Cost-benefits associated with social outcome from neurobehavioural rehabilitation.

PRIMARY OBJECTIVE: To carry out a clinical and cost-outcome evaluation of a neurobehavioural post-acute rehabilitation programme in the UK. RESEARCH DESIGN: The study was a multi-centre prospective cohort study of adults with acquired brain injury admitted for residential rehabilitation. Comprehensive data were collected on type of residence, amount and type of care, functional independence, engagement in constructive occupation and participation in social roles. PROCEDURES: Data were gathered on admission relating to individuals' levels of care and functioning, both pre-morbidly and at the time of admission (pre-rehabilitation). Additional information about functioning was collected upon discharge (post-rehabilitation). Follow-up data was collated in person, by telephone or by post after an average of 18 months by a researcher who was blind to the rehabilitation outcomes. The data were analysed in terms of clinical outcomes and support costs. Savings in costs of care or support were calculated on the basis of difference between pre-rehabilitation and follow-up support costs minus the costs of rehabilitation. RESULTS: Significant gains were evident at discharge and follow-up in virtually all indices of social outcome. Improvements were recorded in type of accommodation, levels of care, functional ability, productive occupation and performance of social roles. Patients admitted within 1 year of injury made the most progress, but improvements were made regardless of time since injury. Patients continued to benefit from rehabilitation well beyond the period when most natural recovery would take place. Economic calculations suggested that the initial costs of rehabilitation are generally offset by savings in care costs within 2 years. Sensitivity analysis on estimated savings in care costs yielded projected lifetime savings of between Pounds 1.1-0.8 M for persons admitted for rehabilitation within 12 months of injury, Pounds 0.7- Pounds 0.5 M within 2 years of injury and Pounds 0.5-0.36 M for admissions after 2 years. CONCLUSIONS: Specialist rehabilitation for neurobehavioural disability produces comprehensive and sustainable improvements in the life of individuals with brain injury. The initial costs associated with neurobehavioural rehabilitation are offset by savings in costs of support in the medium and longer term.

Rehabilitation is compromised by arousal and sleep disorders: results of a survey of rehabilitation centres.

PRIMARY OBJECTIVE: To investigate the impact of disorders of arousal and sleep disturbance on everyday living and participation in rehabilitation. RESEARCH DESIGN: Survey of rehabilitation centres based on naturalistic observation. METHOD: One hundred and thirty-five adults with acquired brain injury were reported by rehabilitation staff in seven centres across the UK for presence of arousal and/or sleep disturbance, the impact on rehabilitation and daily living and treatment strategies in use. OUTCOMES: Disturbance of arousal or sleep patterns was reported in 47% of the sample, with significant adverse effect on activity evident in two-thirds of such cases. Prevalence of disordered arousal was consistent over time for up to 10 years post-injury. Concurrent psychiatric illness, but not epilepsy, was associated with arousal and sleep disorder. Non-pharmacological interventions and benzodiazepine/hypnotic drugs were in use in 34% and 20% of cases respectively. In all cases of prescribed hypnotic drugs, period of use exceeded recommended UK guidelines. CONCLUSIONS: Long-term outcome from severe brain injury can be compromised by enduring disturbance of arousal, most commonly evidenced as sleep disorder. Treatment should be based on judicious use of medication (beyond hypnotic drugs) and greater emphasis on non-pharmacological management.

Delayed discharge from rehabilitation after brain injury.

OBJECTIVE: To investigate the extent of, and factors contributing to, delayed discharges for younger adults in rehabilitation. METHOD: Survey of patients discharged and awaiting discharge in a six-month period in five centres across England operated by a leading independent sector provider. Discharge was classified as delayed if a person had been waiting more than 30 days for transfer. RESULTS: One in three beds was occupied by a delayed discharge (median delay > seven months). Common reasons were absence of a suitable placement (41%) and failure to obtain funding for postdischarge support (31%). Delays were also associated with poor indoor mobility and additional physical/mental health problems. We estimated earlier discharge would have resulted in overall cost savings of almost l490 000. CONCLUSION: Delayed discharge remains a significant obstacle to the development of cost-effective care pathways for younger adults. Our study suggests that health and social services are not exploiting the UK government's legislation for flexible partnership working in this area.