Impact of Level of Effort on the Effects of Compliance with the 3-Hour Rule

Publication date: Available online 20 February 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Cynthia L. Beaulieu, Juan Peng, Erinn M. Hade, John D. Corrigan, Ronald T. Seel, Marcel P. Dijkers, Flora M. Hammond, Susan D. Horn, Misti L. Timpson, Melanie Swan, Jennifer Bogner

Abstract

Objective

To determine if patients' level of effort (LOE) in therapy sessions during traumatic brain injury (TBI) rehabilitation modifies the effect of compliance with the 3-Hour Rule of the Centers for Medicare & Medicaid Services.

Design

Propensity score methodology applied to the TBI-Practice-Based Evidence (TBI-PBE) database, consisting of multi-site, prospective, longitudinal observational data.

Setting

Acute inpatient rehabilitation facilities (IRF).

Participants

Patients (n=1820) who received their first IRF admission for TBI in the US and were enrolled for 3 and 9 month follow-up.

Main Outcome Measures

Participation Assessment with Recombined Tools-Objective-17, FIM^TM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9.

Results

When the full cohort was examined, no strong main effect of compliance with the 3-Hour Rule was identified and LOE did not modify the effect of compliance with the 3-Hour Rule. In contrast, LOE had a strong positive main effect on all outcomes, except depression. When the sample was stratified by level of disability, LOE modified the effect of compliance, particularly on the outcomes of participants with less severe disability. For these patients, providing 3 hours of therapy for 50%+ of therapy days in the context of low effort resulted in poorer performance on select outcome measures at discharge and up to 9 months post discharge compared to patients with <50% of 3-hr therapy days.

Conclusions

LOE is an active ingredient in inpatient TBI rehabilitation, while compliance with the 3-Hour Rule was not found to have a substantive impact on the outcomes. The results support matching time in therapy during acute TBI rehabilitation to patients' LOE in order to optimize long-term benefits on outcomes.

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