Rhaïa December 2019



Australasian Rehabilitation Outcomes Centre (AROC)

On behalf of the AFRM Council, I would like to officially welcome Dr Krystal Song as the new editor of Rhaïa. This is Krystal’s first edition and if her approach to this first edition is any indication, then I know we'll have a re-invigorated and stimulating Rhaïa going forward. I would like to thank Krystal for taking on the role. It's great to have someone permanently in the position. I'd also like to thank Stacey Barabash, AFRM Executive Officer and the various guest editors we've had over the past few years for keeping Rhaïa at a very high standard.

Professor Tim Geraghty
AFRM President
 

Editor introductions: Dr Krystal Song

I am honoured to provide an editorial comment in the final edition of Rhaïa for 2019. This edition features important and latest updates within the realms of the Australasian Rehabilitation Outcomes Centre (AROC). We have undoubtedly evolved in our clinical practices in the last decade and new rehabilitation research is constantly emerging. However, an uncoordinated approach remains and new priorities are currently being established for better coordination of rehabilitation research and enhanced collaborative work in the field. AROC also provides a huge national level source of data for us to access for this purpose. In this edition, we have original articles by both AROC and key rehabilitation clinicians, discussing various activities and significant work undertaken so far, its impact and directions for our immediate future.

We begin with articles by Frances Simmonds and AROC staff members, Tara Alexander and Jacquelin Capell. They discuss the historical journey of establishing AROC as our national benchmarking outcome centre, its role and the commendable efforts it displays in helping us improve rehabilitation outcomes and the quality of our processes in Australia and New Zealand. We have almost all inpatient rehabilitation services across both countries as AROC members, with a rich source of information available from more than 140,000 episodes of rehabilitation each year. The use of AROC data helps services see how they are doing by measuring key rehabilitation outcomes and benchmarking across the country. This allows us to understand and further address factors which influence trends in performance. Further articles discuss how we can use AROC data not just for benchmarking, but in advocacy and research projects. Collaborative projects with AROC and rehabilitation clinicians, trainees and various societies are also highlighted, showing how data can be linked to large datasets of other specialty societies to study rehabilitation outcomes before and after rehabilitation. With the new focus on ambulatory care models, it is important we start identifying ways to collect outcome data moving forward.

The article by Professor John Olver (Clinical Director of AROC), outlines current projects being undertaken by AROC to encourage trainees to use AROC data in research projects and initiatives by Epworth Healthcare in Victoria. It aims to make AROC data more immediate and usable. Associate Professor Michael Pollack encourages rehabilitation clinicians to participate in research with more genuine excitement and interest.  This will help build our reputation in the field and amongst other specialties locally and internationally, as well as to create a solid base of rehabilitation evidence.

We also discuss research projects that have used AROC data and demonstrate how these datasets have been valuable as a resource. Professor Fary Khan presents us with the latest collaborative research projects using AROC data to examine characteristics and rehabilitation outcomes in various neurological conditions. The experience of Dr Kisani Manuel, rehabilitation trainee in South Australia, provides us with a snapshot of reflections of a trainee embarking on a research project using AROC data, and provides great advice for those wishing to take a similar path.

Lastly, the International Society of Physical and Rehabilitation Medicine World Congress held in Kobe Japan (2019) was a highly successful inaugural event attended by over 2,500 participants. Part of the congress included the President’s Cabinet of ISPRM establishing  a new World Youth Forum (WYF) task force. Dr Su Yi Lee presents us with an article as the board representative for the Oceania region on the role of WYF and encourages young rehabilitation physicians, trainees and junior residents interested in the field to join a global network of enthusiastic individuals to promote the mission and goals of ISPRM.

I thank each contributor for their time in providing these articles. I hope that this edition raises awareness of the value of AROC and its opportunities. It is easy to take for granted that we have an excellent data collection system in our backyard (Australia and New Zealand), that many other craft groups in medicine and other countries in the field do not share. It certainly is an excellent system that can be more utilised in measuring and validating important aspects of our patient care and our aim to restore their lives. 
 

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Who and what is AROC?

AROC was the brainchild of two well-known and highly respected medical rehabilitation physicians, Associate Professor Ben Marosszeky and Dr Garry Pearce. AROC opened its doors 17 years ago on 1 July 2002, but the idea behind establishing a national outcome benchmarking initiative for rehabilitation was conceived years before this. It was in May 1998, through the endeavours of Dr Garry Pearce, the Faculty’s Honorary Secretary at the time, that AFRM was awarded a Federal Government grant to develop a Standard Data Set for Rehabilitation. This was essential for developing comparable measurement of outcomes of patient care. It was recognised that the collection and analysis of outcome data would assist in the development of clinical protocols for rehabilitation, help interpretation of outcome and service utilisation data, assist development of quality improvement initiatives, and help interpret variations between service providers.1

A project officer, Lyn Arnold, was employed and with the support of more than 85 per cent of the Fellowship who completed the survey form, an Australian Minimum Data Set for Rehabilitation Medicine was developed.1 Dr Garry Pearce submitted another successful proposal for additional funding to assist in the establishment of a national outcomes benchmarking centre in collaboration with the Centre for Health Service Development (CHSD) at the University of Wollongong. As a result of this successful collaboration, and with further funding support from key stakeholders in the rehabilitation sector, AROC was established.

From small beginnings, AROC encouraged all inpatient rehabilitation services to become members and participate in the national benchmarking initiative. Members collect data describing each episode of inpatient rehabilitation they provide and submit it to AROC. AROC provides members with six monthly benchmarking reports comparing their outcomes with those of peer services, and with national data. It also holds benchmarking workshops which aim to identify best practice processes, infrastructure and models of care, and promote the uptake of these across the sector.

By 2008, almost all inpatient rehabilitation services in Australia became members of AROC and benchmarking in rehabilitation had become a reality. Since then, not only has rehabilitation as a sector expanded, but AROC has evolved. The dataset has been updated and AROC has grown to include all New Zealand inpatient rehabilitation services, paediatric rehabilitation, ambulatory rehabilitation services, and covers newer models of care such as in-reach rehabilitation. Today, AROC members include 292 services, and submission of data describes more than 140,000 episodes of rehabilitation each year. The AROC database holds more than a million records describing rehabilitation outcomes and is a rich source of information.

With rehabilitation playing an increasingly important role within the healthcare system, AROC, as our national outcome benchmarking arm of AFRM and the rehabilitation sector, will continue to play an important role in driving continued improvement in rehabilitation outcomes, and in providing evidence of the value of rehabilitation not only to individuals, but also to the broader health sector.

References:

1. A Brief History of the Australasian Faculty of Rehabilitation Medicine, Chapter 5

By Frances Simmonds
AROC Director, Australian Health Services Research Institute (AHSRI)
University of Wollongong
 

How measuring rehabilitation outcomes leads to improvement — AROC data

In early 2000, AFRM facilitated the collaboration of key rehabilitation sector stakeholders to achieve the establishment of AROC, with the main aim of delivering quality rehabilitation care and achieving better patient outcomes. As part of AROC membership, services receive a suite of outcome benchmarking reports every six months to compare their patient outcomes with those of other rehabilitation services and they are also invited to participate in annual benchmarking workshops. The objective of the workshops is to provide an opportunity for services within a jurisdiction to review the inpatient rehabilitation data submitted to AROC, and to discuss reasons for any differences in processes and outcomes. In the 2019 financial year, which was 17 years after AROC’s inception, 247 inpatient rehabilitation units in Australia (123 public/124 private sectors) and 39 inpatient rehabilitation units in New Zealand reported 140,000 inpatient rehabilitation episodes to AROC (Figure 1). It is interesting to see how key rehabilitation outcomes have significantly changed since the inception of AROC for both Australia and New Zealand.


Figure 1: Growth in AROC since inception - inpatient episodes & member services, FY 2003-2019

figure 1

Rehabilitation is defined in the AROC data set by the impairment code. As per Figure 2, the distribution of impairments has not changed much over time in Australia since the 2008 financial year. A key role of AROC is to also ensure data quality, including education and audits around the inappropriate use of impairment codes. The change in distribution seen in the 2008 financial year stems from a review of episodes coded to 'Other' (Figure 2). Since this review, few episodes have been incorrectly coded to 'Other' for the 2013 financial year, ‘Soft tissue injury’ was added as a separate code.

Inpatient rehabilitation provision differs for various cohorts between Australia and New Zealand. For instance, limited inpatient rehabilitation occurs in New Zealand following orthopaedic replacement surgery, whilst this accounts for 25 per cent of all inpatient rehabilitation episodes in Australia. Across both countries, there has been a proportionate increase in patients receiving rehabilitation following de-conditioning, and a small decrease in those following stroke. Most other reasons for rehabilitation have remained proportionally unchanged.

Figure 2: Distribution of impairment groups by country, FY2003-2019

Figure 2

Key outcome measures for rehabilitation include timeliness from the injury or onset of symptoms to start of inpatient rehabilitation, timeliness of functional assessment on admission to inpatient rehabilitation, length of stay (LOS), improvement in functional ability (as measured by FIM) and patient’s discharge destination. In 2019, patients were twice as likely to start inpatient rehabilitation within a week of onset of their symptoms or injury compared to when AROC initially commenced.

Figure 3: Proportion of patients admitted to inpatient rehabilitation within a week of their injury or onset of symptoms, FY2003-2019


figure 3

Timeliness of the functional assessments is important in order to capture the maximum amount of improvement each patient achieves. AROC trains FIM clinicians to conduct functional assessments as soon as possible post admission. Since AROC commenced, the proportion of patients assessed within the first 24 hours of admission has increased annually from 75 per cent to 92 per cent in Australia (FY2002-2019) and 54 per cent to 86 per cent in New Zealand (FY2009-2019) (Figure 4). This pattern was consistent across all the different reasons for rehabilitation in Australia and for most reasons in New Zealand (slightly higher amongst spinal cord injury patients (SCI) (53 per cent to 96 per cent).

Figure 4: Proportion of patients with a functional assessment (FIM) completed within 24 hours of admission to inpatient rehabilitation, FY2003-2019


figure 4

Relative functional efficiency (RFE) is a unique measure which looks simultaneously at a patient’s functional improvement (relative to their level of function on admission), and their LOS in inpatient rehabilitation. The greater the functional improvement and the lower the LOS, the higher the RFE becomes (reported as a percentage improvement per day). The overall RFE in inpatient rehabilitation has increased annually from 3.8 per cent (FY2003) to 5.1 per cent (FY2019) (Figure 4). The highest RFE in Australia was for orthopaedic replacement patients (5 per cent to 7.5 per cent). RFE is higher in Australia than in New Zealand, with the latter being fairly constant at 3 per cent.

Figure 5: Relative functional efficiency (RFE) by impairment group in Australia, FY2003-2019

figure 4.1

Most patients are discharged from the rehabilitation ward to their final or interim accommodation (88 per cent in Australia, 95 per cent in New Zealand) and this varied little over time. However, results varied by impairment group, with 97 per cent of orthopaedic replacement surgery patients discharging to the community compared with 75-80 per cent of patients following limb amputation, SCI, brain injury or stroke (Figure 5).

Figure 6: Proportion discharged back to the community by impairment group in Australia, FY2003-2019

figure 5

The key outcomes measured above have all been improving since the inception of AROC. In many ways, AROC is unique — it is supported by the entire rehabilitation sector, it covers the vast majority of inpatient rehabilitation episodes in both public and private sectors, and it utilises clinically agreed and endorsed standardised outcome measures. Because of this, it can, and does benchmark rehabilitation services across the country and systematically measure trends in clinical practice. This helps us understand factors that influence rehabilitation outcomes, costs involved and importantly, performance of the rehabilitation sector which embraces transparency and accountability.

