Quality of Care Indicators for the Rehabilitation of Children With Traumatic Brain Injury

doi:10.1016/j.apmr.2011.08.015

Archives of Physical Medicine and Rehabilitation

Volume 93, Issue 3, March 2012, Pages 381-385.e9

https://doi.org/10.1016/j.apmr.2011.08.015 Get rights and content

Abstract

Rivara FP, Ennis SK, Mangione-Smith R, MacKenzie EJ, Jaffe KM, and the National Expert Panel for the Development of Pediatric Rehabilitation Quality Care Indicators. Quality of care indicators for the rehabilitation of children with traumatic brain injury.

Objective

To develop measurement tools for assessing compliance with identifiable processes of inpatient care for children with traumatic brain injury (TBI) that are reliable, valid, and amenable to implementation.

Design

Literature review and expert panel using the RAND/UCLA Appropriateness Method and a Delphi technique.

Setting

Not applicable.

Participants

Children with TBI.

Interventions

Not applicable.

Main Outcome Measure

Quality of care indicators.

Results

A total of 119 indicators were developed across the domains of general management; family-centered care; cognitive-communication, speech, language, and swallowing impairments; gross and fine motor skill impairments; neuropsychologic, social, and behavioral impairments; school reentry; and community integration. There was a high degree of agreement on these indicators as valid and feasible quality measures for children with TBI.

Conclusions

These indicators are an important step toward building a better base of evidence about the effectiveness and efficiency of the components of acute inpatient rehabilitation for pediatric patients with TBI.

Section snippets

Methods

Our approach drew on methodology used by the Agency for Heath Care Policy and Research⁹ and RAND10, 11, 12, 13 in their development of appropriateness and quality of care measures (ie, RAND/UCLA Appropriateness Method [RAM]), and combined a systematic review of scientific evidence regarding “best practices” with ratings by an expert panel of practitioners and researchers.

Results

Initially, 133 indicators were developed. Thirty-nine indicators (30%) were restructured or reworded for clarity, 15 (11%) were omitted based on the rating criteria described above, 3 (2%) were consolidated, and an additional 3 (2%) were added based on panelists' suggestions. The final number of indicators in each domain is shown in table 1; there were 119 in total. There was a high degree of agreement on these indicators as valid and feasible quality measures for children with TBI, as

Discussion

In 2003, the Guidelines for the Acute Management of TBI in Infants, Children and Adolescents were published,³⁷ after similar work to establish guidelines for management of adult TBI.³⁸ These guidelines were evidence-based recommendations made by a team of experts in the acute (emergency department and intensive care unit) care of patients with moderate and severe TBI. Recent studies indicate that full implementation of these guidelines can save a substantial number of lives, while at the same

Conclusions

The 7 key domains of care related to the acute inpatient rehabilitation for pediatric TBI has been developed. The next step is to validate the validity and feasibility of implementing these domain-specific measures in individual acute pediatrics rehabilitation programs nationally, and to measure variations in the care delivered to children with TBI hospitalized in rehabilitation centers in the U.S. These indicators are a necessary step toward building a better base of evidence about the

Acknowledgments

Members of the National Expert Panel for the Development of Pediatric Rehabilitation Quality Care Indicators include: Michael Alexander, MD (Alfred I. DuPont Hospital for Children, Wilmington, DE), Susan Apkon, MD (Seattle Children's Hospital, Seattle, WA), Deborah Gaebler-Spira, MD (Rehabilitation Institute of Chicago, Chicago, IL), Edward Hurvitz, MD (C.S. Mott Children's Hospital at the University of Michigan, Ann Arbor, MI), Linda E. Krach, MD (Gillette Children's Specialty Healthcare, St.

