Health management technology for catastrophic medical conditions.

BACKGROUND: The excessive growth of health care expenditures in the United States is widely acknowledged. Costs are anticipated to double by the year 2006. The intractable issue which remains before health care leaders is how to appropriately restrain these costs while not sacrificing a desired level of care quality. A variety of management approaches have been developed in pursuit of more rational and cost-effective use of health resources. Current management approaches have proven inadequate in stemming health care cost inflation and have raised increasing concerns about their negative impact on the quality of health care. METHOD: One group has created and operated a data and structured, expert consensus-driven health management technology for the management of catastrophic medical conditions, including severe brain and spinal cord injury and severe multiple trauma and burns, since 1992 and has recently applied this same technology to high risk neonates and organ transplants. This integrated, severity risk adjusted, delivery system incorporates adequate clinical data capture and analysis, coupled with empirically derived management principles and consensus expert clinical judgment. INTERPRETATION: Preliminary data analysis indicates that patients treated under the ParadigmHealth model experienced an improvement in the health care process, improved quality in health care delivery and outcomes, and overall cost reduction.

Disability evaluation following traumatic brain injury.

Accurate disability evaluation of a patient with TBI is a very difficult and detailed process. It requires an excellent background concerning the evaluation of all the physical, cognitive, behavioral, and functional abnormalities associated with TBI. Texts that highlight all these abnormalities include Medical Rehabilitation of Traumatic Brain Injury by Horn and Zasler and Rehabilitation of the Adult and Child with Traumatic Brain Injury by Rosenthal et al. In addition, appropriate disability rating can only be performed by a physician with expert skills in obtaining accurate historical information and completing a detailed physical examination. Often, the historical information must be obtained from many sources because the patient may supply inaccurate information because of his or her cognitive deficits. Interviews with family members, caregivers, therapists, friends, and employers are sometimes necessary to obtain an accurate historical picture. Premorbid functioning, behavior, and personality are important because previous abnormalities are often exaggerated after the TBI. The physical examination should be tailored to provide detailed objective information concerning all deficits identified through the history. If cognitive and behavioral problems are identified through either the history or examination, a neuropsychologic assessment is necessary. All this information should be available before the disability or impairment rating. Only with detailed information can a clinician provide an accurate rating.

The effectiveness of traumatic brain injury rehabilitation: a review.

The rehabilitation of traumatic brain injury (TBI) has undergone tremendous development over the past 20 years. A much more aggressive, extended and comprehensive approach is now common and clinically accepted. Multiple new forms and sites of treatment are utilized such as cognitive, behavioural, sub-acute and post-acute rehabilitation programmes. While there has been widespread clinical acceptance of these treatments the appearance of well-designed experimental or quasi-experimental studies actually evaluating the results of such treatment have been, until recently, generally lacking. This review article selects, analyses, and critiques the most salient of recent studies published regarding the overall clinical benefit, and to some extent the cost benefit, of TBI treatment programmes in their multiple forms. A conclusion which is reached following this survey is that while truly randomized controlled studies still have not been achieved, an impressive variety of studies of quasi-experimental design have been completed. The overall conclusion from these studies is that the efficacy (and cost-effectiveness) of TBI rehabilitation is strongly supported.

Brain injury: analysis of outcome in a post-acute rehabilitation system. Part 1: General analysis.

During the past decade the rehabilitation field has developed new, non-hospital based programmes of cognitive, behavioural, social, educational and vocational treatments to address the higher order cognitive, behavioural and social deficits following brain injury. These new arrays of programmes are referred to under the term 'post-acute' rehabilitation. No comprehensive, methodologically sound study of the effects of these new treatments has been made to date. This paper reports data from brain-injured patients who underwent treatment within a co-ordinated system of post-acute brain-injury rehabilitation programmes. This system consists of a continuum of neurobehavioural, residential, day treatment and community and home programmes, and provides overt components of medical and rehabilitation care: behavioural management; activities of daily living, self-management, substance-abuse, social, academic and vocational skills training; counselling; and family education. The changes in function during the course of treatment by this post-acute sequence of rehabilitation have been obtained and are reported here. A defined total population of N = 192 is examined, with exclusions for appropriate causes (e.g. patients seen only for evaluation) producing a study population of N = 173; of these, follow-up was achieved in 145 cases, a follow-up rate of 83.8%. Time from date of injury to data of admission, severity of deficit at time of admission to programme, and other appropriate independent variables are used to characterize the population. A single-blind interview methodology was employed in obtaining dependent measures of outcome at 6, 12, or 24 month periods post-discharge. Measures of outcome included residential status, level of productivity activity and hours per day of attendant care or supervision required. Dependent variables were analysed for the total study population and a subgroup greater than 1 year from date of injury at entry to treatment and not from a treatment facility. Results are presented in terms of the percentage change in dependent measures from the point of admission to follow-up. Appropriate parametric and non-parametric statistical analyses of significance have been carried out. The results document substantial improvements in function during the post-acute rehabilitation of this population and such improvements are unlikely to be the result of spontaneous improvement alone.