Jacquelin Capell
AROC Research Manager, University of Wollongong

AROC data: useful for more than just benchmarking – AROC Research

Beyond benchmarking, AROC data is used in advocacy to support rehabilitation, by AFRM registrars for their research projects, and more recently linking to other datasets to provide more information about patients before or after rehabilitation.

Examples of types of research AROC data is used for are described as follows:

AROC lead

Australian Modified Client-Centred Rehabilitation Questionnaire (AM-CCRQ)

The AM-CCRQ is a patient-reported questionnaire tool used in evaluating patients’ perceptions of their experience (rather than satisfaction) in inpatient rehabilitation. Prior to this project, there was no rehabilitation specific patient experience survey tool that was commonly utilised in Australia or New Zealand. Literature review identified only one relevant instrument, the Client-Centred Rehabilitation Questionnaire (CCRQ). AROC, with permission, evaluated the CCRQ in the Australian context. The CCRQ demonstrated good face validity, with minor modifications to item wording indicated for the Australian context. Trialled in 20 inpatient rehabilitation services across Australia, the modified tool demonstrated good construct validity. Internal consistency reliability provided support for few modifications to further improve reliability. Senior rehabilitation staff feedback from all participating units were highly positive regarding the usefulness of the information the tool provided, particularly the rehabilitation specific focus and level of detail compared to their usual patient experience surveys. The outcome of this project is the Australian-Modified Client-Centred Rehabilitation Questionnaire (AM-CCRQ), a reliable and valid instrument that rehabilitation services can use to support and inform their commitment to person-centred care. The AM-CCRQ, administration protocol and data entry tool are available for use, free of charge. If you would like to access these or would like further information please visit the AM-CCRQ website or contact AROC directly via email

AROC collaboration

Summer Foundation (2018)

Summer Foundation approached AROC with the aim of exploring in-depth AROC data to investigate clinical or social factors of young people (defined as those aged less than 65 years) and to identify those at greater risk of being discharged to residential care following an inpatient rehabilitation episode. For this project AROC undertook the analysis and produced two reports, in conjunction with Summer Foundation, to ensure that the findings were relevant.


AROC data linkages

AROC’s research currently includes linkage of inpatient data with three other registries: Australia New Zealand Intensive Care Society (ANZICS), Australian Stroke Clinical Registry (AuSCR) and Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Collaborative research agreements between AROC and these data registries are currently being developed. AROC does not collect identified data and is using statistical linkage key (SLK581) and key dates to facilitate probabilistic linkage.


Australia New Zealand Intensive Care Society (ANZICS) and Datathons

The linkage of AROC data with ANZICS data stems from the 2018 Bendigo Datathon, in which AROC participated as a data custodian. At the Bendigo Datathon, de-identified Victorian public AROC inpatient data were linked to the Victorian Admitted Episode Dataset (VAED) and then via VAED to ANZICS Adult Patient Database (APD). The Bendigo Datathon gathered inter-professional critical care trainees and clinicians (data novices to gurus), statisticians, data scientists and administrators to tackle clinical problems with large datasets. Participants were divided into teams with a mix of skills and given access to the deidentified data to answer whatever question they chose. Three teams chose to use AROC data. Starting life as Team CardiacArrest at the Bendigo Datathon, the ROSC ANZ study is using linked AROC and ANZICS data to look at 'outcomes of patients that spent time in ICU following a cardiac arrest prior to Rehab', an expansion of their datathon work to incorporate Australia and New Zealand.

To facilitate this research and further collaborative work, in 2019, AROC and ANZICS data were linked across the whole of Australia and New Zealand. The complex linkage was completed by AROC using the statistical linkage key (SLK) and key dates from both datasets. The linked episodes, from 2018 onwards, where a SLK was available, was used at the 2019 ANZICS Datathon held at QUT in Brisbane in June - the fourth Datathon run by ANZICS. At this Datathon, rehabilitation clinicians and trainees in Queensland were specifically invited to participate. Four Datathon teams used the linked AROC inpatient – ANZICS APD data. AROC has already received a request from one team who wish to extend their work on the 'Impact of prolonged ICU stay on Rehabilitation Outcomes'. 


Australian Stroke Clinical Registry (AuSCR)

As a proof of concept, project AROC and AuSCR have a piece of research titled 'Predicting Rehabilitation Outcomes of patients admitted with stroke between 2014-2017 through data linkage of the Australian Stroke Clinical Registry (AuSCR) and Australian Rehabilitation Outcomes Centre (AROC)'.  The linkage was completed by AROC using the statistical linkage key (SLK) and key dates from both datasets. Results will be presented at the 2019 National Stroke Data and Quality Improvement Workshop in November.

AROC Data provided to external researchers

AROC encourages the use of inpatient data for research projects by AROC members and the general scientific community. The degree of data available and the process by which data is made accessible differ according to who is applying for data access.  As part of access to AROC data, the AROC team work with the researcher to ensure the correct use and interpretation of AROC data. All researchers using AROC data must comply with AROC Data Policy. To request AROC data for your research, please contact AROC via email

AFRM Registrar Research Project

AFRM Registrars are invited to access AROC inpatient data to complete their research projects. The advantages of using AROC data are many, including:

a) the data collection already exists so no need to collect data
b) being able to consider national or state-wide view compared with single centre setting
c) analyses support from the AROC team.

A recent registrar project has been accepted for an oral presentation at the 2019 RMSANZ Conference in Adelaide.

Clinician Project

A recent research project for a senior clinician aimed to identify the change in dependency and complexity of patients’ admitted to rehabilitation in Australia over the past 10 years and to identify any associated contributory factors. Please refer to publication details - McKechnie D, Pryor J, Fisher MJ, Alexander T.  'Examination of the dependency and complexity of patients admitted to in-patient rehabilitation in Australia.' Aust Health Rev. 2019 Jan 18. doi: 10.1071/AH18073.

