McElligott, Jacinta MB, Bch, BAO; Carroll, A.; Morgan, J.; Macdonnell, C.; Neumann, V.; Gutenbrunner, C.; Fialka-Moser, V.; Christodoulou, N.; Varela, E.; Giustini, A.; Delarque, A.; Assucena, A.; Lukmann, A.; Tuulik-Leisi, V.; Zoltan, D.
From the UEMS PRM Professional Practice Committee (PPC) and National Rehabilitation Hospital, Ireland (JM); the National Rehabilitation Hospital, Ireland (AC, JM); CARF International (CM); UEMS PRM Professional Practice Committee, United Kingdom (VN); UEMS PRM Professional Practice Committee, Germany (CG); UEMS PRM Professional Practice Committee, Austria (VF-M); UEMS PRM Professional Practice Committee, Cyprus (NC); UEMS PRM Professional Practice Committee, Spain (EV); UEMS PRM Professional Practice Committee, Italy (AG, AA); UEMS PRM Professional Practice Committee, France (AD); UEMS PRM Professional Practice Committee, Estonia (AL, VT-L); and UEMS PRM Professional Practice Committee, Hungary (DZ).
All correspondence and requests for reprints should be addressed to Jacinta McElligott, MB, Bch, BAO, National Rehabilitation Hospital, Rochestown Avenue, Dun Laoghaire Co, Dublin, Ireland.
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
This commentary is being published in cooperation with the European Journal of Physical and Rehabilitation Medicine as part of a collaborative project that started in 2008.
In Europe, rehabilitation in traumatic brain injury (TBI) is recognized as essentially a holistic, multidisciplinary, and educational process, which acknowledges that rehabilitation after head injury is a long-term process with many impairments, particularly in the cognitive domain, and may require 2 yrs or more to achieve maximum recovery.1 Multidisciplinary team (MDT) interventions provide the essence and foundation of rehabilitation service delivery, and "team working" within rehabilitation practice in Europe is valued and indeed recognized as the preferred strategy essential to optimizing patient outcomes especially for those patients with complex impairments, activity limitations, and participation restrictions often associated with TBI.
The importance of MDTs and interdisciplinary teams (IDTs) in European physical and rehabilitation medicine (PRM) practices was highlighted at the Union of European Medical Specialist, Physical and Rehabilitation Medicine Section (UEMS PRM) meeting in Riga Latvia in 2008. The UEMS PRM is the representative body of PRM medical specialists concerned with rehabilitation medical specialist training, continuing medical education, medical specialty practice autonomy, and other aspects of professional practice. The UEMS PRM is organized through three component committees: the UEMS PRM of the board, the Clinical Affairs Committee, and the Professional Practice Committee (Fig. 1).
In addition to guiding and developing rehabilitation services at a national level, PRM specialists in Europe have an opportunity to influence rehabilitation service delivery and development across Europe through participation in the UEMS PRM. The UEMS PRM includes PRM physician delegates from each of the member states within the European Union (EU) and meets biannually. The UEMS PRM plays a key role in the development and harmonization of rehabilitation services in Europe, a considerable challenge given that the EU now includes 27 countries with diverse cultural, political, social, and economic backgrounds.
As a follow-up to the UEMS PRM meeting in Latvia in 2008, the UEMS PRM Professional Practice Committee published a special report on IDTs working in PRM in the Journal of Rehabilitation Medicine.2 The overwhelming view within this working group of European PRM specialists is that team working, especially "interdisciplinary working," is the preferred pattern and that "team working" plays a crucial role in PRM. Team working is considered essential for many reasons, including the need for a broad range of knowledge and skills required to diagnose and assess complex impairments, activity limitations, and participation restrictions; select treatment options; coordinate varied interventions to achieve agreed goals; and critically evaluate and revise plans/goals to respond to changes in the patients' health and function. In a review of the scientific evidence supporting the effectiveness of MDT working, Neumann et al.2 also note that the evidence is strongest for cerebrovascular disease; however, two studies on MDT working and brain injury were noteworthy. In one randomized controlled trial study of community-based brain injury MDT working vs. information only,3 the MDT intervention was better than information alone. In another quasi-random study by Semylen et al.,4 MDT interventions for severe TBI compared with standard hospital care reported better clinical outcomes and less distressed carers. It was the opinion of the UEMS PRM Professional Practice Committee that the evidence from published scientific literature indicated that PRM programs with MDTs achieve better result and that there was a very strong case for recommending MDTs and IDTs working within PRM programs in Europe.
