Prevalence of depression and anxiety disorders following mild traumatic brain injury.

BACKGROUND: Previous studies have identified an association between traumatic brain injuries and the development of psychiatric disorders in general. However, these studies were subject to limitations that demonstrate the need for a study of a large, clearly defined mild traumatic brain injury (mTBI) population within an integrated healthcare system. OBJECTIVE: To determine the prevalence and relative risk of postinjury affective disorders over 4 years following mTBI. DESIGN: Cohort study of mTBI cases and matched controls, over a 4-year period. SETTING: An integrated healthcare delivery system in California. PATIENTS: A total of 9428 adult health plan members diagnosed with mTBI from 2000-2007 and enrolled in the year before injury, during which no TBI was ascertained. Control participants included 18,856 individuals selected based on the following criteria: Two unexposed health plan members per each mTBI-exposed patient were randomly selected and individually matched for age, gender, race/ethnicity, and medical comorbidities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A diagnosis of affective disorder (depressive, anxiety, and adjustment disorders) in the 4 years after mTBI or the reference date, determined according to the International Classification of Diseases, Ninth Revision, Clinical Modification as well as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS: Affective disorders were most prominent during the first 12 months with 23% following mTBI and 14% in the control group. Four-year aggregate adjusted odds ratios for having an affective disorder following mTBI were 1.2 (95% CI: 1.1, 1.2; p < .001) and 1.5 (95% CI: 1.5, 1.6; p < .001) for patients with and without prior affective disorders, respectively. CONCLUSION: mTBI was associated with a significantly increased risk of having subsequent affective disorders. Screening for and addressing affective disorders at earlier stages following the injury is an important step to avoid persisting conditions that may pose a barrier to full recovery.

Daily treatment time and functional gains of stroke patients during inpatient rehabilitation.

OBJECTIVE: To study the effects of daily treatment time on functional gain of patients who have had a stroke. DESIGN: A retrospective cohort study. SETTING: An inpatient rehabilitation hospital (IRH) in northern California. PARTICIPANTS: Three hundred sixty patients who had a stroke and were discharged from the IRH in 2007. INTERVENTIONS: Average minutes of rehabilitation therapy per day, including physical therapy, occupation therapy, speech and language therapy, and total treatment. MAIN OUTCOME MEASURES: Functional gain measured by the Functional Independence Measure, including activities of daily living, mobility, cognition, and the total of the Functional Independence Measure (FIM) scores. RESULTS: The study sample had a mean age of 64.8 years; 57.4% were men and 61.4% were white. The mean total daily therapy time was 190.3 minutes, and the mean total functional gain was 26.0. A longer daily therapeutic duration was significantly associated with total functional gain (r = .23, P = .0094). Patients who received a total therapy time of <3.0 hours per day had significantly lower total functional gain than did those treated ≥3.0 hours. No significant difference in total functional gain was found between patients treated ≥3.0 but <3.5 hours and ≥3.5 hours per day. The daily treatment time of physical therapy, occupational therapy, and speech and language therapy also was significantly associated with corresponding subscale functional gains. In addition, hemorrhagic stroke, left brain injury, earlier IRH admission, and a longer IRH stay were associated with total functional improvement. CONCLUSIONS: The study demonstrated a significant relationship between daily therapeutic duration and functional gain during IRH stay and showed treatment time thresholds for optimal functional outcomes for patients in inpatient rehabilitation who had a stroke.

Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke.

OBJECTIVE: To determine the impact of postacute care site on stroke outcomes. DESIGN: Prospective cohort study. SETTING: Four northern California hospitals that are part of a single health maintenance organization. PARTICIPANTS: Patients with stroke (N=222) enrolled between February 2008 and July 2010. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Baseline and 6-month assessments were performed using the Activity Measure for Post Acute Care (AM-PAC), a test of self-reported function in 3 domains: Basic Mobility, Daily Activities, and Applied Cognition. RESULTS: Of the 222 patients analyzed, 36% went home with no treatment, 22% received home health/outpatient care, 30% included an inpatient rehabilitation facility (IRF) in their care trajectory, and 13% included a skilled nursing facility (but not IRF) in their care trajectory. At 6 months, after controlling for important variables such as age, functional status at acute care discharge, and total hours of rehabilitation, patients who went to an IRF had functional scores that were at least 8 points higher (twice the minimally detectable change for the AM-PAC) than those who went to a skilled nursing facility in all 3 domains and in 2 of 3 functional domains compared with those who received home health/outpatient care. CONCLUSIONS: Patients with stroke may make more functional gains if their postacute care includes an IRF. This finding may have important implications as postacute care delivery is reshaped through health care reform.

