e4 Oral abstracts

Article 7

Mortality in Individuals Unable to Follow Commands at the Time ofRehabilitation Admission

Brian David Greenwald (JFK Medical Center), Flora Hammond,Cynthia Harrison-Felix, Risa Nakase-Richardson, Laura L.S. Howe

Objective: To characterize long-term mortality, life expectancy, causes of

death and risk factors for death among persons who lack command following

at the time of admission for inpatient traumatic brain injury rehabilitation.

Design: Prospective cohort study.

Setting: The NIDRR TBI Model Systems.

Participants: 8,084 individuals injured between 1988 and 2009, with

survival status per December 31, 2009 determined.

Interventions: Not applicable.Main Outcome Measure(s): Standardized mortality ratio, life expectancy,

cause of death.

Results: Individuals with moderate to severe TBI who received inpa-

tient rehabilitation were 2.2 times more likely to die than individuals

in the U.S. general population of similar age, gender and race, with an

average LE reduction of 6.6 years. The subset of individuals who were

unable to follow commands on admission to rehabilitation were 6.9

times more likely to die, with an average LE reduction of 12.2 years.

Relative to the US general population matched for age, gender and

race/ethnicity, these non-command following individuals were over 4

times more likely to die of circulatory conditions, 44 times more

likely to die of pneumonia and 38 times more likely to die of aspi-

ration pneumonia.

Conclusions: The subset of individuals with TBI who are unable to

follow commands upon admission to inpatient rehabilitation are at a

significantly increased risk of death when compared to the US general

population, and compared to all individuals with moderate to severe TBI

receiving inpatient rehabilitation. Respiratory causes of death

predominate.

Key Words: Brain Injury, Mortality, Life expectancy

Disclosure(s): None Disclosed.

Article 8

Effect of Lesion Burden on Recovery and Response to Amantadine inPatients with Traumatic Disorders of Consciousness

Douglas I. Katz (Braintree Rehab Hospital), John Whyte,Helena Chang, Noam Eshkar, Kathleen Kalmar, David Long,Stuart Yablon, Emilia Bagiella, Joseph Giacino

Objective: To assess the effect of lesion burden determined by CT imaging

on recovery and response to amantadine treatment in patients with pro-

longed disorders of consciousness (DoC) after traumatic brain injury.

Design: Retrospective analysis of a randomized controlled trial dataset.

Setting: 11 inpatient neurorehabilitation centers in the USA, Denmark,

and Germany.

Participants: Patients (NZ184; placeboZ 97) with non-penetrating post-

traumatic DoC between 4 and 16 weeks post-injury.

Interventions: N/A.Main Outcome Measure(s): Disability Rating Scale (DRS) and Coma

Recovery Scale e Revised (CRS-R) scores at 4 and 6 weeks post-

randomization.

Results: After visually coding CT scans against a standard template and

summing ratings across all cortical or subcortical areas, higher lesion

burden was significantly associated with worse outcome on the DRS and

CRS-R at 6 weeks post-randomization in the placebo group (cortical:

nZ89, DRS PZ.0124, CRS-R PZ.0324; subcortical: nZ91, DRS

PZ.0067, CRS-R PZ.0256). The relationship was strongest in some

nodes of the default mode and reticulothalamic networks, particularly the

parahippocampal area and thalamus, which have been shown to be related

to level of consciousness. There was no significant interaction of lesion

burden and treatment group (amantadine or placebo) at 4 weeks, however,

examination of slope of change across the 4 weeks suggested that aman-

tadine-treated patients with highest lesion burden recovered more slowly

than those with lower lesion burden, while patients in the placebo group

with lowest lesion burden recovered faster than those with higher

lesion burden.

Conclusions: Higher lesion burden on routine CT imaging, particu-

larly in the parahippocampal and thalamic areas, is associated with

worse recovery in patients with traumatic DoC and may limit the

response to amantadine treatment. Further study is needed to confirm

these results.

Key Words: vegetative state, traumatic brain injury, minimally conscious

state, CT scan, x-ray, recovery of function

Disclosure(s): None Disclosed.

Article 9

Risk Factors Associated with Acute Rehospitalization after InpatientRehabilitation

Amol M. Karmarkar (UTMB), James Graham, Amit Kumar,Kshitija Kulkarni, Kenneth Ottenbacher

Objective: To identify person-level and facility-level risk factors associ-

ated with acute rehospitalization across multiple impairment groups.

Design: Secondary analysis of Medicare data from 2009-2011.

Setting: Medicare certified inpatient rehabilitation facilities across the

United States.

Participants: Patients discharged from acute hospitals for initial inpatient

rehabilitation for the rehabilitation impairment groups: stroke

(nZ121,633), lower extremity fracture (nZ121,055), brain dysfunction

(nZ49,916), and neurological conditions (nZ58,460). These patients were

living in the community prior to acute hospitalization, age 66 or older, on

Medicare fee-for-service, and eligible for Medicare due to

age (NZ351,064).

Interventions: None.Main Outcome Measure(s): Acute rehospitalization was calculated using

’acute hospital claim’ immediately following inpatient rehabilitation stay.

Patient-level variables included sociodemographics, tier comorbidity,

disability status, Medicare-Medicaid eligibility, rehabilitation admission

functional status, number of acute hospitalizations in the prior year, and

pre-rehabilitation acute hospitalization length of stay. Facility-level vari-

ables included were type (rehabilitation unit vs. freestanding rehabilitation

hospital), for-profit status (yes vs. no), and disproportionate share

index (quartiles).

Results: Overall the rate of acute rehospitalization was 8.5%. This

unadjusted rehospitalization rate was highest for brain dysfunction

(11.5%), and lowest for the lower extremity fracture cohort (6.1%).

After adjusting for other covariates, for brain dysfunction, the risk of

rehospitalization was 23% higher in those with a presence of tier co-

morbidity compared to those without (ORZ1.22, 95% CIZ1.15-1.31).

Prior acute admissions were associated with a greater risk of rehospi-

talization (ORZ1.13, 95% CIZ1.11-1.15). For lower extremity fracture

cohort, rehospitalization risk was 53% higher among those with tier

comorbidity (ORZ1.53, 95% CIZ1.45-1.62) and the risk associated

with prior acute admissions was 18% higher (ORZ1.18, 95%

CIZ1.16-1.20).

Conclusions: Identification of risk factors is the first step

towards development of risk prediction models for acute rehospi-

talization following inpatient rehabilitation stay, taking into account

patient-level and facility-level variables. Such models would be

useful in better management of rehospitalization risk, by aligning

resources, and providing continuity between acute and post-acute

care services.

Key Words: Rehospitalization, Inpatient Rehabilitation, Risk Factors

Disclosure(s): None Disclosed.

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