Review question and objective
What is the effectiveness of collaborative care models in facilitating rehabilitation of a traumatic injury?
The objective of this systematic review is to investigate the effectiveness of collaborative care models in relation to traumatic injury rehabilitation.
Trauma is the most frequent cause of significant functional impairment and mortality that leads to the deterioration in health and a delayed functional and psychosocial recovery.1,2 The unmet rehabilitation needs can prolong discharge, limit one's activities and restrict participation, decrease quality of life and increase dependence on significant others.3 Trauma has socioeconomic implications that have a significant impact on the cost of healthcare related to lost economic opportunity and the costs burden of rehabilitation.2 In fact, in 2000–2001 Australia spent $4 billion on trauma survivors.4 As such, for those who sustain traumatic injuries, effective rehabilitation is critical to regain both function and independence to ensure a quality of life. Effective interventions that are developmentally appropriate are in need of justification.
Wade defines rehabilitation as “a problem solving educational process aimed at reducing disability and increasing participation experienced by someone as a result of disease or injury”.5(p. 11) The loss of both function and independence can be physically limiting, requiring aggressive rehabilitation to improve functionality and quality of life.6,7,8 The goals of rehabilitation include optimal restoration of function, an acceptable appearance, reintegration into society and the return to gainful employment.9,10 The foremost principal of rehabilitation is on “reducing symptoms and limitations at the level of activity and participation, and includes personal and environmental factors”2(p. 89) with the eventual goal of returning the patient to their pre-injury functional status. Central to this goal is optimal delivery of rehabilitation to improve functional outcomes for those capable of actively participating in an intense physical rehabilitation program.11 However, delivering and measuring effectiveness of rehabilitation is a challenging task concerning populations that have complex conditions.12 It is doubtful that there will be a definitive clear focus for interventions, and therefore this creates difficulties around defining and measuring rehabilitation outcomes.12
Fundamentally, rehabilitation of those with traumatic injuries surpasses the acute management extending into the reintegration of patients home and the wider community.2,13 Consequently, rehabilitation from a traumatic injury is a multidisciplinary approach that incorporates the continuum of care across different settings and organizations. Rehabilitation of those with a traumatic injury is an expensive and resource intensive exercise, demanding substantial commitment from a broad spectrum of health care professionals.11 The use of collaborative care models in health care are reported to be a feasible and effective approach for improving the quality of care and outcomes.14 Therefore, this calls for an appropriate model of collaborative care that facilitates the coordination and collaboration throughout the rehabilitation journey.
Collaborative care entails:
“…physicians and other providers using complementary skills, knowledge and competencies and working together to provide care to a common group of patients based on trust, respect and an understanding of each other's' skills and knowledge. This involves a mutually agreed upon division of roles and responsibilities that may vary according to the nature of the practice personalities and skill sets of the individuals. The relationship must be beneficial to the patient, the physician and other providers.”15(p. 3)
The collaborative care model is “an evidence-based approach for integrating physical and behavioral health services”16(p. 1) and have the potential to improve access to care; enhance the quality, safety, coordination and efficiency of care; and enhance provider morale and reduce the incidence of burnout within health professions.15 However, collaborative care is an example of a complex intervention involving a number of separate processes where the active constituent is difficult to identify.17 Legault et al.18 demonstrated the difficulties inherent in collaborative care are independent of the patient population being cared for. Despite these difficulties, Katon et al.19 demonstrated that long term effectiveness of a collaborative care intervention among patients with depression are associated with improved outcomes with no evidence of an increase in total healthcare costs. Furthermore, Legault et al.18 found that on examination of the literature concerning collaborative care across sectors of health care, studies suggest the effectiveness of collaboration on the provision of better patient care, improved clinical outcomes and improved patient satisfaction.
The authors wish to emphasize that the initial intention of the systematic review was to investigate burns rehabilitation models of care. Holavanahalli et al.20 stated that there are opportunities that exist for the developing a common document for practice guidelines in rehabilitation of burns; and for collaborative studies that evaluate treatment interventions and outcomes. However, our scoping search found a lack of literature concerning models of care and burns rehabilitation and therefore it was necessary to look at the broader literature relating to rehabilitation and traumatic injuries.
Despite the implementation of systems for improvement of the coordination and organization of care, rehabilitation services are currently not consistently recognized as essential to care.2 A patient's rehabilitation journey through the health care system is influenced by clinical and system processes across the continuum of care.21 Fundamentally, rehabilitation is an expensive resource and the much needed evidence to support its justification is required; however, the issues in study design and research methodology are challenging.2 A recent review by Khan et al.2 highlighted the lack of high-quality studies for effective multidisciplinary rehabilitation in survivors of trauma in terms of the types of rehabilitation setting, duration of therapy, lack of effective care pathways and long-term functional and psychosocial outcomes.
Rehabilitation models of care are delivered across the continuum of care delivery settings that include acute inpatient, sub-acute inpatient and ambulatory care settings including day hospital centre based services, outpatient clinic services and home-based services.22 A working definition of a model of care has been defined as:
“…a multifaceted concept, which broadly defines the way in which health care is delivered including the values and principles; the roles and structures; and the care management and referral processes. Where possible the elements of a model of care should be based on best practice evidence and defined standards and provide structure for the delivery of health services and a framework for subsequent evaluation of care.”22(p. 3)
Significant improvements in the coordination of care have reduced patient mortality; however this does not extended to include rehabilitation services.2 As such, collaborative integrated practice models are required especially relating to those with psychological, occupation, family and social reintegration issues that involve ongoing education and support for survivors, including the multidisciplinary teams.2 It has been reported that collaborative care interventions are effective; however, it still needs to be established which aspects of this complex intervention are essential.23 Therefore, it is the aim of this systematic review to establish the effectiveness of collaborative care models that facilitate rehabilitation from a traumatic injury.
