Abstract
Objective
To determine if patients’ level of effort (LOE) in therapy sessions during traumatic
brain injury (TBI) rehabilitation modifies the effect of compliance with the 3-Hour
Rule of the Centers for Medicare & Medicaid Services.
Design
Propensity score methodology applied to the TBI Practice-Based Evidence database,
consisting of multisite, prospective, longitudinal observational data.
Setting
Acute inpatient rehabilitation facilities (IRF).
Participants
Patients (N=1820) who received their first IRF admission for TBI in the United States
and were enrolled for 3- and 9-month follow-up.
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
When the full cohort was examined, no strong main effect of compliance with the 3-Hour
Rule was identified and LOE did not modify the effect of compliance with the 3-Hour
Rule. In contrast, LOE had a strong positive main effect on all outcomes, except depression.
When the sample was stratified by level of disability, LOE modified the effect of
compliance, particularly on the outcomes of participants with less severe disability.
For these patients, providing 3 hours of therapy for 50% or more of therapy days in
the context of low effort resulted in poorer performance on select outcome measures
at discharge and up to 9 months postdischarge compared to patients with <50% of 3-hour
therapy days.
Conclusions
LOE is an active ingredient in inpatient TBI rehabilitation, while compliance with
the 3-Hour Rule was not found to have a substantive effect on the outcomes. The results
support matching time in therapy during acute TBI rehabilitation to patients’ LOE
in order to optimize long-term benefits on outcomes.
Keywords
List of abbreviations:
ASD (absolute standardized difference), CI (confidence interval), CMS (Centers for Medicare & Medicaid Services), IPW (inverse probability weighting), IRF (inpatient rehabilitation facility), LOE (level of effort), LOS (length of stay), OT (occupational therapy), PART-O (Participation Assessment with Recombined Tools-Objective), POC (point of care), PT (physical therapy), ST (speech therapy), 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: February 20, 2019
Footnotes
Supported by the Patient-Centered Outcomes Research Institute (grant no. CER-1403-13476), the National Institutes of Health, National Center for Medical Rehabilitation Research (grant no. 1R01HD050439-01), the National Institute on Disability, Independent Living, and Rehabilitation Research (grant no. H133A080023), and the Ontario Neurotrauma Foundation (grant no. 2007-ABI-ISIS-525). The statements presented in this work are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its Board of Governors, or Methodology Committee.
Disclosures: none.
Identification
Copyright
© 2019 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine
