2. Feasibility and
piloting
Background
Aims: Development Evaluation
Return to work after traumatic brain injury (TBI) Implementation
• Primary goal (Carlson et al. 2006) • Is TBI specialist VR delivered by an OT part
• Low rates of post injury employment: of a specialist TBI team more effective at
41% (range 0-85%) in work at 1 and 2 years (Van Velzen
supporting work return and retention 12
et al. 2009)
• Failing Rehabilitation? months after injury in people with TBI
• Economic Impact -2.8 Billion Euros (Rickels et al. 2010) than usual care?
• Patchy UK provision (Deshpande and Turner Stokes, 2004, Playford et al .2011) • What is the feasibility of collecting and
evaluating economic data?
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Method
TBI survivors all severities
Recruitment ≤ 4 weeks post discharge
Specialist Service = Routine Care =
Nottingham Traumatic Brain Injury Service Patients outside the
Minor TBI = OT Only catchment area
Postal follow up, 3, 6 and 12 months
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3. Recruitment (22 months) Baseline difference
252 Non- Intervention group in hospital for 11 days less
382 potential people identified eligible people Intervention group = mean12 days (sd 20)*
Non intervention group = mean 23 days (sd 21)*
130 eligible 36 (27.4%) (Mann Whitney U p=0.004)
declined
94 in study
40 Intervention group 54 Non-intervention group
32 Men (80%) 45 men (83%)
33 Mean 34 years (18-66) Mean 34 years (16-68)
Mean GCS 9.4 Mean GCS 10.3
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Return to work – all participants Return to work – moderate/severe TBI
27%
100% difference
Percentage at work
100% 15% OR 3.05 (0.9,10.6)
80%
Percentage in work
80% difference 8% χ2= p= 0.07
60%
12% difference
60% 40%
more in
40% work 20%
20% 0%
0% Pre-injury 4 weeks 3 months 6 months 12 months
Pre-injury 4 weeks 3 months 6 months 12 months
Time since injury
Time since injury
Interventon group Non intervention Interventon group Non intervention
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Return to Work – minor TBI Pilot 12 month - cost effectiveness analysis
37%
120% difference 10%
Fischer's p=0.03 difference Mean Intervention Non- Mean
100%
costs group intervention difference
Percentage in work
80%
per group per person
60%
person
40%
20%
Health £2107 £2032 +£75
0%
costs
Pre-injury 4 w eeks 3 months 6 months 12 months
Time since injury
Society £8786 £10648 -£1862
costs
Intervention group Non intervention College of Occupational
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4. Incremental Cost Effectiveness Ratio Conclusions
Clinical:
- Intervention group had increased work rates at
all time points
- People with moderate and severe TBI showed
greatest difference in RTW rates at 12 months
- Early intervention needed
Cost - effectiveness
- Uncertain if health perspective taken at 1 year
Research
- Results suggest a larger RCT is warranted
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The International Classification of
Functioning (WHO)
What did the
OT do?
E.g. Confidence,
Experience etc.
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Some key points Aim + Method
• Recognises the importance of both health and social Aim
factors in influencing success of vocational • To determine the content of OT intervention
rehabilitation programmes
Method
• Programmes need to address impairment, activity, • Designed a proforma
personal and social / environmental factors to be • Had 15 sections
effective
• Recorded OT treatment in 10 min units after
every session
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5. Sections on the proforma Work Preparation 10 RTW process 10
min min
• Where seen • Cognitive/Executive Routines/time keeping RTW planning meeting
• Assessment skills Discuss work options Work assessment meeting
• Current issues • Work preparation Patient contact with work Monitoring and grading
• Goals • Return to work process place meetings
• Personal ADL
• Miscellaneous Detailed job analysis Maintenance meetings
• Education about TBI
• Liaison Identify potential Written information to
• Instrumental ADL problems/solutions employers
• General issues
• Physical issues Pacing/fatigue Statutory issues
• Psychological issues Other Other
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Participants = 29
Results Glasgow
Coma Score
Severe 14 (48%),
Moderate 7 (24%)
Minor 8 (28%)
Gender Males 24 (83%), Females 5 (17%)
Mean Age 36 (19-66)
Cause Fall 11 (38%), RTA 7 (24%),
Assault 9 (31%), Other 2 (7%)
Work status Full time 21 (72%), Part time 8 (28%)
Job category Professional 4 (14%), Skilled 6 (21%),
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Semi-skilled 10 (34%), Unskilled 9 (31%)
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Outcome of Intervention Style of Intervention
• At discharge 25/29 (86%) = work/study 16
14
Number of participants
14
12
10
– 22/29 (76%) returned to previous 8
8
employer/college in some capacity 6
4
5
2
– 3/29 (10%) had started a new job 2
0
– 4/29 (14%) were not working (2 disengaged) Advice only 7% Treatment only Treatment and Treatment and
- no direct employer involvement of
employer involvement others* 17%
involvement 28%
• Everyone remained in work for 18 48%
months *DEA’s, Occ health doctor, pathway providers
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6. Intervention content Top 5 work concessions
• 66% of the OT intervention directly • Flexible extra breaks (18%)
focused on RTW: • Decreased hours (18%)
– Work preparation (23%) • Reduced duties (15%)
– Assessment (15%) • Reduced days (15%)
– RTW process (13%) • Flexible start/finish times (13%)
– Current issues (15%)
• Graded return to work = 88% participants
• No intervention on PADL
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Distribution of OT time per participant Amount of Treatment
Summary of OT • 65% of treatment in people’s homes
time • 17% of treatment in the work place
OT travel
OT non
21%
• Average session approx 1 hour
participant 1/3 = face to face
face to
face intervention • Mean no. OT sessions –
OT admin
liasion
36% 11%
– mod/severe TBI 7 (1-23)
1/3 = Liaison – minor TBI 4 (2-7)
1/3 = Admin and • Mean length of intervention
OT face to
face with
travel – mod/severe TBI = 9 ½ months (21-838 days)
participant
31% – minor TBI = 4 ½ months (23-188 days)
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Clinical Implications
Use of the proforma
Key messages Intervention
Positive Negative • Job Brokerage and re- • Important to be work
• Quick to use training is hard - more focused
• Some interventions
• Captured main difficult to categorise likely to return to • Clinicians need liaison
treatment focus previous employer and travel time
• Redundant categories • Advise patients to
keep options open
Conclusion
Proforma has potential for development Work site visits: Need flexibility
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7. Lack of consensus
Limitations and lessons
• What is outcomes
Measuring work?
