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In the field of pediatric neurorehabilitation, there is a dearth of well-defined models of care for children with brain injuries and research to support them. Literature reviews of both adult and pediatric studies suggest that programs involving a comprehensive and holistic approach to care may be particularly effective in addressing the issues faced by individuals recovering from acquired brain injury. The primary purpose of this paper is to propose a model of holistic neurorehabilitation for children with an acquired brain injury, and to describe its theoretical bases. The paper describes such a program developed at Children's Specialized Hospital in New Jersey, USA, and presents a brief synopsis of the program's philosophy, components, goals, and therapeutic interventions. In addition, the paper discusses the type of data necessary to demonstrate the clinical utility and cost-effectiveness of such a program, and calls for future research to examine this.

Objectives: To describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation., Design: Qualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison., Setting: The 4 VA polytrauma rehabilitation centers (PRCs)., Participants: Fifty-six purposefully selected PRC providers and providers from consulting services., Interventions: Not applicable., Main Outcomes Measures: Provider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves., Results: According to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding., Conclusions: The VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.

Optimal outcomes for polytrauma survivors depend on the integration of complex medical, psychosocial, financial, educational, and vocational resources across diverse specialties and multiple medical centers, programs, and organizations and all in a setting of high public visibility and family involvement. Well-functioning teams are critical to service integration, and teams are more effective in supportive hospital environments. Here, we offer a model of team functioning relevant to polytrauma and outline a team training program to improve services. Furthermore, we propose a partnership among the team, hospital administrators, and national leaders and with patients and their families. Integrated care requires partnerships among the various stakeholders, and those working in polytrauma have a unique opportunity to create an updated paradigm of the team approach responsive to the complexities of contemporary health care.

Objective: To present a patient care evaluation program exemplified by a rehabilitation clinic for complementary and alternative medicine(CAM) with emphasis on the description of patients and the outcome quality of the facility., Methods: Prospective cohort study on all patients admitted to the hospital over a period of 2 years; physician's questionnaire to assess basic medical data, and patients'questionnaires at admission and at discharge from hospital completed by 3 follow-up queries (at 2, 6, and 12 months after discharge)to assess severity of complaints, health related quality of life, health behavior, demand of medical services, days off work,and patient satisfaction. At the beginning of the intervention, sociodemographic status, basic medical data, experience with CAM and expectations with regard to treatment success were documented., Results: 5,278 patients (83% female, age 54.7+/-11.6 years)with diagnoses mainly out of the domains 'Chronic fatigue' (36.8%), 'Chronic back pain' (19.5%) and 'Chronic headache' (11.9%) were included into the analysis (follow-up return rate 80.6% after 6 months, 73.6% after 12 months). Complaints had persisted for 6 years (median). The intensity of the main complaint decreased from 59+/-25 by an average of 25 points at discharge (19 points at 6-month follow-up) corresponding to an effect size of 0.86 (0.62 at 6-month follow-up). At 6-month follow-up about half of the patients showed a clinically relevant improvement of quality of life (SF-36 sum scores increased by >or=5 points). Intake of drugs was reduced,the number of days off work had decreased after rehabilitation. Patients' satisfaction was 'good' on average, with respect to food satisfaction it was lower. A subgroup analysis regarding the principal diagnosis revealed different emphases in outcome profiles., Conclusions: The patients profile underlines the need of inpatient rehabilitative treatment resembling other patients in CAM care. The outcome profile proved by a representative sample that the majority of patients benefited from rehabilitation with respect to various outcome dimensions at that this benefit still persisted after 6-12 months.

We present our experience with 30 patients on functional outcomes of patients with anoxic brain injury (ABI, n=15) due to cardiac etiologies from freestanding inpatient rehabilitation hospital. A convenience sample of patient with traumatic brain injury (TBI, n=15) with similar demographic characteristic to ABI was used for comparison on indices of activity of daily living, cognition, mobility as well as other indices of functional prognosis such as hospital length of stay, cost and discharge predisposition. No statistical significant differences were found between the two groups on the presently employed outcome measures. This investigation supports the positive impact of inpatient rehabilitation for individuals with hypoxia of cardiac etiology. Future research comparing outcomes of ABI to TBI with larger, controlled trials is warranted.

