[Infantile acquired brain injury, a personal experience. Demands from the socio-familial point of view]. / Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.

We report on the experience of a family in which the youngest child has acquired brain injury and the struggle undertaken by the family to improve the neurorehabilitation resources in the public health service. The article outlines the main demands, from the socio-familial point of view, as regards the improvement of neurological rehabilitation and the resources needed to deliver it.

TITLE: Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.Se describe la experiencia de una familia en la que el hijo menor tiene daño cerebral sobrevenido y la lucha emprendida por la familia para mejorar los recursos neurorrehabilitadores de la sanidad publica. Se recogen las principales reclamaciones, desde el punto de vista sociofamiliar, en cuanto a la mejora en la atencion neurorrehabilitadora y los recursos necesarios.

Cost of detecting a chronic solvent encephalopathy case by screening.

BACKGROUND: Stepwise screening of chronic solvent encephalopathy (CSE), using a postal survey followed by clinical examinations, has been shown to detect symptomatic exposed workers with an occupational disease even in industrialized countries with long-term, but relatively low dose exposure. Previous studies have suggested under-detection and late recognition of CSE, when work ability is already markedly reduced. AIMS: The aim was to estimate the cost of detecting one new CSE case by screening and diagnostics, to estimate the career extension needed to cover the cost of screening, and to study the work ability of the CSE cases. METHODS: A financial analysis of stepwise postal CSE screening followed by clinical examinations (SPC screening) was carried out, and the results were compared to those of the group of CSE cases referred to the Finnish Institute of Occupational Health (FIOH) by the existing national practice of occupational health services (OHS screening). The work ability of the SPC screened CSE cases was studied in relation to the retirement rate and the Work Ability Index (WAI). RESULTS: An analysis of the costs of detecting a new verified CSE case revealed them to be approximately 16,500 USD. Using the mean monthly wages in the fields concerned, we showed that if a worker is able to continue working for four months longer, the screening covers these costs. The cost for detecting a CSE case was twenty times higher with the existing OHS routine, when actualized according to the national guidelines. A CSE case detected at an early stage enables occupational rehabilitation or measures to decrease solvent exposure. The retirement rate of the SPC screened CSE cases was significantly lower than that of the OHS screened cases (6.7% vs. 74%). The results suggest that SPC screening detects patients at an earlier stage of the disease, when they are still capable of working. Their WAI sores were nevertheless lower than those of the general population, implying a greater risk of becoming excluded from the labor market. CONCLUSION: Stepwise screening of CSE using a postal survey followed by clinical examinations detected new CSE cases at lower costs than existing OHS screening routines. Detecting CSE at an early stage prevents early retirement.

Catastrophic medical malpractice payouts in the United States.

Catastrophic medical malpractice payouts, $1 million or greater, greatly influence physicians' practice, hospital policy, and discussions of healthcare reform. However, little is known about the specific characteristics and overall cost burden of these payouts. We reviewed all paid malpractice claims nationwide using the National Practitioner Data Bank over a 7-year period (2004-2010) and used multivariate regression to identify risk factors for catastrophic and increased overall payouts. Claims with catastrophic payouts represented 7.9% (6,130/77,621) of all paid claims. Factors most associated with catastrophic payouts were patient age less than 1 year; quadriplegia, brain damage, or lifelong care; and anesthesia allegation group. Compared with court judgments, settlement was associated with decreased odds of a catastrophic payout (odds ratio, 0.31; 95% confidence interval [CI], 0.22-0.42) and lower estimated average payouts ($124,863; 95% CI, $101,509-144,992). A physician's years in practice and previous paid claims history had no effect on the odds of a catastrophic payout. Catastrophic payouts averaged $1.4 billion per year or 0.05% of the National Health Expenditures. Preventing catastrophic malpractice payouts should be only one aspect of comprehensive patient safety and quality improvement strategies. Future studies should evaluate the benefits of targeted interventions based on specific patient safety event characteristics.

[Mentoring system--performance optimization of treatment by formative case management]. / Das Mentoring-System--Qualitätssteigerung im Rehabilitationsprozess durch gestaltendes Case-Management.