Tara Alexander
AROC Data Manager & Tara Alexander
AROC Research Manager, University of Wollongong
 

Ambulatory Rehabilitation – Key to the future of rehabilitation, but of unproven value yet

As part of its remit, AROC actively identifies new trends in healthcare provision, particularly in rehabilitation settings. Ambulatory care models are clearly an important focus now.

In our current value-based purchasing environment, it is crucial for ambulatory rehabilitation services to demonstrate the outcomes that they achieve for their clients. AROC has had an ambulatory benchmarking system in place for several years. However, it has been an uphill battle to recruit ambulatory rehabilitation services to join AROC, submit data and participate in benchmarking.

Whilst we know that ambulatory rehabilitation services and provision of care tend to be time consuming, resource challenged and involve many models of care, the assessment of function and achieving good functional outcomes for clients is the fundamental raison d’etre of rehabilitation. Given the environment of funding and the need to prove value for money, participating in collecting outcome data and benchmarking outcomes makes perfect sense, and one would think would be an attractive proposition for services.

So, if you oversee an ambulatory rehabilitation service, and are not already participating in AROC, please consider doing so. Please contact AROC to discuss and/or obtain further information via email.

Associate Professor Frances Simmonds
AROC, University of Wollongong

Current Initiatives in AROC

I am now halfway through my third and final two-year term as Clinical Director of AROC, a position appointed by the Council of the Faculty. Each year, AROC receives approximately 140,000 records of inpatient episodes across Australia and New Zealand. The collection of ambulatory rehabilitation episodes began in 2007, and paediatric data in 2017. In this article, I will outline some of the current projects being embarked on by AROC and demonstrate how the data is being used at Epworth HealthCare and integrated into its existing patient management system.

Registrar Positions

In association with the Research Subcommittee of the Faculty, AROC is co-operating in a process which hopes to encourage trainees to use AROC data in their Research Projects. The Research Committee is about to release a new booklet entitled 'Information Booklet: Supported AFRM Trainee Research Project'. The reason for producing this booklet is to help inform and support trainee research projects, which will increase the quality of Rehabilitation Medicine research and facilitate the use of data from AROC. The project will be part of the External Training Module 3 – Research Project. Trainees will lodge an expression of interest to develop a research project. AROC has data access application guidelines and policies regarding the use and access to the AROC data set, custodianship and co-authoring arrangements. The use of AROC data for these research projects is considered low-negligible risk with respect to ethics approval. In general terms, the registrar projects can be completed within two years.

Epworth Hospital Use of AROC Data

Epworth HealthCare Rehabilitation has a total of 271 beds spread over five campuses. Previously, we analysed AROC data on a six-monthly basis using the bi-annual reports including length of stay (LOS) and Functional Independence Measure (FIM) change. This allowed us to compare like clinical programs across each campus. The reports also allowed national benchmarking of outcomes.

Two initiatives at Epworth have made the data we collect for AROC more usable. Firstly, we manually analyse FIM efficiency across all clinical impairment groups and secondly, we are now working on a project to make use of the data we send to AROC on a six-monthly basis more immediate. The data (FIM, LOS), AROC impairment codes and The Australian National Sub-Acute and Non-Acute Patient Classification (AN-SNAP) are now integrated within iPM (our patient management system).  Access to our data in iPM can be queried on a daily basis, therefore enabling Epworth to monitor and instantly track unexpected changes in productivity. With instant and regular access to this data, this allows us to better evaluate outcomes of our programs and respond more efficiently.

Overseas Interest

Having been active since 2002, AROC has been of interest to a number of countries who are trying to develop national data sets for rehabilitation. In the past, we have entertained delegations from Vietnam and China. In November 2019, a delegation from the Singapore Department of Health visited AROC at the University of Wollongong to look at AROC management and clinical outreach. The Singapore Government intends to set up a similar system to monitor rehabilitation output in their country.

Patient-Reported Outcome Measures (PROMs)

Some health funds are starting to use PROMs to judge the effectiveness of rehabilitation. AROC is engaging in a new initiative to trial some PROMs to explore how patients involved in an inpatient rehabilitation program perceive their functional status - measured at rehabilitation episode admission and subsequent time-points. This project is currently undergoing ethics evaluation.

John Olver AM
Clinical Director of AROC
Medical Director of Epworth HealthCare Rehabilitation
Professor in Rehabilitation Medicine (Monash University)
 

AFRM Research Working Group – What’s the point?

Think! Where does your knowledge come from?

How do you make decisions about your treatment options?

How do you personally find confidence in your treatment recommendations, achieve clinical credibility, or identify what you can confidently teach your registrars, junior HMOs, students?

How does our profession as a whole gain (or lose) credibility and respect?

There is no doubt an art to the practice of medicine. But, the core of what we do must be based in some credible science. Where would we be if there was neither science nor evidence to our practice? The field of rehabilitation medicine, in particular, is one of the newest specialties in medicine. Whilst we value the lessons that have come to us from our mentors and masters of the past, we will not survive as a speciality into the future without a strong and evolving evidence base. Fortunately, there is good research that backs up a lot of what we practice. There is also research demonstrating where practices need review and refinement. Without these, there is no drive for evolution of our practice. Without good research, we are like a ship without a rudder.

For many years, the evidence that is important to our practice has been coming to us internationally. The Australian and New Zealand settings are, in many respects, quite different from the international contexts. How valid is the evidence from overseas in our own backyard?

Having said that, we are lucky. We have many excellent researchers amongst our Australasian Fellows. Australian and New Zealand rehabilitation medicine research is published internationally on a regular basis. It is regretful to say that I believe our research numbers are far too few. It is with even greater regret, that I have to say our research activities, priorities, and directions have no real coordination.