Purpose: The concept and results of a pilot project to develop a quality assurance programme for outpatient medical rehabilitation in musculoskeletal and cardiac diseases are discussed. The processes developed and the results that were achieved using the instruments in 24 pilot institutions are described., Methods: The quality of structure was assessed by defining and applying basic and detailed criteria; a version of peer review for outpatient treatment was developed to test the quality of process. The quality of results was determined by means of a prospective study with two or three measurement times and implementation of generic and disease-specific measurement instruments. The process was tested on n=1475 patients with musculoskeletal diseases and n=843 patients with cardiac diseases., Results: The level of the quality of structure in the participating centres is quite high; 89-93% of the structure features required were fulfilled. The peer review indicated that the process had 25-40% serious shortcomings in cardiology and 15-20% for musculoskeletal diseases. The quality of results measurements show that the participating outpatient rehab centres achieved medium effects for the majority of the core rehab dimensions for the respective indications, but the findings also showed that at the time the follow-up reports were made there was often a reduction of positive effects and high effects were quite rare. While there were marked differences in quality of structure and process among the various institutions, there were only slight differences among the outpatient centres regarding quality of results., Conclusions: A scientifically sound quality assurance programme was developed that covers specific aspects of outpatient rehabilitation, to a great extent using the same structures that have been implemented in the quality assurance programmes for inpatient treatment. To implement the results presented here, the scientific findings will need to be evaluated in the respective committees of the cost-carriers. The tests of the programme in 24 pilot institutions showed an overall high level of quality, but also revealed potential for improvement in some areas.

Patients with diabetes and chronic neurological disorders are most commonly "at-risk" with foot problems. The identification of that population is therefore mandatory to prevent severe foot lesions. However, not all health care providers (HCPs) are involved in the screening process in institutions. The authors' aim was to develop and evaluate an educational program for HCP in the field of at-risk foot. All HCPs of the Loëx Hospital (Department of Rehabilitation and Geriatrics, University Hospitals of Geneva) participated in a longitudinal prospective study. Different professions of HCP (doctors, nurses, nursing aides, physiotherapists, occupational therapists, speech-language therapists, and psychologists) attended a structured educational program during a 1-year period based on a specific consultation that the authors developed. During the sessions, risk factors and therapeutic and preventive interventions are discussed with both the patient and care givers. A questionnaire was developed and used to evaluate (1) initial knowledge of HCP in the field of at-risk foot and (2) the impact of the program on the knowledge of HCP 12 months after starting the program. Twelve months after initiating the program, a significant knowledge improvement was noted in all groups of HCP except medical doctors. Nurses presented the most significant rise in knowledge score (P < .001). In conclusion, the consultation is an acceptable and effective form of long-term educational program for HCP in a hospital setting with a huge majority of patients suffering from chronic vascular and neurological conditions and loss of protective pain sensation at the lower limb.

Rehabilitation centers in Germany with a care supply contract according to section 111 Social Code Book Five - statutory health insurance (SGB V) are legally obligated to implement an internal quality management and to participate in comprehensive measures of external quality assurance which particularly aim at improving outcome quality ( section 135a SGB V). The legislator has left it to the central associations of health insurance funds and to the relevant umbrella organisations of care providers to develop these measures as well as the basic requirements on internal quality management in order to reach a joint agreement about it (cf. section 137d [1] and [1a] SGB V). The corresponding agreement was concluded on April 1, 2004. Whereas configuration of the internal quality management to a large extend lies in the discretion of the individual rehabilitation center, although it has to be geared to the objectives and principles set out in the agreement under section 137d SGB V, participation in the external quality assurance procedures of the central associations of health insurance funds (QS-Reha procedure) is obligatory for all rehabilitation centers with a care supply contract according to section 111 or 111a. The QS-Reha procedure comprises a survey of the central quality dimensions (structural, process and outcome quality as well as patient satisfaction) and permits related quality comparisons, which are utilized by the health insurance funds for quality oriented patient allocation and remuneration. The QS-Reha procedure had been developed to implement the legal requirements for external quality assurance in the field of medical rehabilitation ( section 135a in conjunction with section 137d SGB V) as well as to create a basis for quality focussed remuneration and patients allocation, whereas the Eva-Reha database had been developed by the Medical Service of Health Insurances in Rheinland-Pfalz for single case documentation with the objective of utilizing these data for internal quality management and, beyond this, also for various aspects of quality development across centers. The results generated in the framework of external quality assurance and internal management have to be integrated in the concept of internal quality management as they account for important sources of information with respect to the analysis of strengths or weaknesses of the facility. Irrespective of their origin quality relevant results should be integrated into a benchmarking system providing information to the operational and medical management of a rehabilitation center on the effectiveness and efficiency of the medical rehabilitation services provided. Up-to-date data, such as those generated by the Eva-Reha database, or sample survey data as those from the QS-Reha procedure can equally be used for such a benchmarking system and complement each another in a meaningful way. In this paper the main features of the QS-Reha procedure and the Eva-Reha database are described, with the objective of pointing out the particular perspectives of their data structure and results for continuous improvement in the framework of internal quality management.

