Classification of severity for neuro- and trauma rehab patients

Research area: Rehabilitation and occupational therapy

Duration: September 2008 - May 2010

Researcher (Part 1): Christoph Pammer, Muna Abuzahra, (Part 2): Muna Abuzahra, Brigitte Piso,
(Part 3): Muna Abuzahra, Brigitte Piso.
Duration: 09/2008 – 05/2010
Suggested by: HVB
Publications:
HTA Project report 23a (Part 1): https://eprints.aihta.at/866
HTA Project report 23b (Part 2): https://eprints.aihta.at/867
HTA Project report 23c (Part 3): https://eprints.aihta.at/879

Part 1: Classification of severity for neuro- and trauma rehab patients. Instruments used classifying stroke and trauma patients (completed)
Part 2: International experiences in applying classification of severity for quality-assurance, performance-assessement and reimbursement (completed)
Part 3: Status quo in Austria (completed)

Part 1:
Background: The evidence, that the implementation of quality assurance systems in neurologic and trauma rehabilitation is able to improve patients´ functional health status is low. Indicators for outcome measurement should be assessed- not only for quality assurance reasons. Neurologic rehabilitation aims at improving the functional health status of patients as well as reintegrating patients in social participation. Therefore a variety of instruments for assessing functional health outcomes, activity and participation of patients have been developed and validated. The comprehensive and multi-dimensional assessment of patients´ health status is the basis of allocation decisions, standardised planning in rehabilitation as well as coming up to the patients´ and the health care providers´ expectations. The selection of appropriate measuring instruments makes significant contributions to improved patient care and its treatment outcomes.

The first part of this project aimed at identifying instruments for classifying disease severity in patients with neurologic or trauma rehabilitation and assessing them according to test quality criteria. As an example, chose two specific diagnostic groups (stroke and traumatic brain injury)

Method: We identified 2527 publications by systematic literature search and hand search. 167 full text articles met our inclusion criteria and were included in further analyses.

Results: In stroke patients, specific instruments for classifying the severity of the disease show better test quality than generic instruments. We recommend the National Institut of Health Stroke Scale (NIHSS), the Beck Depression Inventory (BDI), the Frenchay Activities Index (FAI), the Stroke Impact Scale (SIS) and the Stroke Specific Quality of Life Scale  (SSQOL) according to test quality criteria. In patients with traumatic brain injury specific instruments do not necessarily perform better than generic instruments. We recommend the Disability Rating Scale (DRS) and the Community Integration Questionnaire (CIQ).

Conclusion: Instrument selection is not only dependant of test quality (and feasibility and acceptability issues), but also of the purpose the measurements should serve in the system. Generic instruments can be used across different diseases, while additionally other criteria have to be assessed disease specific (modular composition of generic and disease specific instruments).

For a choice of measurement instruments in neurological and trauma rehabilitation in Austria, aims of measurements have to be defined. It has to be clarified, whether and in which way measurements for quality assurance and outcome evaluation will be implemented and if it will be connected to reimbursement.

Part 2:
Background: Neurologic and traumatologic rehabilitation are highly complex. The evaluation of quality and performance is important in order to meet the requirements of patients, care providers and funders of health care. Increased efficiency can be achieved by using outcome-oriented payment models.  Differentiation by severity of disease using generic (overall diagnosis) assessment instruments could be used in quality measurement and linked to reimbursement systems.

Method: This report considers whether and which generic assessment instruments are used in quality and performance measurement, or in determining levels of reimbursement, in neuro and trauma rehabilitation. In particular, it explores international experiences with such instruments. A systematic literature review and a selective internet search were conducted in order to answer these questions.

Results: In Germany and in Switzerland pilot studies of generic instruments for quality and performance measurement are being conducted. In Australia the AROC (Australasian Rehabilitation Outcome Centre) carries out quality measurement in rehabilitation almost nationwide, and uses the FIM (Functional Independency Measure).  The application of generic instruments in outcome orientated payment systems has been tested in Germany using the FIM and the SINGER (Selbstständigkeitsindex für die neurologische und geriatrische Rehabilitation). In Switzerland, the LTR (leistungsorientiertes Tarifmodell, performance-oriented tariff model) is currently being tested. In Great Britain the RCS (Rehabilitation Complexity Scale), the NPDS (Northwick Park nursing Dependency Scale), and the NPTDA (Northwick Park Therapy Dependency Assessment) have been developed and are currently being piloted. In Australia the AN-SNAP-Classification (Australian National Sub-acute and Non-acute Patient Classification System), in which the differentiation of severity is based on the FIM, has been developed. In the USA the FIM has been in use for the differentiation of severity in the PPS (Prospective Payment System) since 2002.

Most of the studies reviewed which discuss the use of generic instruments in reimbursement are from the USA.  For the most part, they evaluate the PPS. The costs of neuro and trauma rehabilitation are higher than the level of reimbursement designated by the PPS. Since the implementation of the PPS, the average length of stay has decreased and rate of discharges to home has increased.

Conclusion: Generic Instruments can be used for various purposes. In Austria, pilot projects of the use of generic instruments for the measurement of quality and/or reimbursement, which take into consideration previous international experiences and projects, are recommended.

Part 3:
Background: Based on the first parts of the project “classifying disease severity in patients with neurologic or trauma rehabilitation” (part 1: instruments for stroke and traumatic brain injury . HTA-Projektbericht 023a; part 2: International experiences with quality / performance assessments and reimbursement . HTA-Projektbericht 023b) we aimed at collecting status quo data to the usage of generic and specific instruments and at identifying pilot projects in Austrian rehabilitation institutions. Additionally we wanted to assess opinions about the potentials and constraints of generic instruments.

Methods: For data collection we developed a questionnaire and sent it to 20 Austrian rehabilitation centers via email (response rate 50%).

Results: Some instruments (the 10m walk test, the nine-hole-peg-test, the Barthel Index/BI, the 2min walk test, the Rankin Scale/RS, the Functional Ambulation Categories/FAC, the mini mental state examination/MMSE, the expanded disability status scale/EDSS) are being used in almost all of the centres, most commonly at admission and/or discharge. Most frequently, physicians, nurses, occupational therapists, physiotherapists, speech therapists and (neuro-)psychologists conduct the assessments. Individual goals are arranged with patients in all institutions, but goal attainment is evaluated only in about fifty percent of the institutions. Key objectives of data collection are the documentation of the rehabilitation process and documentation for internal quality management. Overall seven completed or ongoing pilot projects, which test the utilization of measuring instruments or quality assurance systems, could be identified by the survey.

Discussion: The results show that recommendations of the ÖGNR lead to a homogenisation of used instruments. However, a standardized base documentation does not exist and there is still a variety of used measurement instruments. Pilot projects point at increasing interests in quality management and comparison between institutions.