Cowen T D, Meythaler J M, DeVivo M J, Ivie C S, Lebow J, Novack T A
Department of Physical Medicine and Rehabilitation, University of Alabama, Birmingham Medical Center, USA.
Arch Phys Med Rehabil. 1995 Sep;76(9):797-803. doi: 10.1016/s0003-9993(95)80542-7.
To determine the relationship between early variables (initial Glasgow Coma Scale [GCS] scores, computed tomography [CT] findings, presence of skeletal trauma, age, length of acute hospitalization) and outcome variables (Functional Independence Measure [FIM] scores, rehabilitation length of stay [LOS], rehabilitation charges) in traumatic brain injury (TBI).
Inception cohort.
University tertiary care rehabilitation center.
91 patients with TBI.
Inpatient rehabilitation.
FIM, rehabilitation LOS, and rehabilitation charges.
Patients in the severely impaired (GCS = 3 to 7) group showed significantly lower (p = .01) mean admission and discharge motor scores (21.26, 39.83) than patients in the mildly impaired (GCS = 13 to 15) group (38.86, 55.29). Cognitive scores were also significantly lower (p < .01) in the severely impaired group on admission (26.73 vs 54.14) and discharge (42.28 vs 66.48). These findings continued to be statistically significant (p < .01) after regression analysis accounted for the other early variables previously listed. Regression analysis also illustrated that longer acute hospitalization LOS was independently associated with significantly lower admission motor (p < .01) and cognitive (p = .05) scores, and significantly higher (p = .01) rehabilitation charges. Patients with CT findings of intracranial bleed with skull fracture had longer total LOS (70.88 vs 43.08 days; p < .05), rehabilitation LOS (30.01 vs 19.68 days; p < .10), and higher rehabilitation charges ($43,346 vs $25,780; p < .05). Paradoxically, those patients in a motor vehicle crash with an extremity bone fracture had significantly higher (p = .002; p = .04 after regression analysis) FIM cognitive scores on admission (48.30 vs 27.28) and discharge (64.74 vs 45.78) than those without a fracture. Finally, data available on rehabilitation admission were used to predict discharge outcomes. The percentage of explained variance for each outcome variable is as follows: discharge FIM motor score, 69.5%; discharge FIM cognitive score, 71.2%; rehabilitation LOS, 54.1%; rehabilitation charges, 61.1%. The most powerful predictor of LOS and charges was the admission FIM motor score (p < .001), followed by CT findings (p = .02) and age (p = .04).
Information readily available on rehabilitation admission, particularly the FIM motor score, may be useful in predicting discharge FIM scores as well as utilization of medical rehabilitation resources. Earlier transfer to rehabilitation may result in higher functional status and lower rehabilitation charges, as well as lower acute hospitalization charges. The presence of extremity fractures encountered during a motor vehicle crash is associated with a more favorable outcome in TBI as evidenced by higher discharge FIM cognitive scores.
确定创伤性脑损伤（TBI）患者早期变量（初始格拉斯哥昏迷量表[GCS]评分、计算机断层扫描[CT]结果、骨骼创伤情况、年龄、急性住院时长）与结局变量（功能独立性评定[FIM]评分、康复住院时长[LOS]、康复费用）之间的关系。
起始队列研究。
大学三级护理康复中心。
91例TBI患者。
住院康复治疗。
FIM、康复LOS及康复费用。
严重功能受损（GCS = 3至7）组患者入院和出院时的运动评分（分别为21.26、39.83）显著低于轻度功能受损（GCS = 13至15）组患者（分别为38.86、55.29）（p = .01）。严重功能受损组患者入院时（26.73对54.14）和出院时（42.28对66.48）的认知评分也显著更低（p < .01）。在对之前列出的其他早期变量进行回归分析后，这些结果仍具有统计学意义（p < .01）。回归分析还表明，急性住院LOS延长与入院时运动评分显著降低（p < .01）、认知评分降低（p = .05）以及康复费用显著升高（p = .01）独立相关。CT检查发现颅内出血合并颅骨骨折的患者总LOS更长（70.88天对43.08天；p < .05），康复LOS更长（30.01天对19.68天；p < .10），康复费用更高（43,346美元对25,780美元；p < .05）。矛盾的是，在机动车事故中发生四肢骨折的患者入院时（48.30对27.28）和出院时（64.74对45.78）的FIM认知评分显著高于未发生骨折的患者（回归分析后p = .002；p = .04）。最后，利用康复入院时可得的数据预测出院结局。各结局变量的可解释方差百分比如下：出院FIM运动评分，69.5%；出院FIM认知评分，71.2%；康复LOS，54.1%；康复费用，61.1%。LOS和费用的最强预测因素是入院FIM运动评分（p < .001），其次是CT检查结果（p = .02）和年龄（p = .04）。
康复入院时 readily available 的信息，尤其是FIM运动评分，可能有助于预测出院时的FIM评分以及医疗康复资源的利用情况。更早转入康复治疗可能会带来更高的功能状态、更低的康复费用以及更低的急性住院费用。机动车事故中出现四肢骨折与TBI患者更有利的结局相关，出院时FIM认知评分更高即证明了这一点。
