Delivery of a quality improvement program in team-based rehabilitation for patients with rheumatic and musculoskeletal diseases: a mixed methods study.

PURPOSE: To investigate how a quality improvement program (BRIDGE), designed to promote coordination and continuity in rehabilitation services, was delivered and perceived by providers in routine practice for patients with rheumatic and musculoskeletal diseases. METHODS: A convergent mixed methods approach was nested within a stepped-wedge, randomized controlled trial. The intervention program was developed to bridge gaps between secondary and primary healthcare, comprising the following elements: motivational interviewing; patient-specific goal setting; written rehabilitation-plans; personalized feedback on progress; and tailored follow-up. Data from health professionals who delivered the program were collected and analyzed separately, using two questionnaires and three focus groups. Results were integrated during the overall interpretation and discussion. RESULTS: The program delivery depended on the providers' skills and competence, as well as on contextual factors in their teams and institutions. Suggested possibilities for improvements included follow-up with sufficient support from next of kin and external services, and the practicing of action and coping plans, standardized outcome measures, and feedback on progress. CONCLUSIONS: Leaders and clinicians should discuss efforts to ensure confident and qualified rehabilitation delivery at the levels of individual providers, teams, and institutions, and pay equal attention to each component in the process from admission to follow-up.

Quality in rehabilitation should be characterized by a continuous and coordinated process from goal setting to follow-up.To improve the quality, sufficient involvement of next of kin and external services is needed.Clinicians may need training to build confidence in motivational interviewing, action- and coping planning, feedback on progress, and follow-up.Leaders should organize education sessions, optimize schedules, insert standardized outcome measures, and facilitate collaboration across levels of care and services.

Demographic, Medical, and Clinical Characteristics of a Population-Based Sample of Patients With Long-lasting Locked-In Syndrome.

BACKGROUND AND OBJECTIVES: Patients with classic locked-in syndrome (LIS), typically caused by ventral pontine stroke, present with quadriplegia, mutism, intact consciousness, and communication skills limited to vertical gazing and/or blinking. Clinical presentations and definitions of LIS differ, especially regarding incomplete LIS. In our study, we explored the functional diversity of LIS, its outcomes, and the complexity of its course along with variations in the location of lesions and their potential significance for outcomes. METHODS: A national cohort of patients with vascular LIS who remained in the LIS state for at least 6 weeks according to a functional definition of LIS was studied. Demographic, medical, and follow-up data, collected between 2012 and 2022, were obtained from the quality register of the Norwegian National Unit for Rehabilitation of Locked-In Syndrome. Outcomes in verbal communication, motor function, and dependency were evaluated according to criteria for being in or not in the LIS state. The modified Rankin scale and LIS motor recovery scale were applied. Descriptive analysis was performed. The relationship between lesion location and functional outcome was investigated. RESULTS: The sample included 51 patients (median age: 55.7 years, 36 male individuals), 43 of whom had follow-up data. Ischemic stroke was the most common etiology (n = 35). Twenty-three patients had emerged from the LIS state, mostly within 2 years after onset. All but 1 patient achieved some motor improvement, whereas only 3 achieved full motor recovery, and 88% had a persistently high level of dependence. The 3-year survival rate was 87%. Five patients had an isolated pontine lesion, whereas 80% showed various lesions outside the brain stem. Patients who emerged from the LIS state had a significantly lower prevalence of lesions outside the brain stem than patients who remained in the LIS state did. DISCUSSION: Investigating an unselected population-based sample of patients with vascular LIS offers important insights into the functional diversity of LIS. Although most patients remained severely disabled, even small improvements in function can substantially increase the potential for activity and participation. Additional lesions outside the brain stem seem to be common in long-lasting LIS and might be prognostic for remaining in the LIS state.

A quality indicator set for use in rehabilitation team care of people with rheumatic and musculoskeletal diseases; development and pilot testing.

