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Poster 465: Predicting Long-Term Global Outcome after Traumatic Brain Injury (TBI): Development of a Practical Prognostic Tool using the TBI Model Systems National Database
S280
Abstracts / PM R 9 (2017) S131-S290
Main Outcome Measures: Muscle tone (AS) in upper and lower extremities, Functional Independence Measure (FIM), pain, and safety were assessed after 6 months of treatment. Results: Mean (SD) AS in the affected lower limbs decreased by 0.99 (0.75) in the ITB group compared to 0.43 (0.72) in the CMM patients (P<.05). Decrease of AS in upper extremities was 0.66 (0.59) versus 0.17 (0.70) in ITB and CMM groups, respectively (P<.05). FIM improved in the ITB group by 2.68 (10.31) compared to a worsening in CMM arm -2.58 (11.00) (P¼.054). In addition, ITB patients reported reduction in actual, least and worst pain. Difference in the change from baseline to month 6 between ITB and CMM was statistically significant in least and actual pain (P<.05). Seven serious adverse drug reactions (SADR, constipation, fecal impaction, epilepsy, peripheral edema, hypotension, 2 urinary retention) and 4 serious device reactions (device dislocation, infection, catheter occlusion, intracranial hypotension) were observed in the implanted patients (24% and 16% of patients, respectively) versus 1 SADR (epilepsy) in the CMM group (3%). All serious events related to the device or drug were treated and resolved. Conclusions: This is the first RCT clinical evidence showing superior efficacy of ITB therapy compared to conventional oral medication in decreasing post-stroke spasticity. Level of Evidence: Level I
CATEGORY: PRACTICE MANAGEMENT & LEADERSHIP
Poster 463: The Effect of Patient Satisfaction Surveys on Physician Practice Patterns Joshua H. Levin, MD (Stanford University, Palo Alto, CA, United States), David J. Kennedy, MD, Ryan Mattie, MD, Matthew Lungren, MD MPH Disclosures: Joshua Levin: I Have No Relevant Financial Relationships To Disclose Objective: To evaluate if patient satisfaction surveys affect the way that physicians practice. Design: Survey. Setting: Internet based. Participants: Members of the Spine Intervention Society. Interventions: Not applicable. Main Outcome Measures: Voluntary physician responses to survey questions. Results: 74% of physicians use patient satisfaction surveys, and 14% have an income affected by them. 32% of physicians agreed that the surveys improve patient care, while 41% disagreed. 10% of physicians agreed that the surveys should be used as a factor in determining a physician’s compensation, while 75% disagreed. If a poor score would negatively affect physicians’ incomes: 54% would refuse to accept a new patient into his/her practice if he/she suspected the patient might give a poor score, while 43% would discontinue the care of a current patient; 41% would order more imaging test; 32% would perform more invasive procedures; 31% would order more laboratory tests; 29% would prescribe more pain medications; 27% would approve unjustified disability paperwork; 19% would not tell an unsafe driver to stop driving, while 15% would not report this driver to the DMV; 11% would prescribe more antibiotics. 38% of respondents are aware of practitioners who purposefully manipulate the system. Conclusions: The findings of this multi-specialty physician practice survey suggest that routine implementation of patient satisfaction surveys may affect the way that physicians practice medicine, and in some circumstances lead to inappropriate care or denial of health care services. This unintended practitioner behavior may be amplified further when satisfaction scores are tied to physician compensation. More thorough study is undoubtedly needed before patient satisfactions scores can be used as a reliable metric in health care systems. Level of Evidence: Level V
CATEGORY: NEUROLOGICAL REHABILITATION
Poster 465: Predicting Long-Term Global Outcome after Traumatic Brain Injury (TBI): Development of a Practical Prognostic Tool using the TBI Model Systems National Database William C. Walker, MD (Virginia Commonwealth University, Richmond, VA, United States), Katharine A. Stromberg, BS, Jennifer H. Marwitz, MA, Adam P. Sima, PhD, Amma A. Agyemang, PhD, Kristin M. Graham, PhD, CRC, Jeffrey S. Kreutzer, PhD Disclosures: William Walker: Research Grants - NIH R21 grant to VCU supported this research Objective: Build decision tree tools to predict long-term functional outcomes after moderate-severe closed TBI and test their accuracy in an independent sample. Design: Cross-sectional analyses using flexible classification tree methodology within the TBI-Model Systems (TBIMS) National Database (NDB). Setting: Enrollments occurred at 17 