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Risk Factors Associated with Acute Rehospitalization after Inpatient Rehabilitation
e4 Article 7 Mortality in Individuals Unable to Follow Commands at the Time of Rehabilitation Admission Brian David Greenwald (JFK Medical Center), Flora Hammond, Cynthia Harrison-Felix, Risa Nakase-Richardson, Laura L.S. Howe Objective: To characterize long-term mortality, life expectancy, causes of death and risk factors for death among persons who lack command following at the time of admission for inpatient traumatic brain injury rehabilitation. Design: Prospective cohort study. Setting: The NIDRR TBI Model Systems. Participants: 8,084 individuals injured between 1988 and 2009, with survival status per December 31, 2009 determined. Interventions: Not applicable. Main Outcome Measure(s): Standardized mortality ratio, life expectancy, cause of death. Results: Individuals with moderate to severe TBI who received inpatient rehabilitation were 2.2 times more likely to die than individuals in the U.S. general population of similar age, gender and race, with an average LE reduction of 6.6 years. The subset of individuals who were unable to follow commands on admission to rehabilitation were 6.9 times more likely to die, with an average LE reduction of 12.2 years. Relative to the US general population matched for age, gender and race/ethnicity, these non-command following individuals were over 4 times more likely to die of circulatory conditions, 44 times more likely to die of pneumonia and 38 times more likely to die of aspiration pneumonia. Conclusions: The subset of individuals with TBI who are unable to follow commands upon admission to inpatient rehabilitation are at a significantly increased risk of death when compared to the US general population, and compared to all individuals with moderate to severe TBI receiving inpatient rehabilitation. Respiratory causes of death predominate. Key Words: Brain Injury, Mortality, Life expectancy Disclosure(s): None Disclosed.
Article 8 Effect of Lesion Burden on Recovery and Response to Amantadine in Patients with Traumatic Disorders of Consciousness Douglas I. Katz (Braintree Rehab Hospital), John Whyte, Helena Chang, Noam Eshkar, Kathleen Kalmar, David Long, Stuart Yablon, Emilia Bagiella, Joseph Giacino Objective: To assess the effect of lesion burden determined by CT imaging on recovery and response to amantadine treatment in patients with prolonged disorders of consciousness (DoC) after traumatic brain injury. Design: Retrospective analysis of a randomized controlled trial dataset. Setting: 11 inpatient neurorehabilitation centers in the USA, Denmark, and Germany. Participants: Patients (NZ184; placebo Z 97) with non-penetrating posttraumatic DoC between 4 and 16 weeks post-injury. Interventions: N/A. Main Outcome Measure(s): Disability Rating Scale (DRS) and Coma Recovery Scale e Revised (CRS-R) scores at 4 and 6 weeks postrandomization. Results: After visually coding CT scans against a standard template and summing ratings across all cortical or subcortical areas, higher lesion burden was significantly associated with worse outcome on the DRS and CRS-R at 6 weeks post-randomization in the placebo group (cortical: nZ89, DRS PZ.0124, CRS-R PZ.0324; subcortical: nZ91, DRS PZ.0067, CRS-R PZ.0256). The relationship was strongest in some nodes of the default mode and reticulothalamic networks, particularly the parahippocampal area and thalamus, which have been shown to be related
Oral abstracts to level of consciousness. There was no significant interaction of lesion burden and treatment group (amantadine or placebo) at 4 weeks, however, examination of slope of change across the 4 weeks suggested that amantadine-treated patients with highest lesion burden recovered more slowly than those with lower lesion burden, while patients in the placebo group with lowest lesion burden recovered faster than those with higher lesion burden. Conclusions: Higher lesion burden on routine CT imaging, particularly in the parahippocampal and thalamic areas, is associated with worse recovery in patients with traumatic DoC and may limit the response to amantadine treatment. Further study is needed to confirm these results. Key Words: vegetative state, traumatic brain injury, minimally conscious state, CT scan, x-ray, recovery of function Disclosure(s): None Disclosed. Article 9 Risk Factors Associated with Acute Rehospitalization after Inpatient Rehabilitation Amol M. Karmarkar (UTMB), James Graham, Amit Kumar, Kshitija Kulkarni, Kenneth Ottenbacher Objective: To identify person-level and facility-level risk factors associated with acute rehospitalization across multiple impairment groups. Design: Secondary analysis of Medicare data from 2009-2011. Setting: Medicare certified inpatient rehabilitation facilities across the United States. Participants: Patients discharged from acute hospitals for initial inpatient rehabilitation for the rehabilitation impairment groups: stroke (nZ121,633), lower extremity fracture (nZ121,055), brain dysfunction (nZ49,916), and neurological conditions (nZ58,460). These patients were living in the community prior to acute hospitalization, age 66 or older, on Medicare fee-for-service, and eligible for Medicare due to age (NZ351,064). Interventions: None. Main Outcome Measure(s): Acute rehospitalization was calculated using ’acute hospital claim’ immediately following inpatient rehabilitation stay. Patient-level variables included sociodemographics, tier comorbidity, disability status, Medicare-Medicaid eligibility, rehabilitation admission functional status, number of acute hospitalizations in the prior year, and pre-rehabilitation acute hospitalization length of stay. Facility-level variables included were type (rehabilitation unit vs. freestanding rehabilitation hospital), for-profit status (yes vs. no), and disproportionate share index (quartiles). Results: Overall the rate of acute rehospitalization was 8.5%. This unadjusted rehospitalization rate was highest for brain dysfunction (11.5%), and lowest for the lower extremity fracture cohort (6.1%). After adjusting for other covariates, for brain dysfunction, the risk of rehospitalization was 23% higher in those with a presence of tier comorbidity compared to those without (ORZ1.22, 95% CIZ1.15-1.31). Prior acute admissions were associated with a greater risk of rehospitalization (ORZ1.13, 95% CIZ1.11-1.15). For lower extremity fracture cohort, rehospitalization risk was 53% higher among those with tier comorbidity (ORZ1.53, 95% CIZ1.45-1.62) and the risk associated with prior acute admissions was 18% higher (ORZ1.18, 95% CIZ1.16-1.20). Conclusions: Identification of risk factors is the first step towards development of risk prediction models for acute rehospitalization following inpatient rehabilitation stay, taking into account patient-level and facility-level variables. Such models would be useful in better management of rehospitalization risk, by aligning resources, and providing continuity between acute and post-acute care services. Key Words: Rehospitalization, Inpatient Rehabilitation, Risk Factors Disclosure(s): None Disclosed.
