Rehabilitation

Objective: To determine rates of potentially preventable hospitalisation of people with intellectual disability in New South Wales, and compare them with those for the NSW population. Design: Retrospective cohort study. Setting: Potentially preventable hospitalisations in NSW, as defined by the National Healthcare Agreement progress indicator 18, 1 July 2001 ‒ 30 June 2015. Participants: Data collected in a retrospective data linkage study of 92 542 people with intellectual disability in NSW; potentially preventable hospitalisations data for NSW published by HealthStats NSW. Main outcome measures: Age‐adjusted rates of potentially preventable hospitalisation by group (people with intellectual disability, NSW population), medical condition type (acute, chronic, vaccine‐preventable), and medical condition. Results: The annual age‐standardised rate for people with intellectual disability ranged between 5286 and 6301 per 100 000 persons, and for the NSW population between 1278 and 1511 per 100 000 persons; the rate ratio (RR) ranged between 3.5 (95% CI, 3.3–3.7) in 2014–15 and 4.5 (95% CI, 4.2–4.9) in 2002–03. The difference was greatest for admissions with acute (RR range: 5.3 [95% CI, 4.9–5.7] in 2014–15 to 8.1 [95% CI, 7.4–8.8] in 2002–03) and vaccine‐preventable conditions (RR range: 2.1 [95% CI, 1.6–3.0] in 2007–08 to 3.4 [95% CI, 2.2–5.2] in 2004–05). By specific condition, the highest age‐standardised rate was for admissions with convulsions and epilepsy (all years, 2567 per 100 000 population; v NSW population: RR, 22.2; 95% CI, 21.3–23.1). Conclusion: Age‐standardised rates of potentially preventable hospitalisation are higher for people with intellectual disability than for the general population. The reasons for these differences should be investigated, and strategies for averting potentially preventable hospitalisation developed.

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

To the Editor: In their observational study, Kimmel and colleagues1 examined the impact of inpatient rehabilitation (IPR) for isolated lower limb injuries on functional outcomes in working‐aged people using inverse probability of treatment weighting (IPTW) propensity score analysis. It concerns us that the study lacks real clinical perspectives in disability management. Firstly, the authors assumed exchangeability in the baseline characteristics of patients discharged home and patients admitted to IPR. Exchangeability of the samples is a prerequisite for IPTW propensity score analysis.2,3 However, this is a flawed assumption in the Australasian context, where patients discharged home are medically stable, have minimal physical disability and have sufficient psychological coping skills. In contrast, patients admitted to IPR are deemed unsafe to be discharged home, with greater disability, home hazards, or inadequate support. IPR addresses complex therapy and care needs while alleviating pressure on acute beds. Secondly, the study examined disability and returning to work without considering all relevant determinants of health and functioning as listed in the World Health Organization’s International Classification of Functioning, Disability and Health. Rather than IPR resulting in a poorer functional outcome through hospital‐related complications, it is our experience that persons who require IPR will have a higher physical, functional, psychological, personal and social complexity or vulnerability, which may result in the observed long term disability. Thirdly, the study identified adverse 12‐month outcomes in patients discharged home. This control group were physically and functionally fit for discharge home, but 67% reported suboptimal recovery on the extended Glasgow Outcomes Scale (GOS‐E) and 16% failed to return to work at 12‐month follow‐up. Given that return to previous jobs plateaus by 6–12 months,4 gaps in care may aggravate problems by preventing timely access to multidisciplinary interventions to address the medical, psychological, physical, occupational and social impact of a traumatic injury. Finally, we encourage the authors to present the 12‐month follow‐up data in the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) for pain scores, anxiety and/or depression, and other domains of the EuroQol EQ‐5D‐3L Scale.4 Pain perception and depressive symptoms are known predictors for functioning and returning to work following an orthopaedic trauma and likely confounded the results.5