REHABILITATION MDT INTERVENTIONS ACUTE TO COMMUNITIES IN EUROPE
Ireland is good example of how MDT interventions are used effectively in European countries across the spectrum of healthcare delivery for the acute, postacute, and livelong management of complex impairment, activity, and participation restrictions associated with TBI.
There is limited trauma system development in Ireland, and in the acute phase, most TBI patients requiring neurosurgical services are transported to one of two centers and returned to a regional acute hospital, where the MDT rehabilitation interventions may be limited or variable. Those patients with severe TBI requiring acute inpatient rehabilitation are admitted to the National Rehabilitation Hospital. The National Rehabilitation Hospital is the only acute inpatient interdisciplinary rehabilitation program for TBI and serves the Republic of Ireland, a population of approximately 4 million people. The National Rehabilitation Hospital is a Comprehensive Accredited Rehabilitation Facility for its brain injury, spinal cord injury, and amputee programs. Rehabilitation care is delivered through IDTs and MDTs led by PRM consultants. The National Rehabilitation Hospital provides IDT and MDT inpatient, outpatient, and vocational rehabilitation services, and telerehabilitation is used to liaise with services to other cities and rural areas.
Rehabilitation MDT interventions in Ireland are also available across a complex spectrum of patients and over extended periods in the community and include programs for vegetative and minimally conscious patients and neurobehavioral, residential, and vocational and community-based MDT brain injury rehabilitation and residential programs. Rehabilitation MDT service delivery in Ireland are mostly publicly funded, but private and voluntary organizations also play a role especially in community-based residential and long-term care.
Unfortunately, although Ireland PRM practicing clinicians have an opportunity to lead highly skilled and professional MDTs, the availability of and access to appropriate services for patients with TBI are limited. Ireland has the lowest number of PRM specialist per capita in Europe, with just six rehabilitation consultants for a population of more than 4 million. In addition, Ireland has no designated or resourced trauma 1 centers, and services for TBI patients are not yet organized around trauma system development. PRM specialists in Ireland continue to struggle with the Health Service Executive to advocate for TBI national service development.
In most countries in Europe, PRM specialists play a key role in the development of rehabilitation services. For example, the National Institute of Medical Rehabilitation in Hungary established three special rehabilitation services for stroke, spinal cord injury, and TBI in the seventies. These specialized centers are resourced with specialized teams for patients with multifactorial impairments associated with TBI. Zoltan Denes at the National Institute for Medical Rehabilitation in Budapest has noted that there has been significant improvement in the outcome of patients with severe TBI in Hungary in the last 20 yrs and that one-third of patients with severe TBI are now treated in these specialized centers.
FACTORS INFLUENCING REHABILITATION MDT SERVICE DELIVERY AND OUTCOME IN TBI IN THE CONTEXT OF THE EU
The motto of the EU is "United in Diversity," and historically, the EU is founded on an economic and political union of 27 member states (Fig. 2), and there are 23 official and working languages across the member states. The core objectives of the EU remain one of integrating Europe as an "economic community" with the development of a common or single market with the free circulation of goods, capital, people, and services. The EU's population is now 7.3% of the world total; however, the EU covers just 3% of the earth's land, making the EU one of the most densely populated regions of the world. One-third of people in the EU live in cities of more than a million people, and 80% live in urban areas.
In addition to cultural, language, and ethnic differences among the member states in Europe, there are considerable economic disparities and differences in health systems and health system infrastructure. In areas of research, education, and health, the EU has often a limited role in supporting national governments, and the substantial epidemiologic and economic disparities have been found to influence the quality of care and outcome in TBI populations in Europe.