designated TBIMS inpatient rehabilitation facilities. Follow-up assessments were conducted primarily by telephone. Participants: All TBIMS NDB participants (adults with moderate or severe TBI per eligibility criteria) injured between Jan 1997 e Jan 2017 with closed TBI. Time point exclusions were death, vegetative state, insufficient post-injury time, and unavailable outcomes. Analysis sample sizes were 10,125 (year-1), 8,821 (year-2), and 6,165 (year-5). Interventions: Not applicable; Candidate predictors included demographic, premorbid socioeconomic, and injury characteristics. Main Outcome Measures: Glasgow Outcome Scale (GOS) functional levels at 1-, 2-, and 5-year post-injury. Results: The sample was 72.5% male, 9% Hispanic, and 20.9% minority races with median injury age 39.0 years. In our built GOS prediction trees, posttraumatic amnesia (PTA) duration consistently dominated branching hierarchy, and was the lone injury variable to contribute. Lower order variables contributing to the trees were limited to age, premorbid education, productivity, and occupational category. Generally, patients spending fewer days in PTA and who were younger, pre-morbidly more productive, and more highly educated had better outcomes. Across all prognostic groups, the best and worst Good Recovery rates were 65.7% and 10.9% respectively, and the best and worst Severe Disability rates were 3.9% and 64.1%. Predictability in test datasets ranged from C-statistic of 0.691 (year-1; CI: 0.675, 0.711) to 0.731 (year-2; CI: 0.724, 0.738). Conclusions: We developed an easy-to-use decision tree tool to provide prognostic information on long-term functional outcomes in patients with moderate-severe closed TBI, and demonstrated predictive accuracy in an independent test sample. Length of PTA, a clinical marker of injury severity, was by far the most critical outcome determinant. Level of Evidence: Level II
CATEGORY: NEUROLOGICAL REHABILITATION
Poster 466: Prospective Determination of Clinical Neurologic Level of Injury with Early MRI Following Blunt Traumatic Spinal Cord Injury Lisa U. Pascual, MD, FAAPMR (Orthopaedic Trauma Inst, San Francisco, CA, United States), J. Russell Huie, PhD, William D. Whetstone, MD, Sanjay S. Dhall, MD, Geoffrey T. Manley, MD, PhD, Jacqueline C. Bresnahan, PhD, Michael S. Beattie, PhD, Vineeta Singh, MD, Adam R. Ferguson, PhD, Rachel E. Tsolinas, BA, Jason F. Talbott, MD, PhD Disclosures: Lisa Pascual: I Have No Relevant Financial Relationships To Disclose
Abstracts / PM R 9 (2017) S131-S290
Main Outcome Measures: Muscle tone (AS) in upper and lower extremities, Functional Independence Measure (FIM), pain, and safety were assessed after 6 months of treatment. Results: Mean (SD) AS in the affected lower limbs decreased by 0.99 (0.75) in the ITB group compared to 0.43 (0.72) in the CMM patients (P<.05). Decrease of AS in upper extremities was 0.66 (0.59) versus 0.17 (0.70) in ITB and CMM groups, respectively (P<.05). FIM improved in the ITB group by 2.68 (10.31) compared to a worsening in CMM arm -2.58 (11.00) (P¼.054). In addition, ITB patients reported reduction in actual, least and worst pain. Difference in the change from baseline to month 6 between ITB and CMM was statistically significant in least and actual pain (P<.05). Seven serious adverse drug reactions (SADR, constipation, fecal impaction, epilepsy, peripheral edema, hypotension, 2 urinary retention) and 4 serious device reactions (device dislocation, infection, catheter occlusion, intracranial hypotension) were observed in the implanted patients (24% and 16% of patients, respectively) versus 1 SADR (epilepsy) in the CMM group (3%). All serious events related to the device or drug were treated and resolved. Conclusions: This is the first RCT clinical evidence showing superior efficacy of ITB therapy compared to conventional oral medication in decreasing post-stroke spasticity. Level of Evidence: Level I
CATEGORY: PRACTICE MANAGEMENT & LEADERSHIP
Poster 463: The Effect of Patient Satisfaction Surveys on Physician Practice Patterns Joshua H. Levin, MD (Stanford University, Palo Alto, CA, United States), David J. Kennedy, MD, Ryan Mattie, MD, Matthew Lungren, MD MPH Disclosures: Joshua Levin: I Have No Relevant Financial Relationships To Disclose Objective: To evaluate if patient satisfaction surveys affect the way that physicians practice. Design: Survey. Setting: Internet based. Participants: Members of the Spine Intervention Society. Interventions: Not applicable. Main Outcome Measures: Voluntary physician responses to survey questions. Results: 74% of physicians use patient satisfaction surveys, and 14% have an income affected by them. 32% of physicians agreed that the surveys improve patient care, while 41% disagreed. 