Brain injury: analysis of outcome in a post-acute rehabilitation system. Part 2: Subanalyses.

The basic findings of brain-injured patients who underwent treatment within a co-ordinated system of post-acute brain-injury rehabilitation programmes have already been reported. The changes in function during the course of treatment by this post-acute sequence of rehabilitation were obtained and reported. A defined total population of N = 192 was examined, with exclusions for appropriate causes (e.g. patients seen only for evaluation) producing a study population of N = 173; of these, follow-up was achieved in 145 cases, a follow-up rate of 83.8%. Time from date of injury to date of admission, severity of deficit at time of admission to programme, and other appropriate independent variables were used to characterize the population. A single-blind interview methodology was employed in obtaining dependent measures of outcome at 6, 12 or 24 month periods post-discharge. Measures of outcome included residential status, level of productivity activity, and hours per day of attendant care or supervision required. In the work reported in this paper dependent variables are analysed for various subgroups of the total population. The subgroups analysed are: patients with traumatic brain injury only; mild moderate and severe grades of disability; and comparisons of outcomes at 6 months, 1 year, and 2 years post-discharge from treatment. The results are presented in terms of percentage change in dependent measures from point of admission to follow-up. Appropriate parametric and non-parametric statistical analyses of significance are carried out. Additionally, an analysis of cost associated with treatment, and some analysis of cost-benefit is provided. The results document substantial improvements in function during post-acute rehabilitation for both traumatic brain injury and brain dysfunction of other etiologies. Significant improvements are seen to occur in all grades of severity of dysfunction examined, and such improvements are robust and persist without evidence of decrement over the 2-year follow-up period. In addition, economic considerations suggest the potential for the recouping of costs of treatment within a reasonable period of time.

Serial computerized tomographic evaluations in traumatic head injury.

Severely head injured patients often develop lesions requiring neurosurgical intervention after admission to a rehabilitation unit. It is postulated that routine computerized tomography (CT) at regular intervals during inpatient rehabilitation may assist in the discovery of these lesions. This study explores the value of obtaining sequential CT scans in a population where it is often difficult to objectively assess progress and potential outcome. This series is based on 47 patients with traumatic head injuries who were admitted to a comprehensive inpatient head injury unit over a two-year period. CT scans were performed on each patient by prospective protocol at admission, one month, and three months later, unless marked clinical improvement was observed. Nine of 41 patients (22%) scanned required neurosurgical intervention for ventricular enlargement, subdural hematoma, or cerebral abscess after admission to the unit. Two of the nine (22%) had changes noted on preadmission scans and seven (78%) had pathologic changes detected on CT only after admission to rehabilitation. Thus, significant numbers of neurologic lesions were identified in the postacute phase during the inpatient rehabilitation program. Serial CT scanning may allow earlier diagnosis and thereby minimize further brain injury in the rehabilitation setting.

Premorbid prevalence of poor academic performance in severe head injury.

A study of 80 head injured patients revealed poor premorbid academic performance in up to 50% of the sample. Poor academic performance, as defined by diagnosis of learning disability, multiple failed academic subjects, or school dropout during secondary education, is not a previously cited risk factor for head injury. These findings have important implications in the identification of a high risk population and in the subsequent ability to reduce the incidence of head injury.

Neuropharmacologic management of behavior sequelae in head injury: a case report.

A patient with traumatic head injury was confused, agitated, and belligerent. Initial treatment with sedatives (diazepam) and antipsychotics (haloperidol and thioridazine hydrochloride) did not diminish this irritability or destructive behavior. A single case experimental methodology was adopted to evaluate the behavioral response to other sequentially introduced neuroactive drugs. Methylphenidate produced increased agitation. No response was noted to propranolol. Lithium, however, was associated with significant calming of the patient, successful completion of rehabilitation, and discharge to home where the patient safely cared for himself while his wife worked.