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Article 8 Effect of Lesion Burden on Recovery and Response to Amantadine in Patients with Traumatic Disorders of Consciousness Douglas I. Katz (Braintree Rehab Hospital), John Whyte, Helena Chang, Noam Eshkar, Kathleen Kalmar, David Long, Stuart Yablon, Emilia Bagiella, Joseph Giacino Objective: To assess the effect of lesion burden determined by CT imaging on recovery and response to amantadine treatment in patients with prolonged disorders of consciousness (DoC) after traumatic brain injury. Design: Retrospective analysis of a randomized controlled trial dataset. Setting: 11 inpatient neurorehabilitation centers in the USA, Denmark, and Germany. Participants: Patients (NZ184; placebo Z 97) with non-penetrating posttraumatic DoC between 4 and 16 weeks post-injury. Interventions: N/A. Main Outcome Measure(s): Disability Rating Scale (DRS) and Coma Recovery Scale e Revised (CRS-R) scores at 4 and 6 weeks postrandomization. Results: After visually coding CT scans against a standard template and summing ratings across all cortical or subcortical areas, higher lesion burden was significantly associated with worse outcome on the DRS and CRS-R at 6 weeks post-randomization in the placebo group (cortical: nZ89, DRS PZ.0124, CRS-R PZ.0324; subcortical: nZ91, DRS PZ.0067, CRS-R PZ.0256). The relationship was strongest in some nodes of the default mode and reticulothalamic networks, particularly the parahippocampal area and thalamus, which have been shown to be related
Oral abstracts to level of consciousness. There was no significant interaction of lesion burden and treatment group (amantadine or placebo) at 4 weeks, however, examination of slope of change across the 4 weeks suggested that amantadine-treated patients with highest lesion burden recovered more slowly than those with lower lesion burden, while patients in the placebo group with lowest lesion burden recovered faster than those with higher lesion burden. Conclusions: Higher lesion burden on routine CT imaging, particularly in the parahippocampal and thalamic areas, is associated with worse recovery in patients with traumatic DoC and may limit the response to amantadine treatment. Further study is needed to confirm these results. Key Words: vegetative state, traumatic brain injury, minimally conscious state, CT scan, x-ray, recovery of function Disclosure(s): None Disclosed. Article 9 Risk Factors Associated with Acute Rehospitalization after Inpatient Rehabilitation Amol M. Karmarkar (UTMB), James Graham, Amit Kumar, Kshitija Kulkarni, Kenneth Ottenbacher Objective: To identify person-level and facility-level risk factors associated with acute rehospitalization across multiple impairment groups. Design: Secondary analysis of Medicare data from 2009-2011. Setting: Medicare certified inpatient rehabilitation facilities across the United States. Participants: Patients discharged from acute hospitals for initial inpatient rehabilitation for the rehabilitation impairment groups: stroke (nZ121,633), lower extremity fracture (nZ121,055), brain dysfunction (nZ49,916), and neurological conditions (nZ58,460). These patients were living in the community prior to acute hospitalization, age 66 or older, on Medicare fee-for-service, and eligible for Medicare due to age (NZ351,064). Interventions: None. Main Outcome Measure(s): Acute rehospitalization was calculated using ’acute hospital claim’ immediately following inpatient rehabilitation stay. Patient-level variables included sociodemographics, tier comorbidity, disability status, Medicare-Medicaid eligibility, rehabilitation admission functional status, number of acute hospitalizations in the prior year, and pre-rehabilitation acute hospitalization length of stay. Facility-level variables included were type (rehabilitation unit vs. freestanding rehabilitation hospital), for-profit status (yes vs. no), and disproportionate share index (quartiles). Results: Overall the rate of acute rehospitalization was 8.5%. This unadjusted rehospitalization rate was highest for brain dysfunction (11.5%), and lowest for the lower extremity fracture cohort (6.1%). After adjusting for other covariates, for brain dysfunction, the risk of rehospitalization was 23% higher in those with a presence of tier comorbidity compared to those without (ORZ1.22, 95% CIZ1.15-1.31). Prior acute admissions were associated with a greater risk of rehospitalization (ORZ1.13, 95% CIZ1.11-1.15). For lower extremity fracture cohort, rehospitalization risk was 53% higher among those with tier comorbidity (ORZ1.53, 95% CIZ1.45-1.62) and the risk associated with prior acute admissions was 18% higher (ORZ1.18, 95% CIZ1.16-1.20). Conclusions: Identification of risk factors is the first step towards development of risk prediction models for acute rehospitalization following inpatient rehabilitation stay, taking into account patient-level and facility-level variables. Such models would be useful in better management of rehospitalization risk, by aligning resources, and providing continuity between acute and post-acute care services. Key Words: Rehospitalization, Inpatient Rehabilitation, Risk Factors Disclosure(s): None Disclosed.
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