10% of physicians agreed that the surveys should be used as a factor in determining a physician’s compensation, while 75% disagreed. If a poor score would negatively affect physicians’ incomes: 54% would refuse to accept a new patient into his/her practice if he/she suspected the patient might give a poor score, while 43% would discontinue the care of a current patient; 41% would order more imaging test; 32% would perform more invasive procedures; 31% would order more laboratory tests; 29% would prescribe more pain medications; 27% would approve unjustified disability paperwork; 19% would not tell an unsafe driver to stop driving, while 15% would not report this driver to the DMV; 11% would prescribe more antibiotics. 38% of respondents are aware of practitioners who purposefully manipulate the system. Conclusions: The findings of this multi-specialty physician practice survey suggest that routine implementation of patient satisfaction surveys may affect the way that physicians practice medicine, and in some circumstances lead to inappropriate care or denial of health care services. This unintended practitioner behavior may be amplified further when satisfaction scores are tied to physician compensation. More thorough study is undoubtedly needed before patient satisfactions scores can be used as a reliable metric in health care systems. Level of Evidence: Level V
CATEGORY: NEUROLOGICAL REHABILITATION
Poster 465: Predicting Long-Term Global Outcome after Traumatic Brain Injury (TBI): Development of a Practical Prognostic Tool using the TBI Model Systems National Database William C. Walker, MD (Virginia Commonwealth University, Richmond, VA, United States), Katharine A. Stromberg, BS, Jennifer H. Marwitz, MA, Adam P. Sima, PhD, Amma A. Agyemang, PhD, Kristin M. Graham, PhD, CRC, Jeffrey S. Kreutzer, PhD Disclosures: William Walker: Research Grants - NIH R21 grant to VCU supported this research Objective: Build decision tree tools to predict long-term functional outcomes after moderate-severe closed TBI and test their accuracy in an independent sample. Design: Cross-sectional analyses using flexible classification tree methodology within the TBI-Model Systems (TBIMS) National Database (NDB). Setting: Enrollments occurred at 17 designated TBIMS inpatient rehabilitation facilities. Follow-up assessments were conducted primarily by telephone. Participants: All TBIMS NDB participants (adults with moderate or severe TBI per eligibility criteria) injured between Jan 1997 e Jan 2017 with closed TBI. Time point exclusions were death, vegetative state, insufficient post-injury time, and unavailable outcomes. Analysis sample sizes were 10,125 (year-1), 8,821 (year-2), and 6,165 (year-5). Interventions: Not applicable; Candidate predictors included demographic, premorbid socioeconomic, and injury characteristics. Main Outcome Measures: Glasgow Outcome Scale (GOS) functional levels at 1-, 2-, and 5-year post-injury. Results: The sample was 72.5% male, 9% Hispanic, and 20.9% minority races with median injury age 39.0 years. In our built GOS prediction trees, posttraumatic amnesia (PTA) duration consistently dominated branching hierarchy, and was the lone injury variable to contribute. Lower order variables contributing to the trees were limited to age, premorbid education, productivity, and occupational category. Generally, patients spending fewer days in PTA and who were younger, pre-morbidly more productive, and more highly educated had better outcomes. Across all prognostic groups, the best and worst Good Recovery rates were 65.7% and 10.9% respectively, and the best and worst Severe Disability rates were 3.9% and 64.1%. Predictability in test datasets ranged from C-statistic of 0.691 (year-1; CI: 0.675, 0.711) to 0.731 (year-2; CI: 0.724, 0.738). Conclusions: We developed an easy-to-use decision tree tool to provide prognostic information on long-term functional outcomes in patients with moderate-severe closed TBI, and demonstrated predictive accuracy in an independent test sample. Length of PTA, a clinical marker of injury severity, was by far the most critical outcome determinant. Level of Evidence: Level II
CATEGORY: NEUROLOGICAL REHABILITATION
Poster 466: Prospective Determination of Clinical Neurologic Level of Injury with Early MRI Following Blunt Traumatic Spinal Cord Injury Lisa U. Pascual, MD, FAAPMR (Orthopaedic Trauma Inst, San Francisco, CA, United States), J. Russell Huie, PhD, William D. Whetstone, MD, Sanjay S. Dhall, MD, Geoffrey T. Manley, MD, PhD, Jacqueline C. Bresnahan, PhD, Michael S. Beattie, PhD, Vineeta Singh, MD, Adam R. Ferguson, PhD, Rachel E. Tsolinas, BA, Jason F. Talbott, MD, PhD Disclosures: Lisa Pascual: I Have No Relevant Financial Relationships To Disclose