For many doctors, research carries no real attraction. As undergraduate students, junior HMOs and registrars, our focus is usually taken up by the need to pass exams. There is little time, or motivation, to explore research opportunities in any great depth. The new MD undergraduate programs for medicine may help to improve that. Our training programs (AFRM and more broadly in the RACP) obligates some level of exposure to research, but not in any great depth. It is often seen as a chore, but usually not filled with a sense of excitement in the task.

So, let’s take a look into the future - the vast majority of the other medical specialities are striding ahead with established research infrastructures, reputations, funding collaborations and strong track records within their specialty field, with the benefit of a longer history. Rehabilitation medicine has a long way to travel to catch up.

Thus, the establishment of the AFRM Research Working Group serves two key objectives. The first priority is to make access to doing quality research easier and more attractive for our Trainees. We hope to achieve this in the first instance by linking interested trainees with research mentors from within the faculty, and with a remarkable rehabilitation medicine clinical registry, via AROC. We hope that by providing this support and encouragement, a larger proportion of our registrars will be enticed to spend more time in research and to see research as an important part of their vocational careers.

The second priority is to establish a more formalised network of research interested Fellows within our faculty. Such a network has immeasurable benefits including improved collaboration (which then would have multiple advantages such as a larger recruitment pool) and better coordination and prioritisation of research topics. These may, for example, be research arenas that reflect the Australian and New Zealand context, alternatively may reflect the innovations and leadership of Australian and New Zealand science. There are many other advantages, and with maturity; the Research Working Group is likely to identify other priorities as well.

So, what is the point? Our Faculty’s Research Working Group is ultimately seeking to improve our clinical practice evidence base, our credibility, and our leadership in the medical field by improving the quality and quantity of our research output. This is, by no means, an easy task nor one that will necessarily see the fruits of its labour in the very near future. But, by taking these initial steps now and laying the foundations for growth, we hope that in years to come, we will see a solid foundation of research activities by our own Fellows - research that underpins our evolving practice and which guides the evolution of rehabilitation locally and also internationally.

By Associate Professor Michael Pollack
Director of Rehabilitation Medicine
Hunter New England Hospital
 

The Australian Rehabilitation Outcomes Centre (AROC) Dataset: A useful tool for describing rehabilitation outcomes

Rehabilitation is an integral part of medical management for any condition from diagnosis and treatment through to survivorship in the community, palliative and end-of-life care. Despite availability of health service frameworks and clinical guidelines/standards that promote rehabilitation for persons with various medical conditions, gaining access to appropriate rehabilitation services continues to be challenging. One reason for this is the relatively poor understanding of the specific benefits of rehabilitation, and lack of information on patient outcomes. AROC data helps us understand these factors that influence rehabilitation outcomes and costs as it holds a centralised database, with data for over 190 accredited (public and private) rehabilitation facilities.

The Royal Melbourne Hospital (RMH) Rehabilitation Department has conducted several collaborative projects with AROC. These included analyses for inpatient rehabilitation episodes for neurological conditions such as Multiple Sclerosis (MS)1, Guillain-Barre Syndrome (GBS)2 and Long-Term Neurological Conditions (LTNC)3 to better understand the clinical characteristics, rehabilitation outcomes and service implications in Australia. The primary outcomes for these projects include improvement in patient functional status, hospital LOS and discharge destination. In addition, year-to-year trends in LOS, service efficiency, and comparison of outcomes for service provision between the public and private sectors were examined. These analyses provided valuable information for rehabilitation service delivery, future planning and policy development. It provided a snapshot of neurorehabilitation outcomes for these conditions nationally and an opportunity for rehabilitation professionals, researchers and policy makers for benchmarking.

These studies demonstrate that AROC dataset is a unique resource and a valuable research tool for describing rehabilitation outcomes in ‘real life settings’. The prospective, systematic collection of data in the course of routine clinical practice has the potential to distinguish patients’ functional abilities and rehabilitation outcomes to aid service-modification options to reduce LOS and costs.

This study examined outcomes of inpatient rehabilitation for persons with MS, using the AROC database for all rehabilitation admissions during 2003–2007 and using four classes for functional level. The outcomes included FIM scores and efficiency, LOS, and discharge destination. Overall, 1,010 case episodes were analysed. The results demonstrated that 70 per cent were women, admitted from home (n = 851) and discharged into the community (n = 890), and 97 per cent (n = 986) were in the higher three classes for functional level. Majority of the more disabled persons with MS were treated in the public hospital system, with a longer LOS compared with private facilities (P < 0.001). The FIM for lower severity classes showed significant functional improvement during the admission (P <0.001), and those in higher classes showed less change (likely due to higher FIM admission scores). The year-on-year trend was toward reducing hospital LOS and FIM efficiency, but these did not reach significance.

This study evaluated the outcomes of inpatient rehabilitation for GBS survivors using the AROC database. De-identified data from the AROC database was analysed for all rehabilitation admissions during 2003-2008, using four classes for functional level (216-219). The outcomes included: FIM scores and FIM efficiency, LOS and discharge destination. Of 577 case episodes analysed, 58 per cent were male (mean age 56.7 years), 91 per cent were discharged to the community and 64.8 per cent were in the lowest functional classes (217, 218 and 219). The majority of GBS survivors were treated in the public hospital system (434 versus 143) and had a slightly longer LOS compared with patients treated in private facilities (30 versus 24 days, p<0.004). The FIM for all classes (216-219) showed significant functional improvement during the admission (p<0.000). Those in the most functionally impaired classes showed most change (FIM change: 10 in class 216, 37 in class 219). The year-to-year trend was towards reducing hospital LOS.

