Impact of Chronicity on Outcomes Following Post-Hospital Residential Brain Injury Rehabilitation: Application of Multivariate Statistics and Rasch Analysis

This study evaluated the impact of chronicity (onset of injury to admission in-terval) on three domains of functional outcomes for a large group of traumatic brain injured (TBI) survivors. Subjects included 528 TBI adults who were treated in post-hospital residential rehabilitation centers. Subjects were assigned to one of three chronicity groups: 1) Early Interval (EI), 2.00 - 8.00 months n = 245, 2) Mid Interval (MI), 8.01 - 24.00 months n = 129, and (3) Late Interval (LI), 24.01 months and greater n = 154. Functional status was assessed with the MPAI-4. RM MANCOVA was applied to evaluate differences among groups from admission to discharge. Rasch analysis demonstrated satisfactory construct validity and internal consistency (Person reliability = 0.90 - 0.94, Item reliability = 0.99) for the admission and discharge MPAI-4s. Controlling for LOS and age, the RM MANCOVA revealed that each chronicity group showed significant improvement in MPAI-4 abilities, adjustment, and participation indices from admission to discharge (p < 0.001). Improvement observed from admission to discharge was the greatest among the EI group (p < 0.001). This study demonstrated the utility of multivariate statistical approaches for understanding the complexities of TBI treatment outcomes. As measured across three domains of functioning, rehabilitation was effective in reducing disability for participants in each chronicity group. Of the three groups, EI participants presented as the most disabled at admission but also made the greatest gains when assessed at discharge.

Prediction of Functional Outcome in Post-Hospital Brain Injury Rehabilitation

Post-hospital brain injury rehabilitation programs are afforded limited time to reduce chronic disability resulting from acquired brain injury. Therefore, the purpose of this study was to identify deficit areas resulting from acquired brain injury that have the greatest impact on functional outcomes to enable greater efficiency in rehabilitation programming. Study participants were 1717 persons with acquired brain injury treated in residential post-hospital rehabilitation programs. Participants were assessed at admission and discharge on the MPAI-4. Functional status at discharge was evaluated based on T-scores derived from MPAI-4 discharge participation index items: Initiation, self-care and residence. The data base of 1717 was randomly divided into two subsets. Items from admission Abilities Index and select person variables were entered into stepwise multiple regression on subset one and then in a hierarchical multiple regression on subset two. Rash analysis demonstrated satisfactory construct validity and internal consistency of admission and discharge MPAI-4 evaluations (Person reliability > 0.90, Item reliability = 0.99). Both regression analyses revealed that Mobility and Novel Problem Solving accounted for 40% of the variance in functional outcome, p < 0.001. Acquired brain injury results in a myriad of cognitive and physical impairments. Of the many possible deficits, the greatest gains in overall functional outcomes may be achieved by allocating additional treatments aimed at reducing disability in mobility and novel problem solving.

Traumatic Brain Injury and Cerebral Vascular Accident: Application of Rasch Analysis to Examine Differences in Disability and Outcome in Post-Hospital Rehabilitation

The purpose of this study was to demonstrate an application of Rasch analysis to identify differences in disability profiles resulting from traumatic brain injury (TBI) and cerebral vascular accident (CVA) and to examine outcome differences between the two groups following post-hospital residential rehabilitation. Participant data were collected from 32 facilities in 16 states. From 2990 neurologically impaired individuals with consecutive admissions from 2011 through 2017, 874 met inclusion criteria: TBI (n = 687) or CVA (n = 187), 18 years or older, minimum length of stay of one month, and maximum chronicity of 1 year. Participants were evaluated at admission and discharge on the Mayo Portland Adaptability Inventory-Version 4 (MPAI-4). Rasch analysis was performed to establish item reliability, construct validity and item difficulty. A Repeated Measures Multivariate Analysis of Covariance (RM MANCOVA) determined group differences and improvement from admission and discharge. Rasch Analysis demonstrated satisfactory construct validity and internal consistency (Person reliability > 0.90, Item reliability > 0.98 for admission and discharge MPAI-4s). Both groups showed significant improvement on the MPAI-4 (p 0.0005). The TBI group was more impaired on the adjustment scale at both admission and discharge (p 0.001). Rasch analysis identified two distinct impairment patterns. CVA participants exhibited deficits characteristic of focal impairment while the TBI group presented with deficits reflective of diffuse impairment. Rehabilitation was shown to be beneficial in reducing disability following neurologic injury in both groups. Importantly, Rasch Analysis accurately produced unique disability profiles that differentiated the treatment groups. This unique statistical technique offers a promising prescriptive hierarchical model for guiding neurological rehabilitation treatment.

Insight into the post-hospital syndrome

After hospitalization,the patient faces a brief fragile period of susceptibility to disease and a high incidence of adverse events(re-admission or death,etc.),which is described by cardiologist Harlan M.Krumholz as post-hospital syndrome(PHS).PHS is characterized by the risk of early re-hospitalization towing to physiologic stressors from the initial admission,including disruption in sleep-wake cycles,inadequate pain control,deconditioning,and changes in nutritional status.Almost 1 in 6 patients hospitalized for acute myocardial infarction and 1 in 5 of those admitted for heart failure are readmitted within 30 days of discharge.Notably,only 10% and 35% are readmitted for the same diagnosis as that of the original hospitalization,respectively.Through a systematic review,this paper discusses the related concepts,hazards and influencing factors of PHS,and summarizes the counter measures based on the domestic status,in order to provide reference for domestic clinical medical personnel to formulate relevant measures to reduce the incidence of PHS.