Rehabilitation and Functional Recovery Studies in Health Services (ReFReSH)

Introduction: We report on the process of using a learning health systems (LHS) approach to design a data visualization dashboard to monitor the rehabilitation progress of patients with disorders of consciousness (DoC) after severe brain injury.

Methods: Our team conducted a qualitative study using informational interviews with key informants to understand informational needs and priorities for the dashboard from the perspectives of rehabilitation therapists, family members of patients with DoC, and third-party payors. We used a thematic survey approach to organize the findings with the following categories: (a) how the dashboard will be used; (b) content to be displayed; (c) organization and design of content; and (d) technical requirements. We used an iterative process to develop the dashboard, with multiple opportunities for stakeholder feedback.

Results: Seven people participated in informational interviews (n = 2 rehabilitation therapists; n = 2 family members; n = 3 third-party payor representatives). The primary intended use of the dashboard is communication and facilitation of shared understanding across clinical teams, rehabilitation teams, and patients' families, and between payors and facilities. Desired content includes core metrics applied by the DoC program for diagnosis and monitoring. There is a high priority for making the display easily understandable and interpretable. Technical requirements include the ability to pull data for display from existing items in the electronic health record to minimize additional burden on therapists. User feedback on the design resulted in a streamlined main screen, with additional detail accessible by clicking into each assessment.

Conclusions: In the unique case of patients with DoC, who cannot speak for themselves, effective communication among rehabilitation clinicians, family members or care partners, and third-party payors is highly important for optimal care. The key benefit of using an LHS approach is positioning the team to proactively design the dashboard to account for the needs and preferences of different end users.

The purpose of this study was to describe development, application, and satisfaction of a mentoring match algorithm created for the ACRM CDNG Leadership Mentoring Program. We conducted sequential, mixed methods evaluation of a mentoring-match algorithm. Interdisciplinary rehabilitation professionals participated in the program as mentees and mentors. We assessed mentoring matches made and frequency of mentees being matched with their first, second, or third recommended mentor. We also conducted focus groups to explore satisfaction with mentoring matches. There were 13 mentoring matches made (26 participants: 13 mentees and 13 mentors), including 7 mentees (53.8%) matched with their first recommended mentor, 5 (38.7%) with their second, and 1 (7.6%) with their third. Key qualitative findings included quality and structure of the mentoring matches and recommendations for improvements. This novel, interdisciplinary mentoring match algorithm shows promise for use across disciplines, settings, and organizations. More research is needed to evaluate program outcomes.

Objective: To describe the characteristics of patients enrolled in disorders of consciousness (DoC) rehabilitation programs and to examine factors associated with improvement beyond measurement error on neurobehavioral function. Outcomes for adults with DoC after severe brain injury are highly variable and difficult to predict. Applying a minimal detectable change (MDC) threshold to change measures can identify help to distinguish true improvement or decline from random fluctuation. We also evaluated whether change in neurobehavioral function during the first 2 weeks of rehabilitation was associated with change between 2 and 4 weeks.

Design: Retrospective cohort study. Data were generated as part of standard clinical care.

Setting: Postacute inpatient facilities with specialized DoC programs at 2 large, urban health care systems.

Participants: Adults with DoC after severe brain injury (N=696).

Interventions: Not applicable.

Main Outcome Measure: Improvement beyond measurement error, calculated as the MDC with a 90% confidence interval (9 units) on the Coma Recovery Scale-Revised (CRS-R), using an equal-interval 0-100 unit transformed total measure. The MDC threshold was applied to change in CRS-R total measure from first to last CRS-R administration (up to 60 elapsed).

Results: Two-thirds of the sample (n=445) improved beyond the MDC on the CRS-R; 23 participants declined beyond measurement error, and 228 participants changed less than the MDC. Patients with less time elapsed between injury and first CRS-R assessment were more likely to improve beyond the MDC. Change during the first 2 weeks of rehabilitation was not associated with change between 2 and 4 weeks.

Conclusions: Our results underscore the importance of measuring change with greater precision for adults with DoC, as within-state change (or lack thereof) could inform rehabilitation treatment decisions about whether interventions are working as intended.

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.

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

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

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.

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.