Pearl Chung · Mark Haran

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the need for accessible information for people with disability during public health crises. Accessible information — including Easy Read, Auslan, large print, Braille and audiovisual formats — is a human right.1 Such information is critical for people with disability to understand public health crises and know how to remain safe and access support. These needs are important, particularly given that people with disability commonly have underlying health conditions that may make them vulnerable to public health risks,2 are subject to service systems that may enhance their exposure to infection,3 and often face entrenched system‐driven inequalities, such as being excluded from health prevention and response actions.4 In Australia, accessible information is provided by governments, specialist information access agencies, disability advocacy groups, and service providers. As these groups have provided information about COVID‐19, lessons have emerged for informing better practice during future crises.5 To be appropriate for a public health crisis, accessible information must be: Accurate and of high quality — the information needs to be correct and sufficiently accessible. This requires collaboration between medical professionals and information specialists. Timely — delays in producing accessible information are common, but dangerous. Kept up‐to-date — producing accessible information that is never revised is inappropriate when the details of a crisis are constantly changing. Provided in sufficient detail and breadth — just as the rest of the population needs to know about many different aspects of a crisis, so do people with disability. Resources with a range of subtopics are required. Produced with people with disability — including people with disability in producing the information will ensure it is useful to and accepted by them. Disseminated appropriately — people with disability need to be able to access information through agencies they trust, as well as news media and governments. Where applicable, hard copies should be available, not only online.

Ariella Meltzer

Objectives: To develop and validate a frailty index, derived from aged care eligibility assessment data. Design: Retrospective cohort study; analysis of the historical national cohort of the Registry of Senior Australians (ROSA). Participants: 903 996 non‐Indigenous Australians aged 65 years or more, living in the community and assessed for subsidised aged care eligibility during 2003–2013. Main outcome measures: 44‐item frailty index; summary statistics for frailty index score distribution; predictive validity with respect to mortality and entry into permanent residential aged care during the five years after assessment. Results: The mean frailty index score during 2003–2013 was 0.20 (SD, 0.07; range, 0–0.41); the proportion of assessed older people with scores exceeding 0.20 increased from 32.1% in 2003–2005 to 75.0% in 2012–2013. The risks of death and entry into permanent residential aged care at one, three and five years increased with frailty index score level (at one year, high [over 0.35] v low scores [under 0.05]: hazard ratio for death, 5.99; 95% CI, 5.69–6.31; for entry into permanent residential aged care, 8.70; 95% CI, 8.32–9.11). The predictive validity (area under the receiver operating characteristic curve) of Cox proportional hazard models including age, sex, and frailty index score was 0.64 (95% CI, 0.63–0.64) for death and 0.63 (95% CI, 0.62–0.63) for entry into permanent residential aged care within one year of assessment. Conclusions: We used Australian aged care eligibility assessment program data to construct and validate a frailty index. It can be employed in aged care research in Australia, but its application to aged care planning requires further investigation.

Jyoti Khadka · Renuka Visvanathan · Olga Theou · Max Moldovan · Azmeraw T Amare · Catherine Lang · Julie Ratcliffe · Steven L Wesselingh · Maria C Inacio

