Abstract
Objective
To use causal inference methods to determine if receipt of a greater proportion of
inpatient rehabilitation treatment focused on higher level functions, for example,
executive functions, ambulating over uneven surfaces (advanced therapy [AdvTx]), results
in better rehabilitation outcomes.
Design
A cohort study using propensity score methods applied to the traumatic brain injury
practice-based evidence (TBI-PBE) database, a database consisting of multisite, prospective,
longitudinal observational data.
Setting
Acute inpatient rehabilitation facilities.
Participants
Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained
a severe, moderate, or complicated mild TBI, receiving their first inpatient rehabilitation
facility admission to 1 of 9 sites in the United States, and consented to follow-up
3 and 9 months postdischarge from inpatient rehabilitation.
Interventions
Not applicable.
Main Outcome Measures
Participation Assessment with Recombined Tools-Objective-17, FIM motor and cognitive
scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9.
Results
Controlling for measured potential confounders, increasing the percentage of AdvTx
during inpatient TBI rehabilitation was found to be associated with better community
participation, functional independence, life satisfaction, and decreased likelihood
of depression during the year after discharge from inpatient rehabilitation. Participants
who began rehabilitation with greater disability experienced larger gains on some
outcomes than those who began rehabilitation with more intact abilities.
Conclusions
Increasing the proportion of treatment targeting higher level functions appears to
have no detrimental and a small, beneficial effect on outcome. Caution should be exercised
when inferring causality given that a large number of potential confounders could
not be completely controlled with propensity score methods. Further, the extent to
which unmeasured confounders influenced the findings is not known and could be of
particular concern due to the potential for the patient’s recovery trajectory to influence
therapists’ decisions to provide a greater amount of AdvTx.
Keywords
List of abbreviations:
AdvTx (advanced therapy), ASD (absolute standardized difference), HTE (heterogeneity of treatment effect), IPW (inverse probability weighting), PART-O (Participation Assessment with Recombined Tools-Objective), PHQ-9 (Patient Health Questionnaire-9), POC (point of care), SWLS (Satisfaction with Life Scale), TBI (traumatic brain injury), TBI-PBE (traumatic brain injury practice-based evidence)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: December 19, 2018
Footnotes
Supported by Patient-Centered Outcomes Research Institute (award no. CER-1403-13476). The statements presented in this work are solely the responsibility of the author(s) and do not necessarily represent the views of PCORI, its Board of Governors, or its Methodology Committee. Funding for the database used in this study came from the National Institutes of Health, National Center for Medical Rehabilitation Research (grant no. 1R01HD050439-01), the Administration for Community Living, National Institute on Disability, Independent Living and Rehabilitation Research (grant no. H133A080023), and the Ontario Neurotrauma Foundation (grant no. 2007-ABI-ISIS-525).
Disclosures: none.
Identification
Copyright
© 2018 by the American Congress of Rehabilitation Medicine
