Original research| Volume 97, ISSUE 6, P885-891, June 2016

Determinants of Admission to Inpatient Rehabilitation Among Acute Care Survivors of Hypoxic-Ischemic Brain Injury: A Prospective Population-Wide Cohort Study

Published:January 29, 2016DOI:



      To investigate demographic and acute care clinical determinants of admission to inpatient rehabilitation (IR) among patients with hypoxic-ischemic brain injury (HIBI) who survive the initial acute care episode.


      Population-wide prospective cohort study using Canadian Institutes for Health Information administrative health data from Ontario, Canada. All patients who survived their HIBI acute care episode during the study period remained eligible for the outcome, admission to IR, for 1 year postacute care discharge.


      Inpatient rehabilitation.


      We included all patients with HIBI using International Classification of Diseases, Tenth Revision, Canadian Enhancement codes recorded at acute care admission who were ≥20 years old (N=599) and discharged from acute care between the 2002 and 2010 fiscal years, inclusive. Six patients were excluded from analyses because of missing data.


      Not applicable.

      Main Outcome Measure

      Admission to IR.


      Of HIBI survivors admitted to IR within 1 year of acute care discharge (n=169), most (56.2%) had an IR admitting diagnosis indicating anoxic brain damage. Younger age, being a man, lower comorbidity burden, longer length of stay of preceding acute care episode, and shorter duration in special care were most predictive of admission to IR in multivariable regression models. Women had an almost 2-fold lower incidence of admission to IR (risk ratio, .62; 95% confidence interval, .46–.84).


      Older age, higher comorbidity burden, and shorter lengths of stay and delayed discharge from acute care are associated with lower incidence of IR admission for patients with HIBI. That women are almost 2-fold less likely to receive rehabilitation requires further investigation.


      List of abbreviations:

      ABI (acquired brain injury), ALC (alternate level of care), HIBI (hypoxic-ischemic brain injury), ICD-10 (International Classification of Diseases, 10th Revision), IR (inpatient rehabilitation), LOS (length of stay), NTBI (nontraumatic brain injury), TBI (traumatic brain injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Toronto ABI Network
        Definition of ABI.
        2015 (Available at:) (Accessed June 9, 2015)
        • Basso A.
        • Previgliano I.
        • Servadei F.
        Neurological disorders: a public health approach. Traumatic brain injuries.
        in: Neurological disorders: public health challenges. World Health Organization, 2006: 164-176
        • Ropper A.H.
        • Samuels M.A.
        The acquired metabolic disorders of the nervous system.
        in: Ropper A.H. Samuels M.A. Adams and Victor’s principles of neurology. McGraw Hill Medical, New York2009: 1081-1107
        • Arciniegas D.B.
        Hypoxic-ischemic brain injury: addressing the disconnect between pathophysiology and public policy.
        Neurorehabilitation. 2010; 26: 1-4
      1. Colantonio A, Chan V, Zagorski B, Parsons D, Vander Laan R. Ontario Acquired Brain Injury (ABI) Dataset Project Phase III: highlights: number of episodes of care and causes of brain injury. Available at: Accessed June 17, 2015.