Designing and implementing a system for tracking functional status after stroke: a feasibility study.

OBJECTIVE: To determine the feasibility of tracking stroke patients' functional outcomes in an integrated health system across a care continuum using the computer version of the Activity Measure of Post-Acute Care (AM-PAC). SETTING: A large integrated health care system in northern California. PARTICIPANTS: A total of 222 stroke patients (aged ≥18 years) who were hospitalized after an acute cerebrovascular accident. METHODS: An AM-PAC assessment was made at discharge from sites of care, including acute hospital, inpatient rehabilitation hospital, skilled nursing facility, home during home care, and outpatient settings. Assessments also were completed in the patient's home at 6 months. Data from the AM-PAC program were integrated with the health care system's databases. MAIN OUTCOME MEASUREMENTS: (1) AM-PAC administration time at the various sites of care; (2) assessment of a floor or a ceiling effect; and (3) administrative burden of tracking participants. RESULTS: AM-PAC assessment sessions averaged 7.9 minutes for data acquisition in 3 domains: Basic Mobility, Activities of Daily Living, and Applied Cognition. Participants answered, on average, 27 AM-PAC questions per session. A small ceiling effect was observed at 6 months, and there was a larger ceiling effect when the instrument was administered in an institution, ie, when the AM-PAC institutional item bank was used rather than the community item bank. It was feasible to track patients and to assess their function using the AM-PAC instrument from institutional to community settings. Implementation of the AM-PAC in clinical environments, and the success of the project, were influenced by instrumental, technological, operational, resource, and cultural factors. CONCLUSIONS: This study demonstrates the feasibility of implementing a single functional outcome instrument in clinical and community settings to measure rehabilitation functional outcomes of stroke patients. Integrating the AM-PAC measurement system into clinical workflows and the electronic medical record could provide assistance to clinicians for medical decision making, functional prognostication, and discharge planning.

Evaluation of patient and proxy responses on the activity measure for postacute care.

BACKGROUND AND PURPOSE: Our objective was to examine the agreement between adult patients with stroke and family member or clinician proxies in activity measure for postacute care (AM-PAC) summary scores for daily activity, basic mobility, and applied cognitive function. METHODS: This study involved 67 patients with stroke admitted to a hospital within the Kaiser Permanente of Northern California system and were participants in a parent study on stroke outcomes. Each participant and proxy respondent completed the AM-PAC by personal or telephone interview at the point of hospital discharge or during ≥1 transitions to different postacute care settings. RESULTS: The results suggest that for patients with a stroke proxy, AM-PAC data are robust for family or clinician proxy assessment of basic mobility function and clinician proxy assessment of daily activity function, but less robust for family proxy assessment of daily activity function and for all proxy groups' assessments of applied cognitive function. The pattern of disagreement between patient and proxy was, on average, relatively small and random. There was little evidence of systematic bias between proxy and patient reports of their functional status. The degree of concordance between patient and proxy was similar for those with moderate to severe strokes compared with mild strokes. CONCLUSIONS: Patient and proxy ratings on the AM-PAC achieved adequate agreement for use in stroke research when using proxy respondents could reduce sample selection bias. The AM-PAC data can be implemented across institutional as well as community care settings while achieving precision and reducing respondent burden.

Re-orientation of clinical research in traumatic brain injury: report of an international workshop on comparative effectiveness research.

During the National Neurotrauma Symposium 2010, the DG Research of the European Commission and the National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NINDS) organized a workshop on comparative effectiveness research (CER) in traumatic brain injury (TBI). This workshop reviewed existing approaches to improve outcomes of TBI patients. It had two main outcomes: First, it initiated a process of re-orientation of clinical research in TBI. Second, it provided ideas for a potential collaboration between the European Commission and the NIH/NINDS to stimulate research in TBI. Advances in provision of care for TBI patients have resulted from observational studies, guideline development, and meta-analyses of individual patient data. In contrast, randomized controlled trials have not led to any identifiable major advances. Rigorous protocols and tightly selected populations constrain generalizability. The workshop addressed additional research approaches, summarized the greatest unmet needs, and highlighted priorities for future research. The collection of high-quality clinical databases, associated with systems biology and CER, offers substantial opportunities. Systems biology aims to identify multiple factors contributing to a disease and addresses complex interactions. Effectiveness research aims to measure benefits and risks of systems of care and interventions in ordinary settings and broader populations. These approaches have great potential for TBI research. Although not new, they still need to be introduced to and accepted by TBI researchers as instruments for clinical research. As with therapeutic targets in individual patient management, so it is with research tools: one size does not fit all.