Objective: To examine the impact of Medicare's Prospective Payment System (PPS) on patient satisfaction at four inpatient rehabilitation hospitals., Design: Prospective study using a satisfaction survey to examine the effects of Medicare's PPS for rehabilitation hospitals. Surveys were conducted at four affiliated rehabilitation hospitals in the Midwest., Results: Patient characteristics varied only slightly pre- to post-PPS, and several characteristics were related to overall satisfaction, including motor functional gain, discharge to home, and respondent (patient or proxy). A 12-point increase on a 12-item motor function scale resulted in 1.13 greater odds (95% CI: 1.04, 1.24) of reporting excellent satisfaction. Patient respondents were 1.27 times more likely (95% CI: 1.07, 1.50) than proxies to report excellent satisfaction, and patients discharged home were 1.65 times more likely (95% CI: 1.31, 2.07) to report excellent satisfaction than patients discharged elsewhere. We found an increase in observed satisfaction from 60.3 to 63.4% (P < 0.05) after PPS implementation, despite a decrease in motor FIM gain., Conclusions: Patient characteristics such as motor FIM gain, discharge status, and respondent type were significantly associated, although only slightly, with patient satisfaction in inpatient rehabilitation. Percentage of excellent satisfaction improved at these four facilities after PPS implementation, despite declines in motor FIM gain. The improvement may be the result of numerous ongoing quality-improvement initiatives directed at improving patient satisfaction at these facilities.

A surge of research has recently been published on the importance ofpatient-centered communication (P-CC). However, patients with communication disorders are rarely considered in these discussions. Health care workers in long-term care facilities (L-TCFs) and rehabilitation centers were surveyed in order to: (1) assess the level of P-CC used with people with communication disorders versus those without communication disorders; (2) identify the tools and strategies currently used by health care providers in long-term care facilities and rehabilitation centers to enhance P-CC with people with communication disorders; (3) assess the perceived level of efectiveness of these tools and strategies; and (4) identify the tools desired by health care providers in these settings. The results regarding P-CC levels were fairly consistent across settings. Health care providers reported that they achieve slightly higher P-CC with patients without communication disorders than with those with communication disorders. Respondents in both settings used similar tools and strategies, but the reported level of effectiveness varied greatly between the two settings, with rehabilitation centers indicating better success than L-TCFs. Interestingly, rehabilitation center respondents were more interested in obtaining additional tools than were L-TCF respondents, but the types of tools desired were similar.

Background: Among patients with hypertension, those with established left ventricular hypertrophy (LVH) represent a high risk cohort with poor prognosis. We aimed to investigate differences in characteristics and health care management of such patients treated as inpatients or outpatients by cardiac specialists., Methods: Prospective cross-sectional study in patients with hypertension and LVH who were referred to either inpatient care (rehabilitation hospitals) or to outpatient care (cardiology practices)., Results: A total of 6358 inpatients (59.6% males; mean age 66.6 years) and 2246 outpatients (59.5% males; mean age 63.2 years) were followed up for a mean of 23 vs. 52 days, respectively. Inpatients compared to outpatients had a significantly higher prevalence of coronary heart disease, history of stroke, renal failure or diabetes. Mean blood pressure of inpatients compared to outpatients was significantly lower both at entry (150/84 vs. 161/93 mmHg) and at end of follow-up (129/75 vs. 139/83 mmHg). After adjustment for baseline blood pressure and a propensity score, differences between out- and inpatients at end of follow-up were 8.0/5.1 mmHg in favour of inpatients. Blood pressure goals as specified by guidelines were not met by 32% of inpatients and 55% of outpatients., Conclusion: Inpatients had a higher rate of comorbidities and more advanced atherosclerotic disease than outpatients. Control of hypertension of inpatients was already better on admission than in outpatients, and treatment intensity in this group was also higher during the observation period. While blood pressure lowering was substantial in both groups, there were still a high proportion of patients who did not achieve treatment goals at discharge.

