (significant participation limitations) outcome levels at discharge. Predicting broad outcome categories for post-hospital rehabilitation programmes based on admission assessment data appears feasible and valid. Equations to provide patients and families with probability statements on admission about expected levels of outcome are provided. It is unknown to what degree these prediction equations can be reliably applied and valid in other settings.

Effectiveness of home- and community-based rehabilitation in a large cohort of patients disabled by cerebrovascular accident: evidence of a dose-response relationship.

OBJECTIVES: To (1) assess the effectiveness of home- and community-based rehabilitation (HCBR) in a large cohort of individuals with disabilities secondary to cerebrovascular accident (CVA); and (2) evaluate the responsiveness to treatment of the Mayo-Portland Adaptability Inventory (MPAI-4) to changes resulting from HCBR in this patient group. DESIGN: Retrospective analysis of program evaluation data for treatment completers and noncompleters. SETTING: HCBR conducted in 7 geographically distinct U.S. cities. PARTICIPANTS: Individuals with CVA (n=738) who completed the prescribed course of rehabilitation (completed course of treatment [CCT]) compared with 150 individuals who were precipitously discharged (PD) before program completion. INTERVENTION: HCBR delivered by certified professional staff on an individualized basis. MAIN OUTCOME MEASURES: Mayo-Portland Adaptability Inventory (MPAI-4) completed by professional consensus on admission and at discharge. RESULTS: With the use of analysis of covariance, MPAI-4 total scores at discharge for CCT participants were compared with those of PD participants, with admission MPAI-4, age, length of stay, and time since event as covariates. CCT participants showed greater improvement than PD participants (F=99.48, P<.001) with a moderate effect size (partial η(2)=.10). Group differences and effect sizes were similar for the 3 index scores: Ability (F=75.96, P<.001; partial η(2)=.08), Adjustment (F=99.67, P<.001; partial η(2)=.10), and Participation (F=69.15, P<.001; partial η(2)=.07). CONCLUSIONS: Individuals in the CCT group who received the entire planned course of HCBR showed greater improvement on all MPAI-4 indexes than those in the PD group who were discharged before completing the prescribed program. This dose-response relationship provides evidence of a causal relationship between treatment and outcome.

Mayo-Portland adaptability inventory: comparing psychometrics in cerebrovascular accident to traumatic brain injury.

OBJECTIVES: (1) To evaluate the measurement reliability and construct validity of the Mayo-Portland Adaptability Inventory, 4th revision (MPAI-4) in a sample consisting exclusively of patients with cerebrovascular accident (CVA) using single parameter (Rasch) item-response methods; (2) to examine the differential item functioning (DIF) by sex within the CVA population; and (3) to examine DIF and differential test functioning (DTF) across traumatic brain injury (TBI) and CVA samples. DESIGN: Retrospective psychometric analysis of rating scale data. SETTING: Home- and community-based brain injury rehabilitation program. PARTICIPANTS: Individuals post-CVA (n=861) and individuals with TBI (n=603). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: MPAI-4. RESULTS: Item data on admission to community-based rehabilitation were submitted to Rasch, DIF, and DTF analyses. The final calibration in the CVA sample revealed satisfactory reliability/separation for persons (.91/3.16) and items (1.00/23.64). DIF showed that items for pain, anger, audition, and memory were associated with higher levels of disability for CVA than TBI patients; whereas, self-care, mobility, and use of hands indicated greater overall disability for TBI patients. DTF analyses showed a high degree of association between the 2 sets of items (R=.92; R(2)=.85) and, at most, a 3.7 point difference in raw scores. CONCLUSIONS: The MPAI-4 demonstrates satisfactory psychometric properties for use with individuals with CVA applying for interdisciplinary posthospital rehabilitation. DIF reveals clinically meaningful differences between CVA and TBI groups that should be considered in results at the item and subscale level.

Effectiveness of community-based rehabilitation after traumatic brain injury for 489 program completers compared with those precipitously discharged.

OBJECTIVE: To evaluate outcomes of home- and community-based postacute brain injury rehabilitation (PABIR). DESIGN: Retrospective analysis of program evaluation data for treatment completers and noncompleters. SETTING: Home- and community-based PABIR conducted in 7 geographically distinct U.S. cities. PARTICIPANTS: Patients (N=489) with traumatic brain injury who completed the prescribed course of rehabilitation (completed-course-of-treatment [CCT] group) compared with 114 who were discharged precipitously before program completion (precipitous-discharge [PD] group). INTERVENTION: PABIR delivered in home and community settings by certified professional staff on an individualized basis. MAIN OUTCOME MEASURES: Mayo-Portland Adaptability Inventory (MPAI-4) completed by means of professional consensus on admission and at discharge; MPAI-4 Participation Index at 3- and 12-month follow-up through telephone contact. RESULTS: Analysis of covariance (CCT vs PD group as between-subjects variable, admission MPAI-4 score as covariate) showed significant differences between groups at discharge on the full MPAI-4 (F=82.25; P<.001), Ability Index (F=50.24; P<.001), Adjustment Index (F=81.20; P<.001), and Participation Index (F=59.48; P<.001). A large portion of the sample was lost to follow-up; however, available data showed that group differences remained statistically significant at follow-up. CONCLUSIONS: Results provided evidence of the effectiveness of home- and community-based PABIR and that treatment effects were maintained at follow-up.

Rasch measurement analysis of the Mayo-Portland Adaptability Inventory (MPAI-4) in a community-based rehabilitation sample.

The precise measurement of patient outcomes depends upon clearly articulated constructs and refined clinical assessment instruments that work equally well for all subgroups within a population. This is a challenging task in those with acquired brain injury (ABI) because of the marked heterogeneity of the disorder and subsequent outcomes. Although essential, the iterative process of instrument refinement is often neglected. This present study was undertaken to examine validity, reliability, dimensionality and item estimate invariance of the Mayo-Portland Adaptability Inventory - 4 (MPAI-4), an outcome measure for persons with ABI. The sampled population included 603 persons with traumatic ABI participating in a home- and community-based rehabilitation program. Results indicated that the MPAI-4 is a valid, reliable measure of outcome following traumatic ABI, which measures a broad but unitary core construct of outcome after ABI. Further, the MPAI-4 is composed of items that are unbiased toward selected subgroups except where differences could be expected [e.g., more chronic traumatic brain injury (TBI) patients are better able to negotiate demands of transportation than more acute TBI patients]. We address the trade-offs between strict unidimensionality and clinical applicability in measuring outcome, and illustrate the advantages and disadvantages of applying single-parameter measurement models to broad constructs.