BACKGROUND: Systems for monitoring effectiveness and quality of rehabilitation services across health care levels are needed. The purpose of this study was to develop and pilot test a quality indicator set for rehabilitation of rheumatic and musculoskeletal diseases. METHODS: The set was developed according to the Rand/UCLA Appropriateness Method, which integrates evidence review, in-person multidisciplinary expert panel meetings and repeated anonymous ratings for consensus building. The quality indicators were pilot-tested for overall face validity and feasibility in 15 specialist and 14 primary care rehabilitation units. Pass rates (percentages of "yes") of the indicators were recorded in telephone interviews with 29 unit managers (structure indicators), and 164 patients (process and outcome indicators). Time use and participants' numeric rating of face validity (0-10, 10 = high validity) were recorded. RESULTS: Nineteen structure, 12 process and five outcome indicators were developed and piloted. Mean (range) sum pass rates for the structure, process and outcome indicators were 59%(84%), 66%(100%) and 84%(100%), respectively. Mean (range) face validity score for managers/patients was 8.3 (8)/7.9 (9), and mean answering time was 6.0/5.5 min. The final indicator set consists of 19 structure, 11 process and three outcome indicators. CONCLUSION: To our knowledge this is the first quality indicator set developed for rehabilitation of rheumatic and musculoskeletal diseases. Good overall face validity and a feasible format indicate a set suitable for monitoring quality in rehabilitation. The variation in pass rates between centers indicates a potential for quality improvement in rheumatic and musculoskeletal rehabilitation in Norway.

Hand bone loss in early rheumatoid arthritis during a methotrexate-based treat-to-target strategy with or without adalimumab-a substudy of the optimized treatment algorithm in early RA (OPERA) trial.

This study aims to investigate 1-year hand bone loss (HBL1-year) in early rheumatoid arthritis (RA) patients treated with a methotrexate (MTX) and intra-articular triamcinolone treat-to-target strategy +/- adalimumab and to determine if HBL6months is associated with radiographic progression after 2 years. In a clinical trial (OPERA) of 180 treatment-naive early RA patients, bone mineral density (BMD) was estimated from hand radiographs with digital X-ray radiogrammetry (DXR) at baseline, after 6 (n = 90) and 12 months (n = 70) of follow-up. Baseline and 2-year radiographs were scored according to the Sharp/van der Heijde method. Baseline characteristics and HBL6months (0-6 months changes in DXR-BMD) were investigated as predictors of structural damage by univariate linear (∆ total Sharp/van der Heijde score (TSS) as dependent variable) and logistic (+/-radiographic progression (∆TSS >0) as dependent variable) regression analyses. Variables with p < 0.10 were included in multivariable models. In 70 patients with available HBL1-year data, HBL1-year was median (interquartile range (IQR)) -1.9 (-3.3; -0.26 mg/cm2) in the MTX + placebo group and -1.8 (-3.6; 0.06) mg/cm2 in the MTX + adalimumab group, p = 0.98, Wilcoxon signed-rank. Increased HBL (compared to general population reference values) was found in 26/37 and 23/33 patients in the MTX + placebo and MTX + adalimumab groups, chi-squared = 0.99. In 90 patients with HBL6months data and 2-year radiographic data, HBL6months was independently associated with ∆TSS after 2 years (ß = -0.086 (95% confidence interval = -0.15; -0.025) TSS unit/mg/cm2 increase, p = 0.006) but not with presence of radiographic progression (∆TSS >0) (OR 0.96 (0.92-1.0), p = 0.10). In early RA patients treated with a methotrexate-based treat-to-target strategy, the majority of patients had increased HBL1-year, irrespective of adalimumab; HBL6months was independently associated with ∆TSS after 2 years.

Independence, institutionalization, death and treatment costs 18 months after rehabilitation of older people in two different primary health care settings.