Postacute care and ischemic stroke mortality: findings from an integrated health care system in northern California.

OBJECTIVE: To study the association of postacute care (PAC) settings and mortality outcome of patients who sustained an ischemic stroke. DESIGN: A retrospective cohort study. SETTING: An integrated health care system in northern California. PARTICIPANTS: Patients who sustained an acute ischemic stroke between 1996 and 2004, survived the initial acute care hospital stay, and received PAC services within 14 days of discharge (n = 16,538) and 61 days of discharge (n = 16,468). INTERVENTIONS: PAC rehabilitation ranked by resource level, that is, inpatient rehabilitation hospital (IRH), skilled nursing facility (SNF), home health (HH), and outpatient (OP) rehabilitation. MAIN OUTCOME MEASUREMENTS: One-year mortality after acute care hospital discharge. RESULTS: The highest level of PAC services received within 14 days of acute care discharge was IRH for 5.6% of patients, SNF for 48.3% of patients, HH for 18.9% of patients, and OP for 27.3% of patients. The highest level of PAC services received within 61 days of acute care discharge was IRH for 10.9% of patients, SNF for 40.4% of patients, HH for 19.1% of patients, and OP for 29.6% of patients. Cox proportional hazard models showed that patients whose highest level of PAC service was provided by an IRH, through HH, or OP had a significantly better 1-year survival than did those admitted to an SNF. The following factors were associated with a higher risk of 1-year mortality: older age, male gender, African American ethnicity, history of previous stroke, higher Deyo-Charlson comorbidity scores, a longer acute care hospital stay, and hospitalization in one remotely located health service area. CONCLUSIONS: In the year after a stroke occurred, the rate of patient survival varied based on PAC rehabilitation services. Age, gender, race or ethnicity, history of a previous stroke, comorbid conditions, and service area also were significantly associated with 1-year mortality after acute care discharge. Further investigation of the differences in mortality among PAC settings is indicated.

Time to inpatient rehabilitation hospital admission and functional outcomes of stroke patients.

OBJECTIVE: To study the association of time to inpatient rehabilitation hospital (IRH) admission and functional outcomes of patients who have had a stroke. DESIGN: A retrospective cohort study. SETTING: A regional IRH. PARTICIPANTS: Moderately (n = 614) and severely (n = 1294) impaired patients who had a stroke who were admitted to the facility between 2002 and 2006. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in total, motor, and cognitive Functional Independence Measure (FIM) scores between IRH admission and discharge. RESULTS: After controlling for patient demographics and initial medical conditions and functional status, shorter periods from stroke onset to IRH admission were significantly associated with greater functional gains for these patients during IRH hospitalization. Moderately impaired patients achieved a greater total FIM gain when admitted to an IRH within 21 days of stroke. Severely impaired patients showed a gradient relationship between time to IRH admission and total FIM gain, with significantly different functional gain if admitted to an IRH within 30 and 60 days after stroke diagnosis. Results of multiple regression analysis also showed that age, race/ethnicity, side of stroke, history of a previous stroke, functional measures at IRH admission, IRH length of stay, and selected medications were associated with total, motor, and cognitive FIM score changes. In addition, certain factors such as older age, diagnosis of a hemorrhagic stroke or a previous history of stroke, and initial functional status were associated with longer periods between diagnosis and admission to an IRH after the stroke occurred. CONCLUSIONS: Our findings are consistent with the hypothesis that earlier transfer to an IRH may lead to better functional improvement after stroke. However, certain factors such as age, race/ethnicity, initial medical conditions and functional status, and length of stay at an IRH contributed to functional gain. Factors affecting the time to IRH admission also were addressed.

Stroke, disability, and unconscious bias: interrelationships and over-determination in medical decisions.

Many factors influence what and how we communicate with patients after stroke. As physicians, we have a responsibility to examine our medical decisions and prognostication regarding each stroke patient. We must understand how many factors come into play in decisions regarding care, including perspectives that reflect the specific training of physicians in various specialties. How the physician responds to the patient with a stroke is highly individual. The more familiar the physician is with stroke recovery and the more time he or she has for individualized and less automatic approaches, the less likely decisions will be reflexive, based on bias. By examining our unconscious biases, we can provide individualized care that gives patients more latitude to create their own stories of recovery.