• What counts as success? • Small opportunistic study – pragmatic approach
• What are the outcomes of building on existing NHS service expertise
health based vocational • Non-randomised, underpowered = uncertainty
rehabilitation intervention?
• Intervention of a single OT on TBI survivors intending
to return to work
• How should VR
interventions be • OT – PhD study
– Known to acute services = advantage in recruitment
described?
– Persistent, dedicated and determined
– Knowledge of local services – useful in costing care
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Problems The Model
• No TBI Register • Early, Specialist, Health based, Community (Outreach)
Rehabilitation
• Follow up problematic in TBI – ‘Early’ - identifies people at point of injury to prevent job loss
• Costing Usual Care - Identifying with certainty – ‘Specialist’ - TBI specialist & VR specific knowledge
which services were involved – ‘Health Based’ - delivered by NHS professionals in health setting
– ‘Mixed’ - work return and work retention
• Limited Funding (COT) focussed on OT rather
– ‘Community Rehabilitation’ - delivered in community
than team input
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Feasibility and
piloting
NEXT STEPS
Next steps - Feasibility RCT to explore.....
Feasibility Study to explore…. Development Evaluation
Implementation
• Eligible numbers • Completeness of follow up
• Recruitment rate of the primary endpoint
• Research objectives • Can participants be
• The spectrum of
• Can we develop a treatment manual, training package and randomised to the
mentoring model and implement it, so that the ‘Nottingham VR
disease among recruits
intervention’ can be delivered in 3 NHS regional TBI referral • Reasons for non intervention ?
centres? recruiting • The likely effect on drop out
• Can we conduct a randomised trials comparing early specialist TBI • Compliance with VR of randomisation to the
vocational rehabilitation (ESTVR) in addition to standard care with
and with usual care control group
standard care alone
• Are the measures fit for • Can we capture economic
• Can we identify Primary outcomes of an NHS based ESTVR data from TBI survivors?
important to service users, NHS service providers and purpose
commissioners? College of Occupational
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8. Promoting high quality research to
develop rehabilitation practices References
which are effective, relevant and
• Carlson, P. M., M. L. Boudreau, J. Davis, J. Johnston, C. Lemsky, M. A. McColl, P.
forward thinking. Minnes and C. Smith (2006). 'Participate to learn': A promising practice for community
ABI rehabilitation. Brain Inj 20(11): 1111-7
• van Velzen, J. M., C. A. van Bennekom, M. J. Edelaar, J. K. Sluiter and M. H. Frings-
Dresen (2009). How many people return to work after acquired brain injury?: a
A forum to: systematic review. Brain Inj 23(6): 473-88
• Waddell, G., A. K. Burton and N. A. Kendal (2008). Vocational Rehabilitation. What
• Raise the profile of rehabilitation research works, for whom, and when? Vocational Rehabilitation Task Force Group and I. I. A.
Council, TSO (The Stationery Office).
• Encourage evaluation through well designed studies • Hart, T., M. Dijkers, R. Fraser, K. Cicerone, J. A. Bogner, J. Whyte, J. Malec and B.
Waldron (2006). Vocational Services for Traumatic Brain Injury: Treatment Definition
• Foster a climate for developing and sharing skills and Diversity Within Model Systems of Care. J Head Trauma Rehabil 21(6): 467-482.
• Tyerman, A. and M. Meehan (2004). Vocational Assessment and rehabilitation after
• Enable active researchers to share the results of acquired brain injury, Inter-agency guidelines,. British Society of Rehabilitation
Medicine, jobcentreplus, Dept for Work and Pensions, Royal College of Physicians,
their work Clinical Effectiveness and Evaluation Unit, .
• Ownsworth, T. and K. McKenna (2004). Investigation of factors related to
• Advance rehabilitation practice for acute and chronic employment outcome following traumatic brain injury: a critical review and conceptual
model. Disabil Rehabil 26(13): 765-83.
disabling conditions
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