Appendix 1. Question Text and Characteristics

Question 1

1. Does the application of early, interdisciplinary rehabilitation improve outcomes for people with traumatic brain injury?

Rationale:

• The use of interdisciplinary rehabilitation varies in when it is applied.
• The purpose of this question is to find out if there is evidence that the application of this intervention during treatment in the acute care hospital improves outcomes.

Definitions:

• Early applies to the phase of treatment after discharge from the emergency department and prior to discharge from the acute care hospital.
• Interdisciplinary rehabilitation is an intervention that utilizes a variety of methods, usually including but not limited to physical therapy, occupational therapy, and speech therapy.

Patient population:

• People who sustained traumatic brain injury between the ages of 18 and 65 years whose injury severity warranted admission to a hospital emergency department and subsequent transfer to acute care.

Patient characteristics:

• Age, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), and functional status measure. Measures of injury severity include Glasgow Coma Scale Score and multiple injuries.

Studies must include or measure:

• Age
• Glasgow Coma Scale Score
• Severity of injury
• Multiple injuries
• Pre-morbid data
• Mechanism of injury (kind of trauma)
• Intracranial diagnosis
• Functional status measure

Outcome measures:

• Presence or absence of complications (i.e., skin problems, pneumonia)
• Length of stay in hospital.
• Immediate care costs and long-term financial burden.
• Health status at discharge from the acute care hospital (ADLs, locomotion, and short-term functional status measure such as Disability Rating Scale).
• Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).
• Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).

Question 2

2. Does the intensity of inpatient rehabilitation affect outcomes for people with traumatic brain injury?

Rationale:

• The application of inpatient rehabilitation varies in intensity.
• The purpose of this question is to find out if there is evidence that a particular level of intensity of inpatient rehabilitation optimizes outcomes.

Definitions:

• Inpatient rehabilitation applies to the phase of treatment after discharge from the acute care hospital into an inpatient rehabilitation facility.

Intensity--Levels of the intervention vary in intensity based on:

1.

Whether the intervention was directed and managed by a physiatrist.

2.

Number, kinds, and frequency of methods applied.

Patient population:

• People who sustained traumatic brain injury between the ages of 18 and 65 years whose injury severity warranted admission to a hospital emergency department, transfer to acute care, and subsequent transfer to inpatient rehabilitation.

Patient characteristics:

• Age, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis) and functional status measure. Measures of injury severity include Glasgow Coma Scale Score and multiple injuries.

Studies must include or measure:

• Age
• Glasgow Coma Scale Score
• Severity of injury
• Multiple injuries
• Pre-morbid data
• Mechanism of injury (kind of trauma)
• Intracranial diagnosis
• Functional status measure

Outcome measures:

• Length of stay in rehabilitation facility.
• Immediate care costs and long-term financial burden.
• Health status at discharge from inpatient rehabilitation (ADLs, locomotion, and short-term functional status measure such as Disability Rating Scale).
• Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).
• Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).
• Independence, relationships, family life, satisfaction.

Question 3

3. Does the application of compensatory cognitive rehabilitation enhance outcomes for people who sustain traumatic brain injury?

Rationale:

• The efficacy of cognitive rehabilitation is being questioned. In addition, the application of the intervention may be based on patient resources; the availability may be based on regional differences.
• The purpose of this question is to find out if there is evidence that compensatory cognitive rehabilitation is an effective intervention.

Definitions:

• Cognitive rehabilitation -- Treatment to increase or improve the capacity to process and use incoming information so as to allow increased functioning in everyday life.
• Focus is correcting deficits in memory, concentration and attention, perception, learning, planning, sequencing, and judgment. The broad definition includes both methods to restore cognitive function and compensatory techniques, such as use of memory aids.

Patient population:

• People who sustained traumatic brain injury between the ages of 18 and 65 years whose functional status level allows for employment and/or community integration, but who require an intervention to facilitate success.

Patient characteristics:

• Age, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), application and methods of inpatient rehabilitation, and chronicity at time of entry to out-patient program.

Outcome measures:

• ADLs.
• Return to work/school, maintenance of job/school, long-term financial burden.
• Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).
• Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).
• Independence, relationships, family life, satisfaction.

Question 4

4. Does the application of supported employment enhance outcomes for people with traumatic brain injury?

Rationale:

• For people who have sustained traumatic brain injury, the ability to maintain employment may be compromised by cognitive deficits and behaviors not normally accepted in the workplace.
• The purpose of this question is to find out if there is evidence that the intervention of supported employment operates to facilitate job maintenance and success.

Definitions:

• Supported employment -- An intervention in which the occupational tasks and environment are modified specific to the needs of the patient, where training is modified according to the patient's deficits, and where responsibility for attendance and performance at a job are shared by a professional.

Patient population:

• People who sustained traumatic brain injury between the ages of 18 and 65 years whose functional status level allows for employment, but who require an intervention to facilitate success.

Patient characteristics:

• Age, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), application and methods of inpatient rehabilitation, and chronicity at time of entry to supported employment program.

Outcome measures:

• Job maintenance.
• Job success.
• Efficiency.
• Types of work held relative to that of pre-injury.
• Income level relative to that of pre-injury.
• Immediate care costs and long-term financial burden.
• Independence, relationships, family life, satisfaction.

Question 5

5. Does the provision of long-term care coordination enhance the general functional status of people with traumatic brain injury? What is the cost-effectiveness of the provision of this intervention?

Rationale:

• As people with traumatic brain injury move through their recovery process, they may be particularly vulnerable during periods of transition.
• Case management by a certified individual may not always be available or optimal; a family member may provide the service.
• This question asks if there are benefits to continuity of care, and if so, what the costs are relative to those benefits.

Definitions:

• Care coordination -- Service provided by someone other than the patient throughout phases of recovery that:

  1.

  considers alternative interventions and venues relevant to the patient's needs,

  2.

  considers available resources and/or identifies and secures new resources to fund the interventions,

  3.

  provides information to patient and family about alternatives,

  4.

  facilitates selection and implementation of the intervention that best represents the needs and desires of the patient and family, and

  5.

  monitors and communicates about the progress of the patient and family while the patient is participating in the intervention.

• A care coordinator may be a private contractor, representative of an agency, family member or friend, medical professional, or rehabilitation professional.

Patient population:

• People with traumatic brain injury between the ages of 18 and 65 years.

Patient characteristics:

• Age, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis, application and methods of inpatient and/or out-patient rehabilitation. Identification of care coordinator.

Outcome measures:

• Return to work/school, maintenance of job/school, long-term financial burden.
• Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).
• Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).
• Independence, relationships, family life, satisfaction.