The efficiency of the German public health system and its principle of adequate treatment are not up to the standards required by accident insurance companies. These have to be interested in realising optimal treatment, because the amount of pecuniary reparation essentially depends on (the quality of) the state of health of the injured person. To accomplish these objectives, their case management departments have to find a way to use the resources of the public health system and to improve considerably the quality of process und structure of the treatment. This is why case management is becoming increasingly important for insurance companies. Against this background, this case report describes the process of rehabilitation of a 72-year-old woman who had an accident and suffered a traumatic brain injury. This process was managed by AMB Generali Schadenmanagement GmbH in cooperation with the consulting firm Haase & Johanns Consulting, to develop approaches to rehabilitation management. It describes the mutual benefit for the injured person and of the insurer, which is defined by the success of treatment and saving of costs (care home, damages for pain and suffering) amounting to about 700,000 Euros.

Organizational and operational capabilities of specialist centres for children with psychomotor disability in Abidjan.

OBJECTIVE: To describe the organizational and operational capabilities of specialized centres for children with psychomotor disability in Abidjan, Republic of Côte d'Ivoire. MATERIALS AND METHODS: This descriptive study was carried out from February to May, 2006 at the various specialized centres for children with psychomotor disability that exist in the district of Abidjan. The procedure comprised a clinical description of the disabled children admitted to these centres and an assessment of the centres' organization and operational capabilities. RESULTS AND COMMENTS: Six specialist centres for children with psychomotor disability were identified, namely the Infant Guidance Centre, the Awakening and Stimulation Centre for disabled Children, the "Sainte-Magdeleine" Centre, the Medical and Training Institute, the "Page Blanche" institute and the "Colombes Notre Dame de la Paix" Centre. Among the children, 97.15% were day patients, 66.37% were mentally challenged, 30.96% had psychomotor impairment and 2.66% had motor impairments. The level of organization varied but the centres nevertheless had operational administrative, medical and paramedical staff, despite the absence of certain specialties. However, the lack of personnel, equipment and infrastructure is hindering the delivery of adequate services to the children. CONCLUSION: In Abidjan District, reception centres for children with psychomotor impairments are essentially privately run. Organizational and operational performances were suboptimal, with a low carer-to-patient ratio. Reinforcement of the centres' operational capabilities appears to be necessary.

A proposed model for managing cases of neurologically impaired infants.

The current mechanism for obtaining financial support for families with neurologically impaired infants is seriously flawed. It relies on payment awarded through the tort system based on a claim that medical negligence was responsible for the infant's condition. The system is extraordinarily inefficient and expensive, as well as being unfair to many families with affected children and to physicians who are unjustly accused of contributing to outcomes they could not have prevented. Furthermore, the exorbitant malpractice premiums necessary to support the system are threatening the future of obstetric practice in the United States. This article describes a two-pronged program designed to correct these inequities and to assess each case for the occurrence of medical negligence, which has been submitted to the New York State legislature as a proposed bill entitled the Neurologically Impaired Program for New York State (S7748).

Population-based study of determinants of initial secondary care costs of acute stroke in the United Kingdom.

BACKGROUND AND PURPOSE: To determine the cost-effectiveness of specific interventions to prevent or treat acute stroke, it is necessary to know the costs of stroke according to patient characteristics and stroke subtype and etiology. However, very few such data are available and none from population-based studies. We determined the predictors of resource use and acute care costs of stroke using data from a population-based study. METHODS: Data were obtained from the Oxford Vascular study, a population-based cohort of all individuals in nine general practices in Oxfordshire, UK, which identified 346 patients with a first or recurrent stroke during April 1, 2002, to March 31, 2004. Univariate and multivariate analyses were performed to identify the main predictors of resource use and costs. RESULTS: Acute care costs ranged from 326 pounds sterling (lower decile) to 19,901 pounds sterling (upper decile). There were multiple important univariate interrelations of patient characteristics, stroke subtype, and stroke etiology with hospital admission, length of stay, and 30-day case-fatality. For example, patients with primary intracerebral hemorrhage were more likely to be admitted than patients with partial anterior circulation ischemic stroke and less likely to survive without disability, but length of stay was reduced as a result of high early case-fatality such that cost was substantially less. However, the majority of univariate predictors of resource use, cost, and outcome were confounded by initial stroke severity as measured by the National Institutes of Health Stroke Scale score, which accounted for approximately half of the predicted variance in cost. Cost increased approximately linearly up to an National Institutes of Health Stroke Scale score of 18 and then fell steeply at higher scores as a result of rising early case-fatality. CONCLUSIONS: Several patient and event-related characteristics explained the wide range of initial secondary care costs of acute stroke, but stroke severity was by far the most important independent predictor.

Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States.

OBJECTIVE: The goal was to examine the influence of sociodemographic characteristics and health care system factors on the utilization of hospital resources by US children < or = 17 years of age with a diagnosis of traumatic brain injury. METHODS: A retrospective analysis of data from the Healthcare Cost and Utilization Project Kids' Inpatient Database, from January 1, 2000, to December 31, 2000, was performed. National estimates of traumatic brain injury-associated hospitalization rates and resource use were calculated with Kids' Inpatient Database sample weighting methods. RESULTS: Of 2,516,833 encounters between January 1, 2000, and December 31, 2000, 25,783 cases involved patients < or = 17 years of age with a recorded diagnosis of traumatic brain injury. On the basis of these data, there were an estimated 50,658 traumatic brain injury-associated hospitalizations among children < or = 17 years of age in the United States in 2000. The traumatic brain injury-associated hospitalization rate was 70 cases per 100,000 children < or = 17 years of age per year; 15- to 17-year-old patients had the highest hospitalization rate (125 cases per 100,000 children per year). Pediatric inpatients accrued more than $1 billion in total charges for traumatic brain injury-associated hospitalizations in this study. In the multivariate regression models, older age, Medicaid insurance status, and admission to any type of children's hospital were associated with a longer length of stay for pediatric traumatic brain injury-associated hospitalizations. Older age, longer length of stay, and in-hospital death predicted higher total charges for traumatic brain injury-associated hospitalizations. CONCLUSION: Pediatric traumatic brain injury is a substantial contributor to the health resource burden in the United States, accounting for more than $1 billion in total hospital charges annually.

Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries.

OBJECTIVES: To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability. SUBJECTS AND SETTING: Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury. METHODS: Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: "low" (NPDS<10 (n=83)); "medium" (NPDS10-24 (n=112)); "high" (NPDS>24 (n=102)). RESULTS: Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in "weekly cost of care" was greatest in the high dependency group at pound639 per week (95% CI 488 to 789)), as compared with the medium (pound323/week (95% CI 217 to 428)), and low (pound111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups. CONCLUSIONS: The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

Costs of childhood physical abuse: comparing inflicted and unintentional traumatic brain injuries.

OBJECTIVES: To estimate the effect of early childhood abuse (ie, inflicted injury) on medical costs of head trauma. METHODS: Abstracts of patient records were drawn from the annual 1993-2000 Colorado state-mandated hospital discharge database maintained by the Colorado Hospital Association. The 2 dependent variables were total charges (TC) and length of stay. Our key independent variable was the nature of injury, ie, inflicted or unintentional; other independent variables were age, severity level, death, and trauma designation of the hospital. Comparisons of variables between patients with inflicted and unintentional head trauma were performed using Student's t tests or chi2 statistics. Ordinary least squares regression was used to estimate the marginal and total effects of inflicted injury on TC and LOS. RESULTS: Of the 1097 head trauma patients <3 years old, 814 had unintentional and 283 had inflicted head trauma. Head trauma was defined using the Centers for Disease Control definition of traumatic brain injury. Patients with inflicted injuries were younger and had a higher average severity level and overall mortality rate than did patients with unintentional head trauma. The regression models showed that, controlling for age and severity, patients with inflicted head trauma stayed in the hospital 52% longer (2 days), and had a mean total bill 89% higher (4232 dollars more) than did patients with unintentional head trauma. CONCLUSIONS: The findings from multivariate models of TC and length of stay corroborate the simpler univariate findings of earlier studies. By focusing on the impact of those cases of child abuse that lead to a specific, severe clinical entity (traumatic brain injury), we isolated a significant economic impact of abuse on health care expenditures for injury.