BACKGROUND: The optimal setting and content of primary health care rehabilitation of older people is not known. Our aim was to study independence, institutionalization, death and treatment costs 18 months after primary care rehabilitation of older people in two different settings. METHODS: Eighteen months follow-up of an open, prospective study comparing the outcome of multi-disciplinary rehabilitation of older people, in a structured and intensive Primary care dedicated inpatient rehabilitation (PCDIR, n=202) versus a less structured and less intensive Primary care nursing home rehabilitation (PCNHR, n=100). PARTICIPANTS: 302 patients, disabled from stroke, hip-fracture, osteoarthritis and other chronic diseases, aged ≥65years, assessed to have a rehabilitation potential and being referred from general hospital or own residence. OUTCOME MEASURES: Primary: Independence, assessed by Sunnaas ADL Index(SI). Secondary: Hospital and short-term nursing home length of stay (LOS); institutionalization, measured by institutional residence rate; death; and costs of rehabilitation and care. Statistical tests: T-tests, Correlation tests, Pearson's χ2, ANCOVA, Regression and Kaplan-Meier analyses. RESULTS: Overall SI scores were 26.1 (SD 7.2) compared to 27.0 (SD 5.7) at the end of rehabilitation, a statistically, but not clinically significant reduction (p=0.003 95%CI(0.3-1.5)). The PCDIR patients scored 2.2points higher in SI than the PCNHR patients, adjusted for age, gender, baseline MMSE and SI scores (p=0.003, 95%CI(0.8-3.7)). Out of 49 patients staying >28 days in short-term nursing homes, PCNHR-patients stayed significantly longer than PCDIR-patients (mean difference 104.9 days, 95%CI(0.28-209.6), p=0.05). The institutionalization increased in PCNHR (from 12%-28%, p=0.001), but not in PCDIR (from 16.9%-19.3%, p= 0.45). The overall one year mortality rate was 9.6%. Average costs were substantially higher for PCNHR versus PCDIR. The difference per patient was 3528€ for rehabilitation (p<0.001, 95%CI(2455-4756)), and 10134€ for the at-home care (p=0.002, 95%CI(4066-16202)). The total costs of rehabilitation and care were 18702€ (=1.6 times) higher for PCNHR than for PCDIR. CONCLUSIONS: At 18 months follow-up the PCDIR-patients maintained higher levels of independence, spent fewer days in short-term nursing homes, and did not increase the institutionalization compared to PCNHR. The costs of rehabilitation and care were substantially lower for PCDIR. More communities should consider adopting the PCDIR model. TRIAL REGISTRATION: Clinicaltrials.gov ID NCT01457300.

Structured community-based inpatient rehabilitation of older patients is better than standard primary health care rehabilitation: an open comparative study.

PURPOSE: To compare the outcome of multi-disciplinary, structured rehabilitation of older patients in a district inpatient rehabilitation centre (Model 1) versus standard primary health care rehabilitation (Model 2). METHOD: Open, prospective, comparative observational study. Totally 302 patients, 202 in Model 1 and 100 in Model 2, aged ≥ 65 years, with stroke, osteoarthritis, hip fracture or other chronic diseases, considered to have a rehabilitation potential. Referred from district hospital, nursing- or own homes. OUTCOMES: Primary: Sunnaas ADL Index (SI). Secondary: Umeaa Life Satisfaction Checklist (LSC). Cognitive (MMSE), emotional (SCL-10) and marital status, residence, length of rehabilitation and hours/week care services. Follow-up 3 months after end of rehabilitation. RESULTS: Patients in Model 1 improved and persisted 1.9 points higher in SI (CI (1.0, 2.8), p < 0.001) compared to Model 2, with 2.4 weeks shorter rehabilitation (CI (1.6, 3.1), p < 0.001). LSC indicated similar satisfaction within both models. Fewer Model 1 patients received home care services >3 h/week (OR = 0.6 CI (0.4, 0.8), p = 0.002). Cognitive status predicted the SI gain positively, and level of care services negatively, in both models. CONCLUSIONS: Disabled older patients increase their independency significantly more within shorter time upon structured, multi-disciplinary rehabilitation in a district inpatient centre compared to standard primary health care rehabilitation. [Box: see text].