The objective of this study was to examine occupational therapists' (OT) and physiotherapists' (PT) perceptions regarding waiting time and the quality and quantity of the services they provide for children with disabilities. A survey was sent by post to all paediatric OTs and PTs in Quebec, Canada. A Service Delivery Questionnaire included questions regarding therapist/client characteristics, waiting times and quality and quantity of services provided. The Measure of Processes of Care for Service Providers (MPOC-SP) rated use of family-centred care by responding clinicians. Waiting times were longest for OT services (p<0.0001), speech/language interventions (p<0.0001) and services in rehabilitation and community health centres (p<0.0001). Quality of services was rated higher by PTs, experienced therapists and those using more methods of keeping up-to-date. The frequency and duration of services varied according to profession, type of clientele and setting. According to clinicians directly involved in the provision of rehabilitation services, long delays exist for children waiting for rehabilitation services, and perceived quality of services differs according to specific therapist and client characteristics. These findings will assist those involved in planning the distribution of co-ordinated rehabilitation services for children.

Background: To determine the effectiveness of home-based cardiac rehabilitation programmes compared with (i) usual care and (ii) supervised centre-based cardiac rehabilitation on mortality, health related quality of life and modifiable cardiac risk factors of patients with coronary heart disease., Methods: Systematic review and meta-analysis of randomised controlled trials., Main Outcome Measures: mortality, smoking cessation, exercise capacity, systolic blood pressure, total cholesterol, psychological status, and health related quality of life., Results: Eighteen included trials for home versus usual rehabilitation and six trials of home versus supervised centre-based rehabilitation were identified. The home-based interventions were clinically heterogeneous, trials often small, with quality poorly reported. Compared with usual care, home-based cardiac rehabilitation had a 4 mm Hg (95% CI 6.5, 1.5) greater reduction in systolic blood pressure, and a reduced relative risk of being a smoker at follow-up (RR 0.71, 95% CI 0.51, 1.00). Differences in exercise capacity, total cholesterol, anxiety and depression were all in favour of the home-based group. In patients post-myocardial infarction exercise capacity was significantly improved in the home rehabilitation group by 1.1 METS (95% CI 0.2, 2.1) compared to usual care. The comparison of home-based with supervised centre-based cardiac rehabilitation revealed no significant differences in exercise capacity, systolic blood pressure and total cholesterol., Conclusions: Current evidence does not show home-based cardiac rehabilitation to be significantly inferior to centre-based rehabilitation for low-risk cardiac patients. However, the numbers of patients included are less than 750 and ongoing trials will contribute to the debate on the acceptability, effectiveness and cost-effectiveness of home-based cardiac rehabilitation.

Objective: To examine the usefulness of the nursing home quality indicators and nursing home quality measures for differentiating among providers from a rehabilitation outcomes perspective., Design: Retrospective., Setting: Skilled nursing facilities (SNFs) across the United States., Participants: A total of 211 SNFs., Interventions: Not applicable., Main Outcome Measures: All quality indicators, all quality measures except for CWLS01 (residents who lose too much weight), and a set of rehabilitation outcomes including residualized FIM motor gain, the percentage of patients discharged to community, and the percentage of patients reporting "quite a lot" or "completely" prepared to manage their care at discharge from SNF-based rehabilitation., Results: No quality measures correlated with any rehabilitation outcomes. Residualized FIM motor gain did not correlate with any quality indicators or quality measures. Only 1 quality indicator-prevalence of daily use of restraints (QI 22)-correlated with the rehabilitation indicator community discharge percentage. The third rehabilitation indicator, prepared to manage care at discharge, correlated (negatively) only with QI 18 incidence of decrease in range of motion. Among the rehabilitation outcomes, residualized FIM motor gain correlated significantly with both community discharge percentage and prepared to manage care at discharge., Conclusions: Patients and referrers choosing SNF-based medical rehabilitation need tools that differentiate among prospective providers from a rehabilitation outcomes perspective. Data in this study indicate that nursing home quality indicators and quality measures are inadequate for this purpose.

Background and Aims: One of the most important objectives of a rehabilitation program is to improve patients' mobility. Mobility measures are necessary in evaluating treatment effectiveness. The aims of the present study were to assess the usefulness of the "Timed Get Up and Go" (TUG) test as a mobility measure for patients attending a day hospital, and as an additional tool in assisting a multidisciplinary team in clinical decision-making regarding length of stay in a day hospital., Methods: Two hundred and thirty elderly patients, admitted during 2000, were assessed by the TUG test and Functional Independence Measure (FIM) on admission and at discharge. The patients were divided into four performance categories (TUG score <20; 20.01-40; 40.01-60 and >60 seconds). The sensitivity of the test to changes in patients' mobility level and the relationship between it and other measures were assessed., Results: Mean TUG score on admission was 32.6+/-24.2 seconds, and upon discharge 21.8+/-18.3 seconds. The difference in score changes between orthopedic patients (14.2 sec), patients with chronic disabling diseases (10.3 sec) and stroke patients (10.1) was statistically significant (p=0.013). On admission, 35.7% performed the TUG test in <20 seconds and upon discharge in 60.9%. A significant negative correlation was found between TUG scores and FIM and motor FIM scores on admission and at discharge., Conclusions: The TUG test is a sensitive test for measuring changes in the mobility level of patients attending a day hospital. Easy to carry out, the test furnishes additional information that may assist medical personnel in deciding criteria for discharge readiness.

