Rehabilitation and Functional Recovery Studies in Health Services (ReFReSH)
Director: Alison M. Cogan PhD, OTR/L
The mission of the Rehabilitation and Functional Recovery Studies in Health Services (ReFReSH) Lab is to improve rehabilitation outcomes and quality of life for adults with acquired brain injuries. Our work aims to improve the quality of rehabilitation services by identifying what combinations of services work best for whom to enable optimal functional performance and community participation. We address the rehabilitation needs of military service members and Veterans with brain injury as well as the civilian population using a range of quantitative and qualitative research methods. Research in our lab focuses on:
- Understanding recovery trajectories and how the amount and type of therapy is associated with improvement
- Developing data visualization approaches that support effective clinical decision making
- Advancing outcome measurement and aligning outcome measures with treatment goals
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Designing Precision Rehabilitation for Post-acute Care (PRe-PAC) ⟩
The aims of this training award are to (1) create patient profiles of functional recovery in the domains of self-care, mobility, and cognition for adults with stroke to evaluate the association of how rehabilitation service time as distributed among occupational, physical, and speech-language…
Period: Apr 2024 – Mar 2027
Intramural Funding $75,000 + 75% FTE
Learning Health Systems Rehabilitation Research (LeaRRn) Learning Health Systems Scholar — Data visualization for adults with disorders of consciousness ⟩
As a LeaRRn LHS Scholar, Dr. Cogan will partner with Dr. Joe Giacino at Spaulding Rehabilitation, with mentorship from Drs. Mary Slavin and Lewis Kazis. Her project will focus on creation of tools to visualize assessment data from electronic health records to support clinical decision making and…
Period: Aug 2023 – Jun 2025
Federal Funding $15,000
Supporting Improved Clinical Decision Making in Severe Traumatic Brain Injury Through Greater Accuracy and Precision of Neurobehavioral Common Data Elements ⟩
Advances in science have resulted in many survivors of traumatic brain injury living in disordered states of consciousness for up to two decades. However, we have not advanced the state of the science to foster traumatic brain injury survivor’s functional recovery. A critical challenge in…
Period: Sep 2022 – Mar 2025
Federal Funding $299,639
Using EHR Data to Monitor Functional Recovery in Adults with Brain Injury during Inpatient Rehabilitation ⟩
The goals of this pilot study were to (1) document procedures for cleaning and managing electronic health record data for research on rehabilitation services and outcomes and (2) explain the association of functional recovery with therapy time and content over an episode of inpatient rehabilitation…
Period: Dec 2020 – May 2023
Private Funding $92,241
2025
Cogan, A. M., Roberts, P., & Mallinson, T. (2025). Using electronic health record data for occupational therapy health services research: Invited commentary. OTJR: Occupational Therapy Journal of Research, 45(1), 3–11. https://doi.org/10.1177/15394492241246544 Show abstract
Health services research (HSR) is a field of study that examines how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and health and well-being. HSR approaches can help build the occupational therapy evidence base, particularly in relation to population health. Data from electronic health record (EHR) systems provide a rich resource for applying HSR approaches to examine the value of occupational therapy services. Transparency about data preparation procedures is important for interpreting results. Based on our findings, we describe a six-step cleaning protocol for preparing EHR and billing data from an inpatient rehabilitation facility for research and provide recommendations for the field based on our experience. Using and reporting similar strategies across studies will improve efficiency and transparency, and facilitate comparability of results.
2024
Cogan, A. M., Roberts, P., & Mallinson, T. (2024). Association of rate of functional recovery with therapy time and content among adults with acquired brain injuries in inpatient rehabilitation. Archives of Rehabilitation Research and Clinical Translation, 6(4), 100370. https://doi.org/10.1016/j.arrct.2024.100370 Show abstract
Objective. To examine associations among the time and content of rehabilitation treatment with self-care and mobility functional gain rate for adults with acquired brain injury.
Design. Retrospective cohort study using electronic health record and administrative billing data.
Setting. Inpatient rehabilitation unit at a large, academic medical center.
Participants. Adults with primary diagnosis of stroke, traumatic brain injury, or nontraumatic brain injury admitted to the inpatient rehabilitation unit between 2012 and 2017 (N=799).
Interventions. Not applicable.
Main Outcome Measures. Gain rate in self-care and mobility function, using the Functional Independence Measure. Hierarchical regression models were used to identify the contributions of baseline characteristics, units, and content of occupational therapy, physical therapy, and speech-language pathology treatment to functional gain rates.
Results. Median length of rehabilitation stay was 10 days (interquartile range, 8-13d). Patients received an mean of 10.62 units of therapy (SD, 2.05) daily. For self-care care gain rate, the best-fitting model accounted for 32% of the variance. Occupational therapy activities of daily living units were positively associated with gain rate. For mobility gain rate, the best-fitting model accounted for 37% of the variance. Higher amounts of physical therapy bed mobility training were inversely associated with mobility gain rate.
Conclusions. More activities of daily living in occupational therapy is associated with faster improvement on self-care function for adults with acquired brain injury, whereas more bed mobility in physical therapy was associated with slower improvement. A potential challenge with value-based payments is the alignment between clinically appropriate therapy activities and the metrics by which patient improvement are evaluated. There is a risk that therapists and facilities will prioritize activities that drive improvement on metrics and deemphasize other patient-centered goals.