Occult head injury: its incidence in spinal cord injury.

This study investigated the suspicion that a significant proportion of individuals having spinal cord injury (SCI) also sustain a concomitant undiagnosed occult head injury during the trauma accident. The criteria for high risk of head injury included the following: (1) quadriplegia with high energy deceleration accident, (2) loss of consciousness at time of injury, (3) brainstem or cortical neurologic indicators, or (4) respiratory support required at time of injury. In this study, 67 patients admitted to the rehabilitation unit were given a neuropsychologic evaluation a median of 48 days after injury. Motor free scales used were the Galveston Orientation and Amnesia Test (GOAT), Quick Test, Raven Progressive matrices, serial 7s, Shipley Hartford, Stroop Color/Word Interference, and the Wechsler Memory Scale Associate Learning Tests. Forty-three of the 67 patients (64%) scored mildly to profoundly impaired on the test battery. Evidence of poor premorbid academic history was present in 19 (44%) of those with impaired performance on the neurologic evaluation and in only three (13%) of those scoring unimpaired. Consequently, 56% (24/43) of the impaired had no previous record of scholastic difficulties, presumably acquiring cognitive impairment at the time of injury. The implications of this high incidence of impaired cognitive functioning for treatment of individuals with SCI are significant.

Rehabilitation of the severely brain-injured patient: a community-based, low-cost model program.

Survival from severe traumatic head injury requires long-term, comprehensive rehabilitation services. While acute, hospital-based rehabilitation services are becoming plentiful, low-cost community educational and socialization services are still rare. Cognitive impairments and behavioral disinhibitions frequently are so severe that traditional community agencies cannot effectively serve them. A unique low-cost program model has been developed and successfully implemented to prepare the most severely head injured for more traditional programs. Individualized programming is provided in a highly structured social setting by a professional teacher and many trained volunteers.

Glasgow Outcome Scale and Disability Rating Scale: comparative usefulness in following recovery in traumatic head injury.

Clinical experience and analysis of use of the Disability Rating Scale (DRS) and the Glasgow Outcome Scale (GOS) are reported in 70 patients up to two years after head injury. Statistical analysis shows significant change demonstrated by the DRS across the intervals from two to four, two to six, and six to 12 months after injury. The DRS more sensitively reflects improvement during inhospital rehabilitation than the GOS, 71% to 33%, respectively. Significant improvement is shown up to one year after injury. Trend data on seven patients for whom two-year data were available showed continued improvement, although the data were not statistically significant. The DRS has shown itself to be a sensitive, functional, reliable, and quantitative means of monitoring patients with traumatic head injury during the course of their recovery.

Head injury rehabilitation: benefit of early intervention.

Severely head injured patients in an acute rehabilitation setting were retrospectively divided into early and late rehabilitation admission groups (admitted before and after 35 days post injury). The 2 groups consisted of 16 and 20 patients respectively and were matched for length of coma, age, level of disability, neurosurgical procedures required, and other factors which might bias results due to less morbidity in the early admission group. Findings indicated that late admission patients required twice as much acute rehabilitation as early admission patients, even though both groups were comparable in initial disability and at outcome 2 years post-injury. Study findings implied potential cost savings of an average $40,000 per patient for acute hospital care. These benefits may be due to improved neurologic outcome or prevention of secondary complications.

Disability rating scale for severe head trauma: coma to community.

The objective of this study was to develop one instrument for assessing quantitatively the disability of severe head trauma patients so their rehabilitative progress could be followed from coma through different levels of awareness and functioning to their return to the community. This disability rating (DR) instrument was designed to be easily learned, quickly completed, valid, predictive of outcome and to have a high inter-rater reliability. The DR Scale consists of 8 items divided into 4 categories; 1. Arousal and awareness; 2. Cognitive ability to handle self-care functions; 3. Physical dependence upon others; 4. Psychosocial adaptability for work, housework, or school. Completed independently by several raters for more than 88 serious head injury patients, inter-rater correlations were highly significant. The admission DR was significantly related to clinical outcome at 1 year after injury and was significantly related to electrophysiologic measures of brain dysfunction as reflected in degree of abnormality of evoked brain potential patterns. The DR Scale is more sensitive than the Glasgow Outcome Scale in detecting and measuring clinical changes in individuals who have sustained severe head trauma. Also it can be used to help identify patients most likely to benefit from intensive rehabilitation care within a hospital setting. It provides a shorthand global description of a head injury patient's condition that facilitates understanding and communication.