[Can the classification of patients for phase B, C and D of neurological rehabilitation be done by FIM(tm) scores?]. / Lässt sich die Zugehörigkeit zur neurologischen Rehabilitation in den Phasen B, C und D durch FIM(tm)-Werte bestimmen?

The classification of patients for phase B, C and D of neurological rehabilitation follows the suggestions of the Bundesarbeitsgemeinschaft für Rehabilitation (BAR) based on defined clinical criteria and on neurological rehabilitation assessment. The focus of this study is to define the intervals of the complete FIM(tm)-index, intervals covered empirically as well as by evaluations of physicians, that permit utmost accuracy in assigning patients to phase B, C and D of neurological rehabilitation. Therefore, data records of 3686 patients from 4 neurological rehabilitation centres were evaluated. The patients' functional autonomy was classified by FIM(tm) on admission, in intervals of 14 days and at discharge, at the same time all patients in addition were assigned to phases B, C or D by the rehabilitation centre physicians. Statistical analysis of a total of 11,247 links of the phase classifications and FIM-indexes at 6 measurement points showed that correct correlation to phase B, C and D could be obtained on average in 79 to 89 % of the cases, based on the assumption that 18 - 36 points of the FIM-index assign to phase B, 37 - 90 points to phase C and 91 - 126 points to phase D. Discrimination between phases B and C could be obtained accurately in an average of 84 %, discrimination between phases C and D in an average of 89 %. Conformance of the FIM-intervals with TAR-based groups of care efforts compared to the evaluation by physicians indicate that the FIM(tm) represents the need for care with greater validity. If assignment to phases B, C and D would have been done on the basis of the FIM-index instead of evaluation by a physician, 8,9 % fewer patients would on admission have been classified for phase C but, instead, 4,5 % more patients for phase B and 4,4 % for phase D. In case of using the FIM-intervals for classification, 12,1 % more phase B patients could have changed to phases C or D. Of the phase C cases, 17,7 % could have been transferred to phase D before discharge. The number of phase D patients would have remained unchanged comparing admission and discharge. FIM-orientated classification for the phases of neurological rehabilitation offers considerable advantages: operationalized criteria, possibility of statistical evaluation, objectiveness, reliability, validity, reproducibility of the decisions, sensitivity to change, prognostic sensitivity, and suitability as an instrument for internal and external quality assurance.

[Phase specific technical aids prescription in neurological rehabilitation]. / Phasenspezifische Hilfsmittelverordnungen in der neurologischen Rehabilitation.

OBJECTIVE: The purpose of this study was to gain a phase specific survey concerning amount, types and costs of technical aids (TA) in a German neurological rehabilitation centre. Further, a number of common rehabilitation outcome parameters were to be related to technical aids provision. DESIGN: A prospective study included all patients (N = 509) with stroke, traumatic brain injury (TBI), brain tumour and multiple sclerosis (MS) admitted within a two-year period to the Klinik Berlin. The TAs prescribed were registered separately for each phase concerning type, amount and costs. In all, 108 different technical aids were recorded, and the direct costs for these technical aids were calculated. Outcome parameters used were the Barthel Index (BI) at admission and discharge, length of stay, and discharge destination. RESULTS: The mean (median) length of stay in phase B (C) was 76 (56) days with a mean (median) increase of BI score of 25 (15) points. Patients in phase D staid 35 days (median) at the clinic, their BI had been 100 points (median) already on admission. 93,3 % of all patients returned home (phase B and C 78,2 %). On average, patients in phase B and C received 2 technical aids/person, in phase D the median was 0 technical aid/person. On discharge, patients in phase B had an average of 3 technical aids/person, phase C patients had 4,5 TA/person and phase D patients 1 technical aid/person (median). The mean cost of a technical aid was 670 DM in phase B, 405 DM in phase C, and 290 DM in phase D (median). CONCLUSION: Technical aids are important components in rehabilitation, especially for severely affected patients, who receive the most expensive technical aids such as wheelchairs and bath tub lifters. High competence in questions related to technical aids is absolutely indispensable for any unit dealing with these patients. On the other hand, less affected patients mostly receive walking aids and grab bars. Future studies should deal with utilization rates and satisfaction with technical aids at home, as well as with cost-effectiveness issues.