Objective: Short lists of International Classification of Functioning, Disability, and Health (ICF) categories, ICF Core Sets, have been developed as reference standards for clinical practice and research. The objective of this study was to validate the ICF Core Sets for early postacute rehabilitation facilities against the measures most commonly used in early postacute rehabilitation, the FIM instrument, the Functional Assessment Measure, and the Barthel index., Design: Linking study matching the concepts of three commonly used outcome measures to corresponding ICF categories., Results: Corresponding ICF categories could be found for all of the items of the FIM instrument + Functional Assessment Measure and Barthel index. The 40 items of these three measures were linked to 33 different ICF categories. Four items could be linked to ICF categories that were not part of any of the Postacute ICF Core Sets., Conclusions: The Postacute ICF Core Sets cover the concepts of the most frequently used measures in early postacute rehabilitation. Yet, many aspects of human functioning are not measured by the FIM instrument + Functional Assessment Measure and the Barthel index. If this information is considered relevant, these items would have to be added by using supplementary measures. Our comparison demonstrates the benefit of using a common language when comparing items using different wordings and concepts.

Sources of rehabilitation medicine, the need for rehabilitation and its practice in Croatia were studied, based on available data. The study revealed that current practice has advanced since the country's independence, but that there are many shortcomings; adequate care is not provided to all who could benefit from it, and there is wastage of resources.

Objective: To examine the sensitivity of the Short Form Activity Measure for Post-Acute Care (AM-PAC) in comparison to the Functional Independence Measure (FIM) across a 12-month period after discharge from rehabilitation hospital., Design: Prospective longitudinal study. Patients were recruited while receiving inpatient services from facilities in the north-east USA and interviewed 1, 6 and 12 months thereafter., Patients: Convenience sample of 516 patients at baseline (65% retention at the final follow-up) receiving rehabilitation services for neurological, lower extremity orthopedic, or complex medical conditions. Mean age 68.3 years; 47% male., Main Outcome Measures: AM-PAC Physical and Movement, Personal Care and Instrumental, and Applied Cognitive Activity scales; FIM Motor and Cognitive scales., Results: All 3 AM-PAC scales were sensitive to both positive and negative change across the follow-up period. Standardized response means for the AM-PAC were consistently larger than for the FIM across patient and severity groups. A greater percentage of patients showed positive change that exceeded the minimal detectable change on the AM-PAC than on the FIM both 6- and 12-month follow-ups., Conclusion: The short-form AM-PAC scales are more sensitive measures of change in functional activity performance over time in the general population of persons who receive inpatient rehabilitation services compared to the FIM. Thus, the AM-PAC offers a short, comprehensive, and sensitive measure of positive and/or negative change in patients' ability to perform important activities of daily life.

Aim: To identify the standardized outcome measures currently used in routine clinical practice in rehabilitation centres in the UK., Design: Cross-sectional survey by postal questionnaire., Participants: All UK consultant members of the British Society of Rehabilitation Medicine (BSRM) (n = 180)., Results: A total of 108 (60%) responses were received, representing 83 different rehabilitation services. Of these, 71 (86%) collected at least one standardized measure. The Barthel Index and the UK Functional Independence Measure and/or Functional Assessment Measure (FIM +/- FAM) were the most popular global outcome measures: 83% of units measured one or other of these. The Northwick Park Dependency Scale (NPDS) and Care Needs Assessment (NPCNA) (n = 21, 28%) were used for the more dependent patients. Depression and pain scores were more commonly used than general health measures. Sixty (72%) units routinely assessed outcome through the achievement of set goals, but only four transformed data to a goal attainment scale. Outcome measure scores were routinely reported in discharge summaries by 72% of units., Conclusions: The survey demonstrated quite widespread use of outcome assessments in routine clinical rehabilitation within the UK, with an encouraging level of common measurement in some areas of practice. The results have been used to update the BSRM 'basket of recommended measures'.