Effective rehabilitation of older people in a district rehabilitation centre.

OBJECTIVE: To assess the outcome of rehabilitation of older patients in a district rehabilitation centre. DESIGN: Prospective observational study. PATIENTS: A total of 202 patients aged ≥ 65 years rehabilitated at a Norwegian district inpatient rehabilitation centre, referred from district hospital, nursing homes or their own homes. Diagnoses were: stroke, arthrosis, hip fracture and other chronic diseases. METHODS: Admission: according to rehabilitation potential. TREATMENT: multidisciplinary team including an experienced general practitioner. PRIMARY OUTCOME MEASURE: Sunnaas Activities of Daily Living (ADL) Index (SI). SECONDARY OUTCOME MEASURE: Umea Life Satisfaction Checklist (LSC). Cognitive (Mini-Mental State Examination (MMSE)), emotional (Symptom Check List-10) and marital status, residence, length of stay and hours/week private and home care services were recorded. RESULTS: SI increased significantly during the mean 3.1 weeks stay (mean 4.2, 95% confidence interval 3.5, 4.8), p<0.001), persisting after 3 months. Eighty-four percent of patients scored satisfied according to LSC after rehabilitation. SI at discharge (adjusted for SI at admission) was predicted by MMSE and type of residence. Seventy-four percent of the patients needed home care services <3 h/week, at discharge and 3 months later. CONCLUSION: Significant and persisting improvements in activities of daily living may be achieved by rehabilitation of older patients with stroke, arthrosis, hip fracture and other chronic diseases in a district inpatient rehabilitation centre with co-ordinated and multi-disciplinary rehabilitation.

Improvement in behavioral symptoms and advance of activity acrophase after short-term bright light treatment in severe dementia.

Ten elderly subjects with severe dementia were given bright light (5000-8000 lux) for 45 min each morning for 4 weeks. Two rating scales of behavioral symptoms in dementia were used as outcome measures: Cohen-Mansfield Agitation Inventory (CMAI) and Behavior Pathology In Alzheimer's Disease Rating Scale (BEHAVE-AD), a scale for sleep-wake disturbances, and actigraphy to monitor activity rhythm. Behavioral symptoms improved with treatment. No changes in sleep-wake measures were found. There was an advance of the activity rhythm acrophase during treatment. These results suggest that short-time bright light improves behavioral symptoms and aspects of activity rhythm disturbances even in severely demented subjects.

Exposure of Danish workers to trichloroethylene, 1947-1989.

The aim of this study was to investigate the exposure of Danish workers to trichloroethylene (TCE) and the factors that affected such exposure. Data from Danish health authorities were evaluated for use in an epidemiological study of possible adverse health effects of TCE. The paper files relating to 1,075 air measurements taken between 1947 and 1989 at 150 companies were examined to extract information about calendar year, company, industry, type of measurement, and worker. Multiple regression models were used to analyze the effects of various factors on the concentration of TCE. TCE concentrations decreased over the four decades studied. The geometric mean was 329 mg/m3 for measurements taken 1947-1959, and 260 mg/m3, 53 mg/m3, and 23 mg/m3, respectively, for the three subsequent decades. Regression analyses showed that 1) TCE concentrations decreased on average 4 percent per year before 1964 and 15 percent per year afterward; 2) area and personal measurements gave similar concentrations (for the same calendar period, industry, and duration of measurement); 3) longer-duration measurements were associated with lower TCE concentrations; 4) high TCE concentrations occurred in the iron and metal industry; and, 5) in this industry men were exposed to concentrations two times those of women. Moreover, this study indicated that both the exposure level and the proportion of exposed workers in Danish companies increased with decreasing number of employees. Epidemiological studies of health effects of TCE may benefit from evaluating potential risk within different strata of calendar time, number of company employees, sex, and type of industry.