Keywords. Brain injuries; Electronic health records; Recovery of function; Rehabilitation; Stroke
2023
Cogan, A. M., Rinne, S. T., Weiner, M., Simon, S., Davila, J., & Yano, E. M. (2023). Using research to transform electronic health record modernization: Advancing a VA partnered research agenda to increase research impacts. Journal of General Internal Medicine, 38(Suppl 4), 965–973. https://doi.org/10.1007/s11606-023-08289-y Show abstract
Background. The U.S. Department of Veterans Affairs (VA) is undergoing an enterprise-wide transition from a homegrown electronic health record (EHR) system to a commercial off-the-shelf product. Because of the far-reaching effects of the EHR transformation through all aspects of the healthcare system, VA Health Services Research and Development identified a need to develop a research agenda that aligned with health system priorities so that work may inform evidence-based improvements in implementation processes and outcomes.
Objective. The purpose of this paper is to report on the development of a research agenda designed to optimize the EHR transition processes and implementation outcomes in a large, national integrated delivery system.
Design. We used a sequential mixed-methods approach (portfolio assessment, literature review) combined with multi-level stakeholder engagement approach that included research, informatics, and healthcare operations experts in EHR transitions in and outside the VA. Data from each stage were integrated iteratively to identify and prioritize key research areas within and across all stakeholder groups.
Participants. VA informatics researchers, regional VA health system leaders, national VA program office leaders, and external informatics experts with EHR transition experience.
Key Results. Through three rounds of stakeholder engagement, priority research topics were identified that focused on operations, user experience, patient safety, clinical outcomes, value realization, and informatics innovations.
Conclusions. The resulting EHR-focused research agenda was designed to guide development and conduct of rigorous research evidence aimed at providing actionable results to address the needs of operations partners, clinicians, clinical staff, patients, and other stakeholders. Continued investment in research and evaluation from both research and operations divisions of VA will be critical to executing the research agenda, ensuring its salience and value to the health system and its end users, and ultimately realizing the promise of this EHR transition.
Keywords. electronic health records, informatics, Veterans health services, United States Department of Veterans Affairs
Cogan, A. M., & Bailie, J. M. (2023). Therapeutic relationship in mTBI rehabilitation: The disparity between the illness experience and clinical definitions. Military Medicine, 188(9-10), e3010–e3016. https://doi.org/10.1093/milmed/usad143 Show abstract
Introduction. A positive therapeutic relationship is characterized by trust and mutually perceived genuineness. It is positively associated with patients’ adherence to treatment, satisfaction, and health outcomes. When service members with a history of mild traumatic brain injury (mTBI) present to rehabilitation clinics with nonspecific symptoms, a disparity between their experience of disability and clinical expectations of mTBI may disrupt the establishment of a positive therapeutic relationship between patients and providers. The objectives of this study are to (1) explore disparities between military service members and rehabilitation clinicians about the clinical diagnosis and illness experience of mTBI and (2) identify barriers to the establishment of a positive therapeutic relationship.
Materials and Methods. This is a qualitative descriptive study of military service members with prior mTBI (n = 18) and clinicians (n = 16) who participated in interviews and focus groups. Data were analyzed thematically using Kleinman’s framing of illness experience and clinical diagnosis.
Results. Three themes reflected the potential breakdowns in the therapeutic relationship. The first theme, clinical expectations for post-injury recovery versus patients’ experience of ongoing disability, reflects the inconsistency between clinicians’ expectations of symptom resolution within 90 days following mTBI and service members’ experiences of symptoms that worsened over several months or years. The second theme, symptom attribution to mental health conditions versus tissue injury, describes the difficulty in attributing symptoms to the physical impact of the mTBI or mental health diagnoses that may also stem from the injury event. The third theme, suspected malingering versus valid disability, describes clinicians’ reports of frustration with cases in which they suspected malingering for secondary gains in contrast with service members’ feelings that their problems were not taken seriously by clinicians.
Conclusions. This study extended previous research on therapeutic relationships by examining the situation of mTBI rehabilitation services for military service members. The findings reinforce the best practice recommendations of acknowledging patients’ experiences, addressing the presenting symptoms and problems, and encouraging progressive return to activity following mTBI. Acknowledgment of and attention to patients’ illness experience by rehabilitation clinicians is necessary and important for supporting a positive therapeutic relationship and ultimately to optimize patients’ health outcomes and reduce disability.
Cogan, A. M., Saliba, D., Steers, N., Frochen, S., Lynch, K. A., Ganz, D. A., & Washington, D. L. (2023). Provider discussion of health goals and psychosocial needs: Comparing older to younger veteran experience. Health Services Research, 58(S1), 9-15. https://doi.org/10.1111/1475-6773.14054 Show abstract
Objective. To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits.
Data Sources and Study Setting. Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019.
Study Design. Cross-sectional survey of VA users by age group (18–44 years, 45–64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity.
Data Collection/Extraction Method. Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data.
Principal Findings. In unadjusted analyses, VA users age 18–44 had a higher (−8.2%; CI: −9.0, −7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity.
Conclusions. Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.