This study compared outcomes from inpatient rehabilitation (IPR) in working-aged adults across different groups of Long-Term Neurological Conditions, as defined by the UK National Service Framework using AROC dataset for completed IPR episodes (n = 28,596) from 2003-2012. The de-identified data for adults (16–65 years) with specified neurological impairment codes were extracted, cleaned and divided into ‘Sudden-Onset’ conditions: (Stroke (n = 12527), Brain Injury (n = 7565), Spinal Cord Injury (SCI) (n = 3753), GBS (n = 805)) and ‘Progressive/Stable’ conditions (Progressive (n = 3750) and Cerebral Palsy (n = 196)). The results showed that mean LOS ranged from 21 to 57 days with significant group differences in gender, source of admission and discharge destination. All six groups showed significant change (p<0.001) between admission and discharge that was likely to be clinically important across a range of items. Significant between-group differences were observed for FIM Motor and Cognitive change scores (p <0.001), and item-by-item analysis confirmed distinct patterns for each of the six groups. SCI and GBS patients were generally at the ceiling of the cognitive subscale. The ‘Progressive/Stable’ conditions made smaller improvements in FIM score than the ‘Sudden-Onset conditions’, but also had shorter LOS.

By Professor Fary Khan
Director of Rehabilitation, Melbourne Health

References

1. Khan F, Turner Stokes L, Stevermuer T, Simmonds F. Multiple sclerosis rehabilitation outcomes: lessons learnt from casemix dataset from Australia. Multiple Sclerosis; 2009; 15: 869-875.
2. Khan F, Stevermuer T, Simmonds F. Rehabilitation outcomes for Guillain-Barre syndrome: analysis of the Australian Rehabilitation Outcomes dataset. Journal of Clinical Medicine and Research 2010: 2(6):91-97.
3. Turner-Stokes L, Vanderstay R, Stevermuer T, Simmonds F, Khan F, Eagar K. Comparison of rehabilitation outcomes for long term neurological conditions:A cohort analysis of the Australian Rehabilitation Outcomes Centre Dataset for adults of working age. PLoS One 2015;10(7):e0132275.
 
  

Using AROC data in research – Reflections of a trainee

As part of the AFRM Research Project Trial implemented by the AFRM Research Working Party in 2017, I was given the opportunity work with a research mentor and AROC to develop and implement a research project. My project looked at rehabilitation outcomes and complications of patients who have cancer.

I decided to look at patient outcomes and compare these outcomes amongst patients with and without cancer. Following a pilot study reviewing 100 consecutive patients recruited from Flinders Medical Centre Rehabilitation Unit, I then analysed data from AROC, Australia-New Zealand wide. This involved comparing patient LOS, FIM change, medical complications and discharge destination for those with and without cancer over a three-year period.

What drew me to this research project was the access to a large pool of data. Rehabilitation data held by AROC allows not only comparison of facility outcomes, but has large numbers of episodes detailing patient demographics, diagnoses, outcomes and complications during rehabilitation admissions. For my study, this meant that I had access to data from over 180,000 admissions.

To share my experience, I first learnt how to analyse the AROC data collection form in designing a research question. In order to maximise the value of your research, it is important to understand what data AROC actually holds. I wanted to compare rehabilitation outcomes of patients with and without cancer. Looking at the AROC collection forms, I had two ways of doing this. The first was to compare the ‘Reconditioning’ impairment group with the subgroup of ‘Cancer Rehabilitation’. However, many patients who are admitted for rehabilitation and have cancer may be listed as having a different primary impairment. The second was to filter patient admissions coded as having cancer but listed as a comorbidity impacting on their rehabilitation admission. My study ended up incorporating both methods. I would highly suggest liaising with AROC once you have an idea of your topic and what you would like to evaluate. AROC staff are of great assistance in helping you refine your question.

Next, I would recommend thinking big, but being focused. AROC is a huge resource and there are many questions that can be addressed using AROC data which would otherwise be limited in a single centre. Try limiting the scope of your question and refining it so that your question is answerable. I limited my research to three impairment categories – ‘reconditioning’, ‘orthopaedic fractures’ and ‘stroke’. This helped as it would be too large to include all categories and had I included more, the project would have been more complex. Having said this, including all impairments for some studies would be completely appropriate, but more if you were looking at a specific concept. 

A research mentor also helps get things started, especially one who understands both research and using AROC data. Finding one would help keep you on track. As part of this project trial, this mentor was organised for me by Dr. Jane Wu which I’m grateful for as I was assisted and guided throughout the whole process. It would be much easier and fewer revisions to your project needed if you also engaged the help of a data analyst who understands AROC data. If they are not familiar with AROC, take the time to meet with them in person to explain it. This will help minimise errors, revisions and time.

I also had assistance from AROC to check my analyses and conclusions. There is an AROC Data Dictionary, which is accessible online (one version for clinicians and one for analysts) that you may find very useful. Aggregated data can be requested from AROC instead of raw data which minimises the need for a data analyst – this option is open to everyone, not just trainees. With ethics approval, this is important if you intend to publish the results of your AROC data analysis.

Lastly, I would just like to highlight my experience in working with AROC as an extremely positive one and would highly recommend it to other rehabilitation trainees and Fellows.

Kisani Manuel
Rehabilitation Registrar, Flinders Medical Centre, SA
 

Introducing the ISPRM Task Force: World Youth Forum

In June 2019, I commenced my new and exciting role as a board representative of the International Society of Physical Medicine and Rehabilitation (ISPRM) Task Force: World Youth Forum (WYF), representing the Oceania region. The President’s Cabinet of ISPRM established the WYF as an inaugural international task force representing early career rehabilitation physicians (up to 5 years after completion of training), Rehabilitation Medicine Advanced Trainees, Fellows, residents and medical students who have an interest in rehabilitation. It provides a great opportunity for individuals in the early stages of their careers to develop leadership skills and to build a strong foundation in the field.