Visitations (audits) are considered an instrument of external quality assurance by which the structural and organizational set-up of health facilities can be assessed on site by external experts. The Deutsche Rentenversicherung Bund (including the former Bundesversicherungsanstalt für Angestellte, BfA, the statutory pension insurance agency for white collar employees) is the largest body responsible for rehabilitation in Germany, and it regularly carries out visitations in the approximately 650 rehab centres it sends its patients to. The project presented in this article aimed at developing a manual with detailed descriptions of the procedures and criteria of the assessment, as well as at checking the inter-rater-reliability of the assessment. The manual was developed in cooperation with experts of the Deutsche Rentenversicherung Bund. It contains a description of the areas to be assessed during a visitation as well as leading questions and criteria for the evaluation of single features. The manual was examined in "test visitations" in 10 centres, each of which was visited by three visitation teams (1 medical and 1 administrative expert) simultaneously. When the resulting 30 assessments were compared, the criterion "overall quality of the centre" (which was assessed on a 10-point scale) showed precise agreement in 47 %, and a deviation by 1 point in 33 % of the cases. Single features assessed on a three-point scale (no improvement needed/improvement recommended/immediate improvement obligatory) resulted in precise agreement in between 80 % ("medical and therapeutic processes") and 86 % ("structural features") of the cases. Two-point scales (condition fulfilled or not fulfilled) showed an agreement between 89 % ("internal quality management") and 97 % ("single structural features"). In order to maintain and further develop this good inter-rater-reliability, the visitors of Deutsche Rentenversicherung Bund are continually trained in applying the visitation manual. In addition to transferring knowledge, these internal training courses are aimed at exchanging views and experience in order to enhance consensus among the visitors. This approach of Deutsche Rentenversicherung Bund could be regarded as "internal quality assurance" of its visitation procedure.

Objective: Presentation and comparison of basic data from geriatric rehabilitation in Bavaria with analysis of statistical influences on characteristic values like length of stay and Barthel Index. Are differences between participating clinics due to patient characteristics?, Setting: There were a total of 21 656 data records of the Geriatrics in Bavaria- Database (GiB-DAT) collected by 35 clinics within 1 year. RESULTS (PERCENTAGE OR MEAN): 70.6% female patients, age 80.0 years, 95.9% enrollment from acute care hospitals, length of stay in previous hospitals 24.3 days, length of stay in geriatric rehabilitation 24.6 days., Diagnosis: 41.7% orthopedics, 24.9% neurological, 33.4% others. Barthel Index on admission 44.1 points, on discharge 65.8 points (difference 21.8 points). We found a large variance of all items between participating clinics. Variance for Barthel Index and length of stay is partly cleared up by regression analysis (multinomial logistic) and is mostly due to patient characteristics., Conclusions: Basic data of Bavarian geriatric rehabilitation clinics is matching with nationwide reference statistics. Differences exist for the lower rate of stroke and direct enrollment of outpatients. A simple ranking of outcome parameters (e. g. Barthel Index) does not make sense due to multiple influencing factors.

A methodological framework for conducting a systematic, mostly qualitative, meta-synthesis of community-based rehabilitation (CBR) project evaluation reports is described. Developed in the course of an international pilot study, the framework proposes a systematic review process in phases which are strongly collaborative, methodologically rigorous and detailed. Through this suggested process, valuable descriptive data about CBR practice, strategies and outcomes may be synthesized. It is anticipated that future application of this methodology will contribute to an improved evidence base for CBR, which will facilitate the development of more appropriate policy and practice guidelines for disability service delivery in developing countries. The methodology will also have potential applications in areas beyond CBR, which are similarly "evidence poor" (lacking empirical research) but "data rich" (with plentiful descriptive and evaluative reports).

Background: Disease-specific, multimodal inpatient rehabilitation programmes are designed to improve the physical, emotional, and social functioning of patients with cystic fibrosis (CF). This study investigates the effects of a 4-week inpatient rehabilitation program on health-related quality of life (QL)., Methods: 84 German patients with CF (16-62 years of age, FEV1 mean 52.9% of the predicted), participating in an inpatient rehabilitation programme, completed the Questions on Life Satisfaction-Modules (FLZM) at the beginning and one month after the end of intervention. The FLZM allows the multi-dimensional evaluation of subjectively perceived satisfaction with general and health-specific life domains. In addition, medical parameters (FEV1, Body Mass Index) and socio-demographic data were registered., Results: Compared to the baseline scores, after rehabilitation, participants were significantly more satisfied with general, health-related, and CF-related aspects of their lives. Specifically, improvement was noted in the following items: breathing difficulties/cough, sleep, integration of therapy into daily routine, leisure activities, general health perception, physical condition and being free from anxiety., Conclusion: Comprehensive inpatient rehabilitation programmes are a promising strategy to improve the quality of life of adolescent and adult CF-patients.