        • Wilson B.A.
        Cognitive functioning of adult survivors of cerebral hypoxia.
        Brain Inj. 1996; 10: 863-874
        • Lu-Emerson C.
        • Khot S.
        Neurological sequelae of hypoxic-ischemic brain injury.
        Neurorehabilitation. 2010; 26: 35-45
        • Khot S.
        • Tirschwell D.L.
        Long-term neurological complications after hypoxic-ischemic encephalopathy.
        Semin Neurol. 2006; 26: 422-431
        • Wilson M.
        • Staniforth A.
        • Till R.
        • das Nair R.
        • Vesey P.
        The psychosocial outcomes of anoxic brain injury following cardiac arrest.
        Resuscitation. 2014; 85: 795-800
        • Middelkamp W.
        • Moulaert V.
        • Verbunt J.A.
        • van Heugten C.M.
        • Bakx W.G.
        • Wade D.T.
        Life after survival: long-term daily life functioning and quality of life of patients with hypoxic injury as a result of cardiac arrest.
        Clin Rehabil. 2007; 21: 425-431
        • Cullen N.K.
        • Park Y.
        • Bayley M.T.
        Functional recovery following traumatic vs. non-traumatic brain injury: a case-controlled study.
        Brain Inj. 2008; 22: 1013-1020
        • Cullen N.
        • Crescini C.
        • Bailey M.
        Rehabilitation outcomes after anoxic brain injury: a case controlled comparison with traumatic brain injury.
        PMR. 2009; 1: 1069-1076
        • Cullen N.K.
        • Weisz K.
        Cognitive correlates with functional outcomes after anoxic brain injury: a case-controlled comparison with traumatic brain injury.
        Brain Inj. 2011; 25: 35-43
        • Smania N.
        • Avesani R.
        • Roncari L.
        • et al.
        Factors predicting functional and cognitive recovery following severe traumatic, anoxic, and cerebrovascular brain damage.
        J Head Trauma Rehabil. 2013; 28: 131-140
        • Fitzgerald A.
        • Aditya H.
        • Prior A.
        • McNeill E.
        • Pentland B.
        Anoxic brain injury: clinical patterns and functional outcomes: a study of 93 cases.
        Brain Inj. 2010; 24: 1311-1323
        • Fertl E.
        • Vass K.
        • Sterz F.
        • Gabriel H.
        • Auf E.
        Neurological rehabilitation of severely disabled cardiac arrest survivors. Part 1. Course of post-acute inpatient treatment.
        Resuscitation. 2000; 47: 231-239
        • Chan V.
        • Zagorski B.
        • Parsons D.
        • Colantonio A.
        Older adults with acquired brain injury: a population based study.
        BMC Geriatr. 2013; 13: 97
        • Kraus J.F.
        • Chu L.D.
        in: Silver J.M. McAllister T.M. Yudofsky S.C. Textbook of traumatic brain injury. Arlington: American Psychiatric Publishing, 2005: 3-26
        • Jourdan C.
        • Bayen E.
        • Bosserelle V.
        • et al.
        Referral to rehabilitation after severe traumatic brain injury: results from the PariS-TBI Study.
        Neurorehabil Neural Repair. 2013; 27: 35-44
        • Foster M.
        • Tilse C.
        • Fleming J.
        Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making.
        Soc Sci Med. 2004; 59: 1867-1878
        • Chen A.Y.
        • Zagorski B.
        • Parsons D.
        • et al.
        Factors associated with discharge destination from acute care after acquired brain injury in Ontario, Canada.
        BMC Neurol. 2012; 12: 16
        • Canadian Institute for Health Information
        National Rehabilitation Reporting System data quality documentation, 2007–2008.
        CIHI, Ottawa2009
        • Zielinski A.
        • Kronogard M.
        • Lenhoff H.
        • Halling A.
        Validation of ACG Case-mix for equitable resource allocation in Swedish primary health care.
        BMC Public Health. 2009; 9: 347
        • Brilleman S.L.
        • Salisbury C.
        Comparing measures of multimorbidity to predict outcomes in primary care: a cross-sectional study.
        Fam Pract. 2013; 30: 172-178
        • Austin P.C.
        • van Walraven C.
        • Wodchis W.P.
        • Newman A.
        • Anderson G.M.
        Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada.
        Med Care. 2011; 49: 932-939
        • Chen A.
        • Zagorski B.
        • Parsons D.
        • Vander Laan R.
        • Colantonio A.
        Acute care alternate-level-of-care days due to delayed discharge for traumatic and non-traumatic brain injuries.
        Healthc Policy. 2012; 7: 41-55
        • Canadian Institute for Health Information
        Analysis in brief: alternate level of care in Canada.
        2009 (Available at:) (Accessed May 30, 2015)
