For patients recovering from a traumatic brain injury (TBI), the rehabilitation process -- compensating for changes in functioning, adaptation and even community reintegration -- can be challenging. Unfortunately, not all rehab programs are created equal, and with the differences comes a difference in outcomes, according to a first-of-its-kind study published in The Journal of Head Trauma Rehabilitation.
Collectively authored by Baylor researchers, the outcomes study (titled "Comparative Effectiveness of Traumatic Brain Injury Rehabilitation: Differential Outcomes Across TBI Model Systems Centers"), set out to identify if outcomes at the post-discharge and one-year points varied across 21 Traumatic Brain Injury Model System (TBIMS) centers. The Baylor Institute of Rehabilitation (BIR) was one of the centers studied.
At the study's onset, researchers had an idea of what they might find, but their findings revealed the opposite.
"We expected that, after accounting for differences in patient characteristics and severity of injury, patient outcomes would be similar across centers," said Marie Dahdah, PhD, investigator at the Baylor Institute for Rehabilitation. "They were not. There were significant variations, with a 25 percent to 45 percent difference between the best performing site and the site with the lowest outcomes at discharge."
While differences in outcomes have long been reported in designated trauma centers (and for other specialties, including general and cardiac surgery, transplant and oncology), the study was the first piece of research to demonstrate that those differences exist in the rehabilitation context.
The team acknowledged that those variances could be attributed to institutional structures, resources and clinical practices, but that more research is needed to determine which of these factors is associated with optimum outcomes.
"In order to identify factors that contribute to variation in patient outcomes across centers, we are undertaking research that identifies different patient, injury and process-level factors associated with functional outcomes of patients," Dr. Dahdah said. "Those factors can then be targeted to improve patient outcomes."
In other phases of this study, these Baylor investigators (along with teams from three other TBIMS sites) are reviewing the quantity and frequency of various types of rehabilitation therapies used in inpatient TBI settings. The team will also study evidenced-based best practices for speech, occupational, physical and recreational therapy interventions, as well as neurocognitive and psychosocial interventions.
The results from those subsequent studies could help identify gaps between current practices and evidence-based best practices, with the aim of helping inform rehabilitation programs across the country and ensuring that all centers have the same opportunities for quality outcomes.
"I think I speak for my entire research team when I say that our involvement in this type of research comes out of our collective desire to improve quality of rehabilitation care, thereby enhancing outcomes following TBI," Dr. Dahdah said. "My hope is that by synthesizing and disseminating what is known about effective evidence-based rehabilitation interventions, BIR as part of the North Texas TBIMS will be able to encourage changes necessary to help institutions, clinicians and therapists to provide the best quality TBI rehabilitation care to their patients."
Of course, with the Baylor Institute of Rehabilitation being among the 21-center pool, one very obvious question remains. How did BIR's outcomes compare with the other 20 centers?
"I cannot count for you the number of times I have been asked that question," Dr. Dahdah said. "To ensure the integrity of our study, even our research team is blind to the identity of the centers."
But despite how well even the strongest inpatient rehab centers perform in a comparative context, there is always room for improvement, especially with best-practice regimens.
"Our research has already started discussions within the TBI Model Systems research community," Dr. Dahdah said. "We believe more research needs to be done to identify the key determinants of patient outcomes so that benchmarks for quality rehabilitation care can be derived for patients and their families."
- Marie N. Dahdah, Mark T. Barisa, Kathryn Schmidt, Sunni A. Barnes, Rosemary Dubiel, Cynthia Dunklin, Caryn Harper, Librada Callender, Amy Wilson, Ramon Diaz-Arrastia, Shahid Shafi. Comparative Effectiveness of Traumatic Brain Injury Rehabilitation. Journal of Head Trauma Rehabilitation, 2013; 1 DOI: 10.1097/HTR.0b013e3182a61983
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