Pulmonary rehabilitation is an integral and original part of the German National Disease Management Guideline for Asthma with clearly defined tasks within a comprehensive long-term management of asthma. The following short overview describes methods, indications for and effectiveness of pulmonary rehabilitation for adult patients with asthma.

This article examines the distinctive opportunities and challenges of multiple-site clinical trials, as distinguished from trials conducted by a single program. Among the topics discussed are: the role of clinical trials generally in medical rehabilitation research; definitions of "clinical trials" and "multiple site"; the distinction between exploratory and capstone trials; the potential advantages and disadvantages of multiple-site trials; planning issues in terms of sampling designs, the choice of outcome measures, approaches to dealing with intervention fidelity, organizational structures, authorship, and the conduct of collateral studies; and implementation issues in terms of pilot-testing procedures, handling emerging issues, and optimizing communication.

Objective: We sought to assess whether outcomes and reimbursement differ for Medicare beneficiaries with hip fracture when treated in an inpatient rehabilitation facility (IRF) compared with a skilled nursing facility (SNF) subacute rehabilitation program., Participants: Clinical data were linked with Medicare claims for 29,793 Medicare fee-for-service beneficiaries with a recent hip fracture who completed treatment in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation., Outcome Measures: We measured discharge destination, change in motor FIM rating, and Medicare Part A reimbursement., Results: For patients with moderate-to-severe and severe disabilities, case mix groups (CMGs) 704 and 705, the percentage of patients discharged to the community from IRFs was lower than for patients treated in subacute rehabilitation SNFs, after controlling for covariates. Adjusted odds ratios were 0.71 (95% confidence interval 0.55-0.92) for CMG 704 and 0.72 (95% confidence interval 0.63-0.83) for CMG 705. For patients in the 3 other CMGs, no significant differences were detected. Improvement in motor functional status was roughly equivalent for patients treated in IRFs and those treated in the subacute rehabilitation programs across all 5 CMGs, after controlling for covariates. Medicare Part A payments for IRFs were significantly higher than SNF payments across all CMGs., Conclusion: SNF-based subacute rehabilitation was less costly and outcomes were in most, but not all, instances similar or better than IRF-based rehabilitation for Medicare fee-for-service beneficiaries who had a recent hip fracture.

Background: The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment., Objectives: We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855)., Research Design: We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis., Results: We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions., Conclusion: For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

Background: The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs., Objectives: We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models., Research Design: A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting., Results: We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed., Conclusion: We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.

The Disability Discrimination Act (1995) protects disabled people from discrimination in access to services, facilities and goods as well as in education and employment. All hospitals have an inherent duty to enable access to services but this will now be enshrined in law. As the health sector has most contact with disability, it may be expected that most hospitals would already be in a good position to comply with the Act, especially one treating many patients with disability. However we identified many problems in a rehabilitation hospital setting by means of a simple access audit in March 2004. Recommendations were set out and by March 2005 considerable improvements had been made costing Pound 100,000. Although many necessary changes will be expensive, not all problems identified require costly correction. Many simply involve a change in staff attitudes and practices. We recommend that all hospitals start to identify the changes needed under the Act by means of a simple access audit that can be carried out by hospital staff with no specialist equipment.

For a fair comparison of rehabilitation centres with respect to the effects of the treatment provided (e. g. for the purpose of quality assurance programmes), it is essential that those factors which influence the outcome of rehabilitation treatment and over which the rehabilitation centres have no control (the so-called "confounders", such as co-morbidity and age of the patients on commencement of treatment) are included in the statistical analysis. Simple linear regression models without random effects and without interaction terms are frequently used for this purpose. However, this method has certain limitations which can be avoided if hierarchical linear modelling (HLM) is employed. HLM has the advantage over standard regression analysis methods in that it can be used to take into account the multi-level structure of a comparison problem, allows predictors to be introduced at the level of the centres and also makes it possible to model variations of regression coefficients for the centres. When the HLM technique is used, separate linear models can be produced for the various hierarchically structured data levels of the question (e. g. the levels "patients" and "centres" for rehabilitation centres, for example). Moreover, it can be empirically tested with HLMs whether the rehabilitation coefficients (e. g. effects of mean age of patients on the outcome of rehabilitation) differ significantly between the centres. In this article, we describe the use of hierarchical linear modelling on the basis of data obtained from the quality assurance programme of the statutory health insurance schemes in the field of medical rehabilitation ("QS-Reha").