        • Ottenbacher K.J.
        • Hsu Y.
        • Granger C.V.
        • Fiedler R.C.
        The reliability of the Functional Independence Measure: a quantitative review.
        Arch Phys Med Rehabil. 1996; 77: 1226-1232
        • Canadian Institute for Health Information
        About National Rehabilitation Reporting System (NRS) QuickStats.
        2014 (Available at:) (Accessed June 5, 2015)
        • Zou G.
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Spiegelman D.
        • Hertzmark E.
        Easy SAS calculations for risk or prevalence ratios and differences.
        Am J Epidemiol. 2005; 162: 199-200
        • de Guise E.
        • Feyz M.
        • LeBlanc J.
        • Richard S.L.
        • Lamoureux J.
        Overview of traumatic brain injury patients at a tertiary trauma centre.
        Can J Neurol Sci. 2005; 32: 186-193
        • Rittenberger J.C.
        • Raina K.
        • Holm M.B.
        • Kim Y.J.
        • Callaway C.W.
        Association between cerebral performance category, modified Rankin scale, and discharge disposition after cardiac arrest.
        Resuscitation. 2011; 82: 1036-1040
        • Chen A.
        • Bushmeneva K.
        • Zagorski B.
        • Colantonio A.
        • Parsons D.
        • Wodchis W.
        Direct cost associated with acquired brain injury in Ontario.
        BMC Neurol. 2012; 12: 76
        • Colantonio A.
        • Gerber G.
        • Bayley M.
        • Deber R.
        • Yin J.
        • Kim H.
        Differential profiles for patients with traumatic and non-traumatic brain injury.
        J Rehabil Med. 2011; 43: 311-315
        • Samayoa L.
        • Grace S.L.
        • Gravely S.
        • Scott L.B.
        • Marzolini S.
        • Colella T.J.
        Sex differences in cardiac rehabilitation enrollment: a meta-analysis.
        Can J Cardiol. 2014; 30: 793-800
        • Stewart Williams J.A.
        Using non-linear decomposition to explain the discriminatory effects of male-female differentials in access to care: a cardiac rehabilitation case study.
        Soc Sci Med. 2009; 69: 1072-1079
        • Sandel M.E.
        • Wang H.
        • Terdiman J.
        • et al.
        Disparities in stroke rehabilitation: results of a study in an integrated health system in northern California.
        PMR. 2009; 1: 29-40
        • Macleod M.R.
        • Smith S.J.
        Gender and deprivation and rates of referral and thereby admission to a national neurorehabilitation service.
        Clin Rehabil. 2005; 19: 109-115
        • Graham J.E.
        • Radice-Neumann D.M.
        • Reistetter T.A.
        • Hammond F.M.
        • Dijkers M.
        • Granger C.V.
        Influence of sex and age on inpatient rehabilitation outcomes among older adults with traumatic brain injury.
        Arch Phys Med Rehabil. 2010; 91: 43-50
        • Ratcliff J.J.
        • Greenspan A.I.
        • Goldstein F.C.
        • et al.
        Gender and traumatic brain injury: do the sexes fare differently?.
        Brain Inj. 2007; 21: 1023-1030
        • Altman B.M.
        • Smith R.T.
        Rehabilitation service utilization models: changes in the opportunity structure for disabled women.
        Int Disabil Stud. 1990; 12: 149-156
        • Haag H.L.
        • Caringal M.
        • Sokoloff S.
        • Kontos P.
        • Yoshida K.
        • Colantonio A.
        Being a woman with acquired brain injury: challenges and implications for practice.
        Arch Phys Med Rehabil. 2016; 97: S64-S70
        • Avesvani R.
        • Roncari L.
        • Khansefid M.
        • et al.
        The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients.
        Eur J Phys Rehabil Med. 2013; 49: 611-618
        • Bejor M.
        • Ramella F.C.
        • Toffola E.D.
        • Comelli M.
        • Chiappedi M.
        Inpatient rehabilitation outcome: a matter of diagnosis?.
        Neuropsychiatr Dis Treat. 2013; 9: 253-257
        • Kunik C.L.
        • Flowers L.
        • Kazanjian T.
        Time to rehabilitation admission and associated outcomes for patients with traumatic brain injury.
        Arch Phys Med Rehabil. 2006; 87: 1590-1596
        • Statistics Canada
        Population by year, by province and territory.
        2014 (Available at:) (Accessed June 8, 2015)
        • Juurlink D.
        • Preyra C.
        • Croxford R.
        • et al.
        Canadian Institute for Health Information Discharge Abstract Database: a validation study.
        Institute for Clinical Evaluative Sciences, Toronto2006
      2. Canadian Institute for Health Information. Rehabilitation. Available at: Accessed June 8, 2015.