Australia has managed the crisis well so far but we should now also plan for future waves and the recovery phase Coronavirus disease 2019 (COVID‐19) pandemic management is focused on prevention, case finding and survival. Australia and New Zealand have done well and the numbers in our intensive care units (ICUs) are currently manageable. Our subacute sector is presently able to deal with patients requiring rehabilitation. However, rehabilitation needs following COVID‐19 are broad, complex and include cognitive, motor and respiratory sequelae to the infection, acute respiratory distress syndrome, and the thromboembolic response. Planning and anticipatory action has been Australia's strength so far. In the same vein, an active planning approach is now required for the post‐acute and rehabilitation response. This pandemic will inevitably have its waves, and will continue to threaten until a vaccine is rolled out. Not having a plan for possible surges is unconscionable, particularly when the consequences of the relaxation of restrictions are unknown. Currently, Australian numbers are at a trickle; however, the challenge has been front and centre in countries such as Italy,1 Spain, the United Kingdom and North America.2 In Wuhan, China, 36% of those with severe COVID‐19 had neurological complications such as stroke, critical care neuropathy, and the complications of prolonged bed rest (eg, venous thromboembolism, disseminated intravascular coagulation, acute kidney injury, delirium anxiety, post‐traumatic stress disorder).3 In Italy, rehabilitation physicians have been treating post‐extubation dysphagia, impaired mobility, critical care myopathy and neurocognitive losses,1 while the British Society of Rehabilitation Medicine has established a framework of partnership with acute services to improve patient flow, outcomes and access to ventilators.4 In the United States, hospitals have had to rapidly transition acute patients to rehabilitation hospitals. In New Orleans, a 1000 bed post‐acute hospital was dedicated to post‐COVID‐19 disability, with rehabilitation teams treating patients battling persistent hypoxia, stroke and mental illness.5 The majority of patients who are ventilated for more than 7 days suffer complications that require rehabilitation, 60% are unable to walk, and 17% die within a year.7 One‐third suffer neurological complications, many require inpatient rehabilitation for over 3 weeks, and some take over 150 days to regain their capacity to walk independently.8 Others with stroke or cardiac complications of COVID‐19 will require rehabilitation for up to 6 weeks, with some requiring lifelong support. Australia needs to plan now, not just for survivors in the initial post‐acute stage, but also to manage individuals affected in subsequent waves. Such patients may require rehabilitation, along with those, fearful of infection, who present to hospital late with non‐COVID‐19 conditions like stroke, and those with deteriorating chronic diseases who have not had access to hospital based services. That means not only estimating the patient population but also ensuring that subacute health workers have sufficient access to personal protective equipment, staffing and training. In the Australian Government's emergency response plan,9 the recovery phase devolves to the states, but there is no mention of the post‐acute phase. In April, the New South Wales Ministry of Health established a rehabilitation community of practice to advise it. This follows international experience, as the International Society of Physical and Rehabilitation Medicine's disaster committee lead, Australia's Fary Khan states: “early rehabilitation reduces disability and improves clinical outcomes”.10 Currently, many rehabilitation units are not prepared. Inpatient rehabilitation units (public and private) are almost always working to capacity. COVID‐19 patients will be expect to be accommodated in addition to usual patients (eg, strokes, spinal injuries, amputations). The NSW Rehabilitation Community of Practice has developed a staged COVID‐19 escalation plan,11 but the plans turn on one integral point — contagion. When COVID‐19 survivors come to rehabilitation wards will they no longer be infected? While a national statement exists,12 local de‐isolation protocols are yet to be implemented or updated in many hospitals and local health districts. Many people with severe COVID‐19 have positive nasal swabs for up to 37 days13 but are not considered infectious once 10 days have elapsed from after first symptoms. Attention to this timetable is critical should we need to make ICU beds readily available by shifting patients to rehabilitation. In some US rehabilitation hospitals, patients are assumed to always be infectious, which has a significant impact on personal protective equipment usage. To ensure de‐isolation, moderate and severe COVID‐19 patients transferring to rehabilitation must have negative swabs on 2 consecutive days, be symptom‐free for 2–3 days and be at least 10 days from symptom onset. In NSW, these criteria are currently being put in place and such a protocol will require discussion, review of the evidence, and leadership to execute. Once we have a de‐isolation protocol, we can confidently activate a staged escalation plan. While our ICUs are coping with current numbers, our subacute sector has been managing with innovative models of care, such as mobile rehabilitation teams.14 The NSW Rehabilitation Community of Practice's COVID‐19 response principles11 refer to mobile rehabilitation teams, variously called ART (acute care rehabilitation team) or SMART (specialist management with acute rehabilitation treatment) teams. They provide rehabilitation and discharge planning services to patients in the acute hospitals. It is a parallel care model in partnership with acute care that has been successful in decreasing length of stay and facilitating early discharge or transfer to inpatient rehabilitation facilities. These teams have discharged almost 50% of their patients directly home, avoiding inpatient rehabilitation admissions, and have been active in many NSW hospitals since 2009. Once home, tele‐rehabilitation physician consultations, supported by community‐based allied health practitioners, can be delivered, although additional resources are still being sought. Similar models exist or are under development in other jurisdictions as well. In the event that our acute hospitals start to face challenges in accommodating those needing COVID‐19 or ICU beds, the subacute sector will need to escalate to the next stage to create access. Options include decanting non‐COVID‐19 patients to the private sector, increasing resources to acute or mobile rehabilitation teams, scaled up tele‐rehabilitation services, and preparation for public hospital rehabilitation inpatient units to manage COVID‐19 patients. However, in order to decant to the private sector we need completed agreements with private hospitals, as flagged on 31 March by the Minister of Health.15 Many private hospitals have facilities that are well suited for rehabilitation patients. This would require delineating private hospitals as COVID‐19‐free facilities and would be dependent on appropriate triage and testing facilities. Managing the logistics will be a challenge in the subacute sector, particularly if planning is left as an afterthought. The efficient flow of disabled COVID‐19 patients from acute to rehabilitation care will likely produce better patient outcomes and improve safety. Egress from acute hospitals means access to intensive care and ventilation for the community. If Australia and New Zealand's success at flattening the curve continues, our existing subacute sector will manage. If not, mobile rehabilitation teams will need to be expanded, systems for patient flow to the private sector will need to be operational, and enhanced tele‐rehabilitation services will need to be working. This will require the same vision and leadership that made our acute COVID‐19 response world leading, collaborative and publicly supported. In the UK and the US, we see the brutality of this pandemic, with mass burials and the tragic toll on health care workers. Australia and New Zealand have avoided this so far, but it is because we have planned well. We now need to prepare for the recovery phase because surviving may not be the same as living.