EPIDEMIOLOGY AND TBI IN EUROPE
Epidemiologic studies in Europe have identified that there is a significant association between the economic status of the countries in Europe and the health system development and outcome of patients with TBI. Tagliaferri et al.5 published a review article that included a compilation of 23 European epidemiologic studies from 1980 to 2003. Fourteen European countries were included, including national studies from Denmark, Sweden, Finland, Portugal, and Germany and regional studies from Norway, Sweden, Italy, Switzerland, Spain, Denmark, Ireland, and the United Kingdom. An aggregate hospitalized plus fatal TBI rate within these studies was estimated at 235 per 100,000, with a derived average mortality rate of about 15 per 100,000 and case fatality rate of 11 per 100. The authors report that it was difficult to reach a consensus across the European studies because there were critical differences in research methodology, the external cause of the TBI varied considerably in line with the economic and political factors, and the health system of different countries affected the quality of care and outcomes for patients in different countries in Europe.
ECONOMIC FACTORS, TRAUMA SYSTEMS, AND OUTCOME OF TBI IN EUROPE
Mauritz et al.,6 in a prospective multicenter study, tested the hypothesis that the economic status of regions across Europe would influence the quality of care and outcome of patients with severe brain injuries. In this study, treatment and outcome data relating to 1172 patients with severe TBI were collected from 13 centers in Europe. The centers were classified as "high income" (HI; five centers in Austria), "upper middle income" (UMI; six centers in Croatia and Slovakia), or "lower middle income" (LMI; two centers in Bosnia and Macedonia). Data on accident, treatment, outcome, and quality of care were collected and compared across the high, middle, and lower economic group classifications.
There was a significant difference in epidemiologies, treatments, and outcomes between the HI and LMI centers. Patients treated through the HI and UMI centers were older, and more women were admitted to the HI and UMI centers than to the LMI centers. The HI centers admitted fewer students and more retired people. Low-level falls and motor vehicle accidents contributed to more than two-thirds of the trauma-related TBI in each of the centers; however, violence, both blunt and penetrating, was a significantly more frequent cause of TBI in UMI and LMI centers. The rate of patients transported by helicopter was highest in the HI centers, and the HI centers received most of their patients directly from the scene of accident, whereas the other centers had a significantly higher rate of secondary transfers. With regard to quality of care, the number of available nurses per intensive care unit bed decreased significantly with decreasing wealth; also, LMI centers most frequently reported no funding for intracranial pressure monitoring catheters, although the necessary monitors were available. The expected mortality rate was lower in HI centers and the UMI centers but 13% higher than expected in the LMI centers. International and European Brain Injury Consortium guidelines7 were most closely adhered to in the HI and UMI centers compared with the LMI centers; however, adherence to guidelines was nearly impossible in regional health systems that lacked the economic support to provide efficient prehospital care, rapid transport, and high-level hospital care.
In summary, in Europe as in other countries, a well-funded healthcare system at a national level is necessary for successful implementation of the guidelines for TBI management, and this study is similar to other international studies in that outcomes after TBI depended on age, neurologic status, trauma severity, and quality of care. Furthermore, this study demonstrated a significant association between the economic status of the countries in Europe and the outcome of patients with severe TBI.
EUROPEAN MODELS OF MDT REHABILITATION IN TBI
Despite the diversity and differences in economic and political climates within European countries, the value and effectiveness of MDT working within rehabilitation service delivery for TBI are valued and recognized as effective in rehabilitation service delivery for patients with TBI. The disparate economic and healthcare systems in different countries in Europe have been shown to influence the quality of care and outcomes in TBI, and PRM specialists in Europe play a key role in influencing and advocating for rehabilitation TBI service development within their national health systems; in addition, as delegates to the UEMS PRM committee, PRM specialists have opportunities to participate in leading and harmonizing the future development of rehabilitation services across the European community, including the development of health systems that ensure that all patients with TBI have the benefit of effective MDT and IDT rehabilitation interventions.
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