Deep pockets or blueprint for change: traumatic brain injury (TBI) proactive strategy.

The Pacific Conference scheduled for October 1-3, 1988, is a critical event in the development of an integrated community-based plan for a comprehensive continuum of services to address the "silent epidemic," Traumatic Brain Injured (TBI). This paper provides insights of the complex nature and the special problems faced by the TBI survivors; their families, natural supports and caregivers, as well as the health, social and educational care providers in Hawaii. Process for the development of the community plan is presented.

VR experience with neurological patients: basic cost/benefit issues.

The future of VR applications for mental health is currently regarded as depending on the rational development of ideas and systems. Criteria to guide this development have been suggested that are both clear and agreeable. Their application, however, may not be easy at this stage. While we may already be able to predict costs of specific VR applications, a period of more extensive clinical research is needed in order to assess adequately any benefit. In our still limited experience, the development of VR applications to increase the diagnostic sensitivity of traditional tests to strategy application disorders is worthwhile, but the uniqueness of VR assets may make the adherence to some of the proposed criteria somewhat problematic.

Outcome, cost analysis, and long-term follow-up in preterm infants with massive grade IV germinal matrix hemorrhage and progressive hydrocephalus.

OBJECTIVE: The benefit of aggressive management and surgical intervention in preterm infants with massive Grade IV intracranial hemorrhage has been questioned based on the poor outcome of this group of patients despite such therapy. To further delineate this problem, we reviewed the records of premature neonates in this category as to outcome and initial hospital cost. METHODS: We performed a retrospective review of the medical records at our institution from 1977 to 1987 to identify premature neonates who had sustained massive hemorrhagic infarction of one hemisphere in addition to having blood in both ventricles and progressive hydrocephalus. RESULTS: During the study, a total of 52 such patients were identified, only 19 (6 female and 13 male patients) of whom survived. Intellectual function was observed to be greater than 2 standard deviations below the mean in 15 of the 19 patients, between 1 and 2 standard deviations below the mean in 1 of 19, and 1 standard deviation below the mean in 3 of 19. Motor function was as follows: 12 of 19 had marked spastic quadriparesis, 2 of 19 had moderate spastic quadriparesis, 3 of 19 had spastic hemiplegia, 1 of 19 had spastic diplegia, and 1 of 19 had mild spastic hemiparesis. Eleven of 19 had chronic seizure disorders. The first hospitalization cost for the group of patients exceeded, on the average, $150,000 per patient for the 19 long-term survivors. CONCLUSION: As we have previously reported, logistic regression analysis determined that grade of hemorrhage was the only significant predictor of cognitive and motor outcomes. Most premature neonates with massive intracranial hemorrhages do not survive. The outcomes in those who do is very poor and the cost so high that we suggest that until therapeutic intervention exhibits efficacy, the consideration of withdrawal of life support should be presented as an option to the parents of these unfortunate children.

Community-based rehabilitation of the person with a severe brain injury.

Community-based rehabilitation (CBR) recognizes that in the secure, loving environment of his/her own home, the person with a brain injury and the family, provided with support and guidance, can effectively augment or supersede hospital-based rehabilitation. This paper will explore the methods used to establish a rehabilitation programme in the home, the initial moves, the family dynamics, the advantages, and some of the programmes required for the restoration of function of sensory, cognitive and motor abilities. The mobilization of the therapy workforce, including the use of extended family and trained volunteers from the community, is explained. The importance of volunteer meetings and the continuing education of the family and volunteers is emphasized. Respite care for the family and the aim of returning the family towards normality is considered. The enormous cost/benefit of the community-based rehabilitation is detailed, and comparative costs between this method and hospital-based rehabilitation are provided.