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To demonstrate the application of second-order growth mixture modeling (SO-GMM) using life satisfaction among adolescents and young adults with traumatic brain injury (TBI) up to 15 years post injury.
SO-GMM, a data-driven modeling approach that accounts for measurement errors, was adopted to uncover distinct growth trajectories of life satisfaction during 15 years post injury. Membership in growth trajectories was then linked with baseline characteristics to understand the contributing factors to distinct growth over time.
Traumatic Brain Injury Model System National Database.
A total of 3756 adolescents and young adults (AYAs) with TBI aged 16-25 years (mean age, 20.49±2.66 years; 27.24% female).
Not applicable.
Satisfaction With Life Scale.
Four quadratic growth trajectories were identified: low-stable (16.6%), which had low initial life satisfaction and remained low over time; high-stable (49.3%), which had high life satisfaction at the baseline and stayed high over time; high-decreasing (15.8%), which started with high life satisfaction but decreased over time; and low-increasing (18.2%), which started with low life satisfaction but increased over time. Sex, race, preinjury employment status, age, and FIM cognition were associated with group assignment.
This study applied SO-GMM to a national TBI database and identified 4 longitudinal trajectories of life satisfaction among AYAs with TBI. Findings provided data-driven evidence for development of future interventions that are tailored at both temporal and personalized levels for improved health outcomes among AYAs with TBI.
A Population-Based Study of the Incidence, Medical Care, and Medical Expenditures for Pediatric Traumatic Brain Injury
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Traumatic brain injury (TBI) is one of the leading causes of pediatric trauma morbidity and mortality around the world. However, limited research exists regarding disparities in the incidence of TBI and medical care seeking behaviors and medical expenditures for TBI, particularly using population-based and nationally-representative data.
The present study used the Medical Expenditure Panel Survey (MEPS) Panels 9-19 (2004-2015) to provide nationally-representative estimates for the civilian, non-institutionalized U.S. population. We examined differences in TBI incidence and associated medical care seeking behaviors and expenditures in relation to individual and family sociodemographic characteristics.
From a total of 50,563 children in the MEPS Panels 9-19, we identified 449 children with TBI. For 82% of these children, medical treatment was sought. The estimated annual total expenditure associated with pediatric TBIs nationally was approximately $667 million, with mean expenditures per TBI being $1,532 and family out of pocket expenditures accounting for 8.3% of total expenditures. Race/ethnicity was the only significant factor associated with both medical care seeking behavior and total expenditures.
The present study is among the first to compare pediatric TBI-related medical expenditures among different sociodemographic groups in the U.S. Our findings can inform future intervention research and policy-making from the perspectives of both epidemiological and behavioral sciences.
Quality and Outcome Measures for Medical Rehabilitation
2020, Braddom's Physical Medicine and Rehabilitation
Optimal healthcare quality can be defined as the provision of safe and effective care that improves outcomes, optimizes health, results in higher patient satisfaction, and furthers quality of life. The focus of healthcare worldwide has shifted from the fee-for-services model in which healthcare services rendered were rewarded in terms of volume to an emphasis on the best possible quality, safety, and outcomes as the top priorities. Thus the evaluation, measurement, and reporting of quality and outcomes have become the business of not only every healthcare institution and hospital but also of every individual healthcare provider. Physical medicine and rehabilitation practitioners have become increasingly aware of the importance of measuring healthcare quality and outcomes. This comes from increased scrutiny of healthcare quality, the cost of care, and quality reporting requirements from third-party payers, insurance companies, and reimbursing agencies. However, practicing physiatrists and professional member societies have also been realizing the importance of data on healthcare quality and outcomes. This has driven advancements in and availability of data repositories such as clinical registries. This chapter discusses healthcare quality, evidence-based medicine, clinical practice guidelines, outcome measures, performance measures, practice improvement, patient safety, and accreditation as it applies to healthcare in general and the practice of physical medicine and rehabilitation in particular.
A Systematic Critical Appraisal of Evidence-Based Clinical Practice Guidelines for the Rehabilitation of Children With Moderate or Severe Acquired Brain Injury
2019, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
Table 1 presents an overview of the CPG characteristics. Three guidelines originated in the United States,30-32 2 from Canada,33,34 2 from the United Kingdom,35,36 1 from New Zealand,37 and 1 from Australia.38 The dates of the most recent literature searches included in the guidelines were 2016 (n=3),35,36,38 2015 (n=1),34 2012 (n=1),32 2010 (n=1),31 2009 (n=1),30 2006 (n=1),33 and not stated (n=1).37
The aim of this review was to critically appraise the quality of evidence-based clinical practice guidelines (CPGs) for the rehabilitation of children with moderate or severe acquired brain injury (ABI).
A systematic search of MEDLINE, PsycINFO, Embase, CINAHL, and the Cochrane Library was conducted and an extensive website search of prominent professional rehabilitation society websites.
CPGs were eligible for inclusion if they incorporated recommendation statements for inpatient and/or community rehabilitation for children with ABI and they were based on a systematic evidence search.
Methodological quality of eligible CPGs were appraised by 3 independent reviewers using the AGREE II instrument. Characteristics of eligible CPGs and strength of supporting evidence for included recommendations were extracted.