During the ISPRM World Congress held in Kobe, Japan in June 2019, a panel discussion comprising of appointed Board Members of the WYF Task Force, young rehabilitation physicians, Fellows, trainees and medical students took place. The free event provided an opportunity for participants to share exciting and novel information on Physical Therapy and rehabilitation medicine globally. Some of the discussions highlighted the need for rehabilitation services to be established in countries without access to rehabilitation input for disability management. Discussions also focused on various training curriculums and competencies of rehabilitation trainees from different countries. The overall aim of the panel discussion was to allow participants to share information on ways to develop the rehabilitation workforce in countries which have limited awareness of rehabilitation, encourage interest in the field amongst junior doctors and medical students, as well as to encourage a stimulating network of individuals who have commenced embarking their careers. 

The WYF is currently in process of recruiting one official Country Ambassador from each country, nominated by the National Society, to assist with promoting activities of the Task Force amongst young rehabilitation physicians and trainees. For Australia and New Zealand, Country Ambassadors will be nominated by the Australasian Faculty of Rehabilitation Medicine (AFRM). Applications for general membership are now welcomed, with the number of general members being unlimited.

Eligibility of Country Ambassadors and general members include:

  1. Any current Rehabilitation Medicine Advanced Trainee, Fellows, early-career rehabilitation specialist (up to five years after becoming a specialist), residents or medical students who have an interest in rehabilitation medicine
  2. An active ISPRM individual member in good standing

More information on application eligibility and process is available on the ISPRM website - World Youth Forum of ISPRM. We will be anticipating more future activities in each country (e.g. research, education, workshops, social events), coordinated by each country representative. The next WYF meeting will take place at the ISPRM World Congress 2020 in Orlando, USA and we invite all eligible participants to participate in WYF activities then.

Dr Su Yi Lee
Rehabilitation Physician
Deputy Secretary & Board Member of the ISPRM Task Force - World Youth Forum, Australia

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Report from the Chair - Faculty Policy and Advocacy Committee (FPAC)

Faculty Policy & Advocacy Committee Membership  
    

Name

Position

Dr Greg Bowring

Chair, AFRM President-Elect

Professor Timothy Geraghty

AFRM President

Dr Cassandra McLennan

QLD Representative

Dr Lisa Sherry

VIC/TAS Representative

Dr Tai-Tak Wan

NSW Representative

Dr Rabin Bhandari

SA/NT Representative

Dr Emma-Leigh Synnott

WA Representative

Dr Robin Sekerak

New Zealand Representative

Dr Louis Baggio

Rural and Remote Representative

Dr Monika Hasnat

Paediatric Representative

Dr Angela Wills

Trainee Representative

 
It's been another busy year for FPAC and I would like to thank all members for their significant contributions and commitment to the effective running of the Committee.

FPAC Work Updates

Consideration of mandatory non-metropolitan AFRM training

AFRM FPAC will work closely with the Faculty Education Committee (FEC) continue discussion on the consideration of mandatory non-metropolitan AFRM training. FPAC has agreed that this piece of work should feed into the Advanced Training Curriculum Renewal process.

Australian & New Zealand Hip Fracture Regulatory (ANZHFR) Intention to Collaborate
The CPAC have approved the College entering into an 'Intention to Collaborate' agreement with the Australian and New Zealand Hip Fracture Registry (ANZHFR).

AFRM Position Statement on Bariatric Rehabilitation
Dr Peter Sturgess will lead the Working Party on the development of the 'AFRM Position Statement on Bariatric Rehabilitation'. Dr Sturgess with assistance from the P&A unit will commence preparing the scoping document and expressions of interest for membership will open shortly after.

Guiding principles for the management of patients with multi-resistant organisms (MROs) in rehabilitation units
Dr Rania Abdelmotaleb, has agreed to lead the Working Party. The P&A unit are working to schedule their first meeting in the coming weeks.

Position Statement on Stem Cell Therapy for Children with Cerebral Palsy Working Group
The P&A unit are working with the Faculty office to draft the Terms of Reference and get the EOI process underway.

Review of the Australasian Clinical Indicator Report (ACIR) 20th Edition 2011-2018.
RACP has been invited to comment on the Rehabilitation Medicine Clinical Indicators aggregated data in Full Report 2011-2018.

The review has now been completed and the AFRM Executive and Australasian Rehabilitation Outcomes Centre (AROC) are establishing a new review process for the next edition.

Other matters

The AFRM FPAC has been consulted on the following policy matters: 

The MBS Review
In February 2019 the College was invited to comment on the draft report from the Specialist and Consultant Physician Consultation Clinical Committee of the MBS Review Taskforce. Extensive and multiple consultation has been undertaken from February to June 2019, with all Australian Fellows and trainees through College wide communication channels, and direct to all DFACs and Specialty Societies to develop the draft submission. The draft submission was written in such a way as to be transparent about the consultation process, the range of member views and concerns expressed and caveats (were the recommendations to be adopted). CPAC AC reviewed the final draft submission & formally approved the submission for progression to Board on Monday, 24 June 2019. The Board passed a circular resolution to approve the submission on Wednesday, 26 June 2019. The College provided its final submission to the MBS review taskforce on Thursday, 27 June 2019.

Royal Commission into Aged Care Quality and Safety
The Policy and Advocacy (P&A) Unit is currently drafting a submission and closed consultations at the end of June 2019. The P&A Unit will circulate a final draft for comment before progressing to CPAC.
  • AFOEM-led submission to the NSW State Insurance Regulatory Authority's (SIRA) Consultation on Health professionals and earning capacity decisions in the CTP scheme
  • RACP response to proposed amendments to the Coroners Act 2009 (NSW)
  • Draft RACP submission to MBA consultation on clearer regulation of medical practitioners who provide complementary and unconventional medicine and emerging treatments
  • Heads of Workers’ Compensation Authorities - draft Principles of Practice for Workplace Rehabilitation Providers
  • Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2020-21
  • National air pollution standards consultation
  • Draft Evolve Strategy 2019-21
  • Safe Work Australia Consultation Regulation Impact Statement
  • Standards Australia Consultation - Distribution and Licensing Policy Discussion Paper

Finally, I would particularly like to thank Renata Houen, Policy and Advocacy Officer, supporting FPAC as well as AFRM Executive Officer Stacey Barabash and Joanne Goldrick from the Faculties Office for their support throughout the year.