Steven G Faux · Kathy Eagar · Ian D Cameron · Christopher J Poulos

Some patients may not benefit from inpatient rehabilitation, but numerous factors must be considered

Ian D Cameron

If I am allowed to anaesthetise again, I'll share a few quiet reassuring words with my patients I had spent the past 25 years working in hospitals, intensive care units (ICUs) and theatres. So many thousands of operations on so many patients, and yet here I was, fearful and frankly embarrassed. I lay motionless, face fixed in an unconvincing grin for the benefit of former colleagues as I floated past them, a single off‐white sheet covering my goosebumps. Just another patient this time. Paraded down the corridor; relatives and staff trying to guess whether you were haemorrhoids or a vasectomy. I was no longer the operating room DJ, “gasman” and “wannabe comedian”. Rather than choosing a playlist and sipping the first of many espressos that morning, I had stiffly, illegibly signed a consent form and wet my parched lips from a plastic cup. The last time consent for surgery had been requested, it had been during an emergency helicopter flight, given by my shell‐shocked wife, thousands of miles away. She had tearfully agreed to the trauma team's plans to stabilise my broken neck and jaw, sew my ear back on and drain my exploded right chest, ruptured lung and kidney. The good news was that the pulverised hands and multiple lumbar fractures could wait for another day. It hadn't been clear at that stage if walking was going to be an option, nor whether the brutal deceleration would take a longer term toll upon my brain. It would be a week in the ICU, ventilated and restrained, plus many months of interminable rehabilitation before anyone would know for certain. I remembered accelerating down that long steep hill into Apollo Bay, tucking low on the frame, not even having to pedal to gain speed rapidly, looking ahead for the group I had lost contact with. I flew past other riders, cautiously feathering their brakes on the descent. My eyes watered in the chill jet stream and the bike's carbon wheels chattered on the gleaming tarmac. Then darkness. Silence. Darkness. A large, calloused hand gently, insistently squeezed mine. Like waking from a deep restful sleep, I realised that I had been aware of the pressure on my palm for some time before I understood to try to respond. Slowly, hesitantly, I opened my eyes. The voice was deep, resonant and strangely familiar. It was my son. The brain damage that I sustained on that cold morning in Melbourne, head on into a street pole at 65 km/h tossed me onto the other side of life's road. Each of us doctors spends our training and junior years formulating our own personal and crucially professional identity. Born from repetitive, regular crises of confidence through patient deaths, personal errors and sometimes just promotion to the next terrifying level of responsibility. It wasn't so much learning what to do to be a competent doctor; it was more learning what it was to be a doctor, how we saw ourselves and how society regarded us. I realised that I could no longer muster that theatre blues’ confidence, that surgical squad strut. Laying on a theatre trolley, in a queue for the lifts, I was just another tremulous punter, nervous about the loss of control. I was most afraid of the drug‐induced, return to the darkness. The maxillofacial surgeon had asked me, many weeks after the plates and metalwork had been screwed in, between loosening yanks on the wires holding my face together, if I remembered the accident. I gargled denial noises, my mouth jammed open. “That's a good job,” she laughed. “What a mess!” Operating lists had been my working day and I missed them and my colleagues too, diligent and quirky, good‐hearted and generous. I watched them quietly busy around me, hushed and focused as they made their last detailed preparations. Part of me was ashamed that I knew so little about each of them individually, especially since so many had spontaneously sought me out, given me support and warmth during my months in rehabilitation. Perhaps there was more to medicine than just caring for people. Health teams build something together. Trust, empathy, a united resolve to do the best we can. It looked simple enough when you saw staff doing the same operation a thousand times, but it was the commitment to excellence and good outcomes that defined these humble, generous people. Many of the staff knew me that day as I arrived in the cool clinical space, air conditioner humming, the last stop before the deep dive. A familiar face checked me in for the final time. Knowing her well as I did, I was fleetingly relieved that it was my arm, and not some more delicate area that had been crushed as I was catapulted from the bike. I lay there quietly and felt the emotions rise again, tears welling up. The crash trauma and the rehabilitation had made me afraid of the absence, the journey into that anaesthetic void. I could picture the theatre scene on the day of the accident. Probably not much different to today really. Relaxed, professional and all quite routine. Shredded Lycra, chest drains, ruptured organs and the rest. Sometimes, when I had been the boss, patients would get worried when I told them that things were routine. That wasn't to say we weren't concentrating, it's just that we had done it many times before. I would deliberately avoid the patient's back story just to keep my own anxiety at bay, ignore the injustice and bypass the random cruelty of their situation. Just put an airway into them and keep them asleep while the damaged bits got sorted. No doubt, when they lay my broken body onto a theatre table after the crash, it was much the same. Maybe some passing banter about the weekend's footy results, the crappy Melbourne weather and “middle‐aged men in Lycra” who really should know better. How ironic it would have been had I not hit the pole with my chin, but with my forehead and pithed my brain. Imagine the plaudits for the State Medical Director for DonateLife who felt so impassioned about saving other people's lives through organ donation, that he selflessly became a donor himself. Surely at least an Order of Australia for me? It could have been one of my team informing my family, hands held tight, that their husband and father was not going to make it but that he could save other people's lives. Drugs now flowed into a vein. I often tried to excel at the flippant and the ridiculous in the face of the worst of emergency situations, but not today, not on the other side, a scared patient. “Another one bites the dust” had always got a giggle if I played it from my Spotify favourites, just before sleep time. I used to jokingly tell patients before I put them under that being worried was quite understandable and that if anything bad happened, they would never know because they'd be dead. Strangely, that didn't seem funny anymore. Perhaps if I am allowed to anaesthetise again, once my brain is straight, I'll just share a few quiet reassuring words with my patients, tell them that it's okay to be frightened, that they're safe and that I won't leave their side until they awake. I used to pat myself on the back when a patient left my ICU. Now I have seen that leaving the ICU is not the end of the journey but the start of a new journey. I tried to explain through the mist of my confusion to the nurse caring for me that without her company and support, I wouldn't have survived. She started to cry. I hadn't meant to upset her but I wanted her to know that I was grateful. The outpatients’ clinic since then has been shocking and revelatory. I was the only one not in a wheelchair and for that I felt terrible guilt. Proper patients with proper injuries, courage and optimism by the bucketload have been a sombre reminder of what might have been. I have no memory of those first few steps, my wife's tears or the cheers from my hemiplegic room‐mate as I edged back onto my bed for a well earned rest. Because of the brain injuries, the thought of anaesthetising someone now fills me with an unfamiliar fear. It took me all my waking hours to craft this cast‐iron professional identity of mine and an instant to fatally fracture it. I even had the Rod of Asclepius tattooed on my biceps on my 50th birthday just to affirm a life's commitment to medicine. The supreme irony that I may never practise again and the loss of that coveted persona have been the most traumatic part. Who am I now? I used to be a doctor until that day on the Great Ocean Road. Not anymore. Perhaps one day I will accept the crash and its consequences; move on with my life. Not quite yet.

Bruce Powell

A 59-year-old woman attended a spasticity clinic with treatment-resistant atypical pressure ulcer in the right hand caused by focal spasticity secondary to upper motor neuron lesion

Anupam Datta Gupta · David H Wilson

The known: Rehabilitation reduces the patient's risk of death and disability after a stroke.

Elizabeth A Lynch · Shylie Mackintosh · Julie A Luker · Susan L Hillier

A benchmark for the referral rate to inpatient rehabilitation could reduce the evidence–practice gap

Justine M Naylor · Richard Walker

Substantial variation in inpatient rehabilitation rates is unexplained by patient factors, suggesting some low value care

Chris Schilling · Catherine Keating · Anna Barker · Stephen F Wilson · Dennis Petrie

Current permissible use of botulinum toxin in Australia does not match newer understandings of human impairment and functioning

Anupam Datta Gupta · David H Wilson

More expensive treatment options do not always achieve better outcomes

Andreas Loefler

Joint replacement outcomes do not justify the costs of inpatient rehabilitation for many patients

Justine Maree Naylor · Andrew Hart · Rajat Mittal · Ian Harris · Wei Xuan

Ageing and physical disability are major barriers to accessing health care in northeast India

Rebekah Young

Intensive acute hospital physiotherapy is safe and reduces the length of hospital stay

Lara A Kimmel · Susan M Liew · James M Sayer · Anne E Holland

Patients using a home-based cardiac rehabilitation program delivered via a smartphone app are more likely to complete it

Mohanraj K Karunanithi · Marlien Varnfield · Darren L Walters