This article presents the case of the first ISO 9001:2000-certified small healthcare organization (the Center for Therapy and Rehabilitation) providing therapeutic and rehabilitation services for disabled children in Northern Poland. Elements of the process-oriented healthcare quality system implementation, initial benefits, and the organization's quality system structure and process descriptions are described. Particular attention has been paid to assumptions and methods used in monitoring of therapeutic processes at the Center. The initial benefits of the system are also presented.

Purpose: To identify outcome measures cited in published studies focusing on rehabilitation in the acute hospital and in early post-acute rehabilitation facilities, and to identify and quantify the concepts contained in these measures using the ICF as a reference., Methods: Electronic searches of Medline, Embase, CINAHL, Pedro and the Cochrane Library from 1997 to March 2002 were carried out. In a first step, abstracts of the retrieved studies were checked and data on the outcome measures and certain characteristics of the included studies were extracted. In a second step, the items of the questionnaires and their underlying concepts were specified. These concepts were then linked to ICF categories using standardized linkage rules., Results: From the 1,657 abstracts retrieved, 259 studies met the inclusion criteria. In a second step, 277 formal assessment instruments and 351 single clinical measures were retrieved. A total of 1,353 concepts were extracted from the clinical and technical measures. Ninety-six percent of these concepts could be linked to ICF categories. Fifty-six second-level ICF categories representing the concepts contained in the measures. Twenty-six (46%) of the 56 categories belong to the component Body Functions, five (9%) to the component Body Structures, and 25 (45%) to the component Activities and Participation., Conclusions: The ICF provides a valuable reference to identify and quantify the concepts of outcome measures focusing on rehabilitation in the acute hospital and in early post-acute rehabilitation facilities. Our findings indicate a need to define and to agree on 'what should be measured' in rehabilitation care to allow for a comparison of patient populations.

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for patients with musculoskeletal conditions in early post-acute rehabilitation facilities., Methods: The ICF Core Set development involved a formal decision-making and consensus process integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients., Results: Fifteen experts selected a total of 70 second-level categories. The largest number of categories was selected from the ICF component Body Functions (23 categories or 33%). Seven (10%) of the categories were selected from the component Body Structures, 22 (31%) from the component Activities and Participation, and 18 (26%) from the component Environmental Factors., Conclusion: The Post-acute ICF Core Set for patients with musculoskeletal conditions is a clinical framework to comprehensively assess patients in early post-acute rehabilitation facilities, particularly in an interdisciplinary setting. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for patients with cardiopulmonary conditions in the acute hospital., Methods: The ICF Core Set development involved a formal decision-making and consensus process, integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients., Results: Twenty-two experts selected a total of 48 second-level categories. The largest number of categories was selected from the ICF component Body Functions (21 categories or 44%). Four (8%) of the categories were selected from the component Body Structures, 10 (21%) from the component Activities and Participation, and 13 (27%) from the component Environmental Factors., Conclusion: The Acute ICF Core Set for patients with cardiopulmonary conditions provides all professionals with a clinical framework to comprehensively assess patients in the acute hospital. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for geriatric patients in early post-acute rehabilitation facilities., Methods: The ICF Core Set development involved a formal decision-making and consensus process, integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients., Results: Fifteen experts selected a total of 123 second-level categories. The largest number of categories was selected from the ICF component Body Functions (51 categories or 41%). 14 (11%) of the categories were selected from the component Body Structures, 30 (29%) from the component Activities and Participation, and 28 (23%) from the component Environmental Factors., Conclusion: The Post-acute ICF Core Set for geriatric patients is a clinical framework to comprehensively assess patients in early post-acute rehabilitation facilities, particularly in an interdisciplinary setting. This first version of the ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.

The goal of this paper is to report on the background and the methods used in the ICF Core Set development for patients in the acute hospital and early post-acute rehabilitation facilities. ICF Core Sets are sets of categories out of the International Classification of Functioning, Disability and Health (ICF) which can serve as minimal standards for the assessment, communication and reporting of functioning and health for clinical studies, clinical encounters and multi-professional comprehensive assessment and management. The ICF Core Sets were developed in a formal decision-making and consensus process, integrating evidence gathered from preliminary studies and expert opinion. The Acute ICF Core Sets for patients with neurological, musculoskeletal and cardiopulmonary conditions are intended for use by physicians, nurses, therapists and other health professionals working in the acute hospital on medical, surgical or other units not specialised in rehabilitation. The Post-acute ICF Core Sets for geriatric patients and patients with neurological, musculoskeletal or cardiopulmonary conditions are intended for use by physicians, nurses, therapists and other health professionals involved in early post-acute rehabilitation. The Acute and Post-acute ICF Core Sets are first versions and need to be tested and validated in the patient and professional perspective and in different countries, regions, health care and provider settings.