Of the 9 included guidelines, 2 covered all ABIs, 5 focused specifically on traumatic brain injury, and 2 on stroke. Five of the CPGs were classified as high quality and 4 were of average quality. In general, CPGs scored better for scope and purpose, rigor of development, and clarity of presentation. They scored most poorly in applicability, involvement of target users, and procedures for updating the guidelines. Interrater reliability for the AGREE II was generally high across domains. Very few of the 445 recommendations included across the 9 CPGs were evidence based.
Despite variability in quality of the guideline development process, the included CPGs generally provided clear descriptions of their overall objectives, scope and purpose, employed systematic methods for searching, selecting, and appraising research evidence, and produced unambiguous, clearly identifiable recommendations for children with ABI. Overall, existing CPGs focusing on rehabilitation for children with ABI are based on low-quality evidence or expert consensus. Future work should focus on addressing the limitations of most of the current CPGs, particularly related to supporting implementation and integrating stakeholder involvement.
Using Rehabilitation along the Pediatric Trauma Continuum as a Strategy to Define Outcomes in Traumatic Brain Injury
2018, Clinical Pediatric Emergency Medicine
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in the pediatric population. It impacts all levels of care in our medical system. Despite numerous published guidelines and significant resources dedicated to acute management of pediatric TBI, most patients who are discharged have unrecognized or unmet needs at 6, 12, and 24 months after injury. Rehabilitation services have been developed to address the gap in both the inpatient and outpatient setting, though access to them is variable across the country. This article examines the importance of rehabilitation in the management and outcome of pediatric TBI, recognizing that there is substantial room for growth in rehabilitation services, as well as a need for further research that examines the benefits of rehabilitation on outcomes in all categories of TBI and at many time points along the continuum of care.
Use of Mental Health Services by Adolescents After Traumatic Brain Injury: A Secondary Analysis of a Randomized Controlled Trial
2018, PM and R
Citation Excerpt :
The cost of inpatient and outpatient rehabilitation, long-term care, and ongoing medical monitoring has been estimated at more than $1.5 billion in the first year after injury alone [6]. Although quality indicators for acute inpatient rehabilitation have been identified [7], there is still large variation in adherence to these care indicators [8]. Specifically, substantial variation exists in addressing neurobehavioral, psychosocial, cognitive, and communication needs and facilitating community reintegration [9,10].
Mental health problems are common after pediatric traumatic brain injury (TBI). Many patients in need of mental health services do not receive them, but studies have not consistently used prospective and objective methods or followed samples for more than 1 year.
To examine adolescents’ use of mental health services after TBI.
Secondary analysis from multicenter prospective randomized controlled trial.
Five level 1 U.S. trauma centers.
Adolescents aged 12-17 years with moderate-to-severe TBI were recruited for a randomized clinical trial (n = 132 at baseline, 124 at 6 months, 113 at 12 months, and 101 at 18 months).
Participants were randomly assigned to counselor-assisted problem-solving or Internet resource comparison. Follow-up assessments were completed at 6, 12, and 18 months after baseline. Generalized estimating equations with a logit link were used to examine use of mental health services. Treatment group and participant impairment were examined as predictors of use.
Mental health care use was measured with the Service Assessment for Children and Adolescents; daily functioning and clinical outcome with the Child and Adolescent Functional Assessment Scale; behavioral and emotional functioning with the Child Behavior Checklist; and executive dysfunction with the Behavior Rating Inventory of Executive Function.
Use of mental health services ranged from 22% to 31% in the 2 years post-TBI. Participants with impairments were about 3 times more likely than those without impairments to receive services (odds ratio 4.61; 95% confidence interval 2.61-8.14; P < .001). However, 50%-68% of patients identified as impaired had unmet mental health care needs.
Less than one half of adolescents with behavioral health needs after TBI received mental health services. Future studies are needed to examine barriers associated with seeking services after TBI and psychoeducation as preventive care for this population.
II

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: Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant no. R21 HD059049-01A1).

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Reprints are not available from the author.

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Original articleQuality of Care Indicators for the Rehabilitation of Children With Traumatic Brain Injury

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measure

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgments

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Womens Health Issues

Health Policy

Arch Phys Med Rehabil

Crossing the quality chasm: a new health system for the 21st century

Evaluating the quality of medical care

Milbank Mem Fund Q

Costs, mortality likelihood and outcomes of hospitalized US children with traumatic brain injuries

Brain Inj

Prehospital and in-hospital mortality: a comparison of intentional and unintentional traumatic brain injuries in Colorado children

Arch Pediatr Adolesc Med

Surveillance for traumatic brain injury-related deaths–United States, 1997-2007

MMWR Surveill Summ

Quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury

Arch Phys Med Rehabil

From a process of care to a measure: the development and testing of a quality indicator

Int J Qual Health Care

The appropriateness of performing coronary artery bypass surgery

JAMA

Quality of health carePart 2: measuring quality of care

N Engl J Med

The quality of ambulatory care delivered to children in the United States

N Engl J Med

Original article
Quality of Care Indicators for the Rehabilitation of Children With Traumatic Brain Injury