Dr Greg Bowring
Chair, FPAC
 

Report from the President – AFRM Council

AFRM Council Membership 

Name

Position

Professor Tim Geraghty

AFRM President

Dr Gregory Bowring

AFRM President-elect

Associate Professor Andrew Cole

Immediate Past President

Dr Caitlin Anderson

Faculty Education Committee Chair

Dr Venugopal Kochiyil

SA/NT representative

Dr Richard Seemann

NZ representative

Dr David Eckerman

QLD representative

Dr David Murphy

VIC/TAS representative

Dr Malcolm Bowman

NSW/ACT representative

Dr Jon Ho Chan

WA representative

Dr Lisa Copeland

Paediatric representative

Dr Ashlyn Alex

Trainee representative

 
Firstly, I would like to welcome Dr Krystal Song as the new Editor of Rhaia and thank her very much for agreeing to take on the role. This edition is Krystal’s first and she has approached it with great enthusiasm and commitment so I hope you enjoy it and beware Krystal may be tapping you on the shoulder in the near future to seek your assistance by contributing an article to a future edition of Rhaïa.

2019 seems to be plummeting towards its end at an alarming rate. AFRM Council met in June and August and will have its last meeting of the year in November.

Ongoing matters under discussion by Council include: 

AFRM Value Proposition and Narrative document

Council is continuing to progress the strategy to use this completed document and others to promote the work of rehabilitation medicine physicians and the value that it brings to key stakeholders. A communications toolkit has been developed. Watch this space. For more details, read the narrative document.

Australasian Rehabilitation Outcomes Centre (AROC)

AFRM Executive has been having regular teleconferences with Frances Simmonds and key AFRM Fellows with key roles in AROC. Coming out of those discussions, we developed a plan to improve awareness of AROCs work amongst Fellows, trainees and other stakeholders. You will now find a link to the AROC website and an AROC Fact Sheet on the main page of the Faculty webpage. As well as other activities, this edition of Rhaïa is focused on AROC.

AFRM Clinical Indicators

In liaison with AROC, we are in the very early stages of developing a working party to review the current ACHS Rehabilitation Medicine Clinical Indicators.

Completion of Work Profile on MyRACP

We have recently started a process to encourage Fellows to complete their Work Profile in MyRACP. This is very important to help us understand the current workforce and think about future workforce needs. There are currently very few AFRM Fellows who have completed the workforce profile and I therefore encourage you to do so as soon as possible. Simply login to MyRACP and in the top left hand square you will see ‘Update My Work Profile’. It only takes five to ten minutes. See my Presidents Post in the eBulletin from 20 September for further information.

All the best,

Professor Tim Geraghty
President, AFRM  
 

Report from Chair, AFRM Faculty Education Committee

Introduction and last meeting

The AFRM Education Committee (FEC) had their last meeting on 25 July 2019. The next meeting will be held in November.

AFRM Education Committee Membership

Name

Position

Dr Caitlin Anderson

Chair

Dr Kirily Adam

Lead in Overseas Trained Physicians

Dr Toni Auchinvole

New Zealand Representative

Dr Clayton King

Lead in Continuing Professional Development

Associate Professor Louisa Ng

Lead in Teaching and Learning

Dr Shari Parker

Lead in Assessment

Dr Michael Ponsford

Lead in Physician Education

Associate Professor Adam Scheinberg

Lead in Paediatric Rehabilitation

Dr Angela Wills

Trainee Representative


FEC Membership

Dr Michael Johnson stepped down as Chair of the FEC, with Dr Caitlin Anderson assuming the role. Dr Angela Wills was also nominated as the new Trainee Representative.

The Deputy Chair position is currently vacant, with an expression of interest to be published on the College website shortly.

Committee Memberships

Training (Faculty Training Committee and Faculty Paediatric Training and Assessment Committee)
As of September 2019, there were 245 adult trainees and 11 paediatric trainees of the AFRM.

Accreditation (AFRM Accreditation Sub-Committee)
There are currently 120 Accredited Training Sites for Advanced Training in Rehabilitation Medicine (General and Paediatric combined). 

Assessment (Faculty Assessment Committee)
I would like to thank all of the committed fellows who have taken time to join the committees that sit under the AFRM Education Committee. They donate a considerable amount of their time to ensure the smooth running of the AFRM Education services and the program literally would not be able to function without them. We are also enormously appreciative of the support of Lanica Roventa, our Executive Officer who provides us with expert advice and advocacy. There are always opportunities to contribute to AFRM committees, so please consider it the next time you see an expression of interest.

FEC Work Updates

RACP is running several concurrent training renewal projects which are large in scope and likely to impact training delivery into the future. FEC is working with RACP to help tailor the program changes to ensure that rehabilitation medicine training delivers the best outcomes for trainees and supervisors.

The focus for 2019 is on Curriculum Renewal. The aim of this renewal project is to put a greater focus on competency-based program outcomes throughout the course of training.  While the development of these changes is still in the early stages, it is hoped that the new model of training delivery and assessment will help us continue to ensure our training is fit for purpose and develops expert rehabilitation medicine physicians into the future. Many of the changes are expected to mirror those for Basic Training where the Curriculum Renewal project is further advanced and expected to be rolled out over 2020-2023.

Additional changes are also planned in the supervisor and site accreditation sphere. How this will be implemented for rehabilitation medicine is a work in progress, with any changes to be communicated directly to AFRM Fellows.

There has also been a significant change to the classification of CPD credits for 2019. The purpose of this is to put a greater emphasis on Fellows reflecting on performance aspects of our work. CPD categories are now entered into one of three categories: Educational Activities, Reviewing Performance and Measuring Outcomes with a maximum of 60 points in each category being able to contribute to the 100 point minimum.

Dr Caitlin Anderson
Chair, AFRM Education Committee
 

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