Models of Outpatient / Follow-up Care

Dunn et al. 2000
USA
Downs & Black score=12
Prospective Controlled Trial
(inadequate control)
Initial N=371;
Final N=371

Population: People with SCI receiving SCI-specialist follow-up care (N=235) vs those not (N=136); Age = 56.6 vs 47.9; Gender = 99% Male vs 66% Male; paraplegic, tetraplegic; complete, incomplete; Time since injury = 19.4 vs 18.2 years.
Treatment: Follow-up care (routine check-ups in SCI Outpatient Clinic) vs no Follow-up care (presumably problem-based primary care).
Outcome Measures: Secondary Condition Surveillance Instrument (SCSI), Check Your Health (CYH) Questionnaire. One time survey of both groups.

• Those receiving regular follow-up scored higher on all 3 subscales of CYH, Health (p=0.0068), Independence (p=0.005) and Absence of Depression (p<0.0001).
• Those receiving regular follow-up reported similar secondary conditions as those without routine follow-up but with reduced frequency and rated it as less severe.

Bloemen-Vrencken et al. 2007
The Netherlands
Downs & Black score = 21 Prospective Controlled Trial
Initial N=149
N=62 (31 matched subjects in each group)

Population: Those receiving initial rehabilitation care; Mean age=37.8 (transmural) , 36.1 (usual care) years; Gender: males=48, females=14; Level of injury: tetraplegia, paraplegia; Severity of injury: Complete, incomplete; Avg rehab stay = 270.7 (transmural) , 294.1 (usual care) days.
Treatment: Matched sample of those receiving transmural care (community patients served by transmural nurse liaising with other health professionals) vs ‘usual follow-up care’ (periodic visits to rehabilitation doctor / centre.
Outcome Measures: Prevalence of pressures sores, UTIs or other complications and number and duration of associated hospital re-admissions assessed over first year post-discharge.

• No difference between groups in prevalence of pressure sores and UTIs or other complications.
• No difference between groups in hospital re-admissions due to secondary complications.

Lugo et al. 2007
Columbia
Downs & Black score = 15
Pre-Post
Initial N=208 (Period 1)
N=42 (Period 2)

Population: Mean age=32.6yrs; Gender: males=33, females=9; Level of injury: C=14, T1-6=14, below T6=14; Severity of injury: AIS A=26, B=4, C=5, D=6, E=1
Treatment: Patients received a 2-phase interdisciplinary rehabilitation program consisting of a short in-patient phase (mean=13.5 days) and an out-patient phase over 18 months.
Outcome Measures: Motor FIM, ASIA motor score, Complications assessed over 5 periods including admission to the end of the first month and then months 2 – 3, 4 – 6, 7 – 12, 13 – 18.

• Motor FIM scores progressively increased significantly from admission to first month and after 1 year of rehabilitation (p<0.01) showing most marked increase between admission and months 2-3.
• Patients in AIS A and B groups reached motor FIM ceiling scores in the 18th month, while those is the C, D, E group reached ceiling in the 12th month.
• AIS motor scores progressively increased from admission over 18 months, however, persons with cervical injuries had most marked increases between admission and months 2-3.
• Complication rates for those conditions often associated with SCI (i.e., pressure sores, spasticity, pain, incontinence) remained high over the study period (deemed no different that in hospital-based programmes).

Telehealth Applications in Follow-up Care

Dallolio et al. 2008
Italy, Belgium, UK
PEDro score = 6
RCT
Initial N=137
N= 127 (62 vs 65, telemedicine vs control)

Population: Those discharged from initial rehabilitation care; Mean age=40 years; Gender: males=107, females=20; Level of injury: tetraplegia=47, paraplegia=77, ?=3; Median rehab stay = 186.5-230 days.
Treatment: Usual follow-up care vs  the same combined with 8 weekly telemedicine sessions followed by 9 bimonthly telemedicine sessions. Telemedicine sessions consisted of patient interviews to assess signs / symptoms of various complications & associated recommendations. Alternatively, sessions focused on functional issues.
Outcome Measures: FIM, SCIM II, healthcare utilization, status of various complications and satisfaction with care collected just before discharge and 6 months post.

• There was no difference in FIM or SCIM II scores across all 3 sites, however there was a significant increase in FIM gain at the largest (Italian) site for both overall FIM and FIM motor score (p<0.01) as well as some individual SCIM II items.
• There was no difference between groups in prevalence of secondary complications.
• Persons receiving the telemedicine contacts were significantly more satisfied with their care than those receiving routine follow-up care (p<0.001).

Phillips et al. 1999
USA
Prospective controlled trial
Downs and Black Score=17
N=35

Population: 35 subjects (26 male, 9 female); mean age: 33±12.1 yrs; newly spinal cord injured.
Treatment: Subjects were recruited for one of 3 groups: i) Video group: received weekly counselling sessions for 10-12 wks using AT&T Picasso Still-Image video unit for the first 6-8wks followed by 4-6 wks of weekly telephone counselling sessions; ii)Telephone group: telephone counselling for 10 wks; iii) Standard care group.
Outcome measures: Pressure ulcer incidence; frequency of health care utilization. All groups were surveyed every 2-3 mths.

• Ulcer incidence: video group had highest number of identified/reported pressure ulcers followed by the standard care group then the telephone group although none of these differences were statistically significant (p>0.05).
• Health care utilization: annualized ER visits, hospitalizations and provider visits were lowest in standard care group and similar for telephone and video groups although none of these differences were statistically significant (p>0.05).

Vesmarovich et al. 1999
USA
Downs and Black Score=4
Pre-post
N=8

Population: 8 male subjects; age: 38-78 yrs; Injury: cervical (n=5) or thoracic (n=3).
Treatment: Weekly telerehabilitation visits using Picasso Still-Image Videophone: simultaneously transmits video and audio over ordinary telephone lines. Participants and family members received 30-minute hands-on training session with equipment. Informal interviews with participants and families conducted to determine satisfaction.
Outcome measures: Number of clinic visits; status of pressure ulcers, subjective; subjective satisfaction assessment by patients, families and care providers.

• Mean of 7 visits /patient (range 1-18) via in-home video consult
• Seven of 12 wounds were healed over 8 patients.
• Telerehabilitation approach was accepted as a valid alternative to clinic visits by patients and family members – for many it was preferred. Clinicians identified several technical concerns throughout project but these were solved.