The authors of the current systematic review proposal wish to draw attention to an existing systematic review recently published by Khan et al.2 This review focuses specifically on interdisciplinary and multidisciplinary rehabilitation in patients with multiple traumas as opposed to the systematic review the current authors are proposing which will have a broader focus on traumatic injuries that require rehabilitation across multiple settings as opposed to within the acute setting with an emphasis on nature of rehabilitation rather than the type of trauma as described in the review by Khan.2 In addition, that systematic review specifically excluded burns, which is an area of interest that this systematic review will endeavour to explore.
Types of participants
This review will consider all studies that include adult patients with a traumatic physical injury requiring rehabilitation across settings/organizations above 18 years of age and of either gender. Studies focusing on pediatric or adolescence populations will be excluded from the review as their needs differ from those in the adult population. Such injuries include:
- Spinal cord Injuries
- Traumatic head injuries.
- Traumatic brain injuries
- Polytrauma/ multiple trauma
Types of intervention(s)
Interventions will be those related to the determination of models of collaborative care that facilitate those rehabilitating from a traumatic physical injury across the different care types and settings including acute and sub-acute hospitals, ambulatory care, community-based centres and home care. Examples of the central elements of these models include care navigators, or care coordinators who are an integral component of rehabilitation and negotiate the implementation of rehabilitation across services. Comparison interventions are expected to be current care or ‘usual care’ (a term used to describe the full spectrum of current patient care practices) will be the control arm in order to analyze any comparisons.
Types of outcomes
Coordination is required to ensure the continuity of care when more than one setting is involved in rehabilitation.24 The aim of coordinated rehabilitation is the improvement of functional outcomes and reduction of costs.3 The International Classification of Functioning has shifted the focus from “cause of injury” to “impact of injury”. “By shifting the focus from cause to impact, it places all health conditions on an equal footing allowing them to be compared using a common metric - the ruler of health and disability.”25(p. 3)
The specific outcomes that are of interest include, but are not confined to the following:
- Return to employment
- Scales of community integration (e.g. Community Integration Questionnaire)
- Functional Independence measure
- Functional Assessment Measure
- Disability Rating Scale
- Barthel's Index
- Quality of life
- Self-perception of Confidence
- Hospital Anxiety and Depression Scale
- Mini-mental State Examination
- Goal Attainment Scale (GAS). The potential acceptability and appropriateness of GAS as a routine outcome measure for rehabilitation is supported as a validated tool.12
Types of studies
This review will consider any RCT that demonstrates the effectiveness of collaborative models of care that facilitate the rehabilitation process of those with a traumatic injury. In the absence of RCTs, other research designs such as non-randomized controlled trials and other lower level comparative studies will be considered. Descriptive/observational studies without comparator will only be included in the absence of comparative studies.
The search strategy aims to find both published and unpublished studies. The search strategy will be designed to capture published and unpublished research without language restrictions. The authors have access to a network of non-English language colleagues who are able to assist with translation. No limits by publication date will be imposed on the systematic review. A three phase search strategy will be conducted. An initial scoping search of the PubMed and CINAHL databases will be conducted to identify keywords and phrases within the abstracts and titles and to identify index terms used that are used to describe papers. Thereafter, a second extensive search will be conducted that incorporate all keywords, phrases and index terms identified. This will be followed by the third phase of searching the reference lists of all relevant paper that were not capture in the comprehensive search.
Initial search terms will be:
multiple wound* OR multiple injur* OR polytrauma* OR trauma* wound* OR multiple trauma OR multiple trauma* OR burn* OR thermal injur* OR burn* OR injury severity score OR spinal cord injur* OR brain injur* OR trauma severity indices OR TBI OR traumatic brain injury
integrated health care OR trauma system model* OR integrated care OR international classification of functioning, disability and health OR collaborative care OR model of care OR models of care OR care navigat* OR case manage* OR continuity of care OR continuum of care OR managed care OR delivery of health care OR patient navigat* OR patient-centered care OR patient-centred care OR primary health care OR tertiary healthcare OR discharge planning OR model* OR telemedicine OR telehealth
recovery of function* OR social reintegration OR social integration OR pain management OR activities of daily living OR social participation OR independent living OR employ* OR goal* OR social support OR psychosocial OR return to work OR vocational rehabilitation OR quality of life
The data bases to search will incorporate:
- Cochrane Central Register of Controlled Trials
- Latin American and Caribbean of Health Sciences Information System (LILACS)
- Allied and Complementary Medicine
- Physiotherapy Evidence Database
- Dissertation Abstract International
- ProQuest Dissertations and Theses
Papers will be assessed for relevance utilizing the title, abstract and index terms including papers found from searching reference lists of relevant papers.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review, using the standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI, Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer. In the absence of RCTs, evaluating other research designs such as non-randomized controlled trials JBI's Critical Appraisal Checklist for Comparable Cohort/ Case Control will be utilized.
Data will be extracted using the MAStARI Data Extraction Instruments - JBI Data Extraction Form for Systematic Review of Experimental/Observational Studies (Appendix II). In the event that there is missing data, the authors of this systematic review will endeavour to contact the author(s) of the paper in question to seek clarification.
Where possible, quantitative research study results will be pooled in statistical meta-analysis using Review manager software JBI MAStari software. Where necessary, sub group analysis will be performed on heterogeneous groups such as different population groups or models of care. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form.
Conflicts of interest
No conflict of interest.
Anne Darton, Statewide Burn Injury Service Network Manager. Agency for Clinical Innovation
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Appendix I: Appraisal instruments
MAStARI appraisal instrument
Appendix II: Data extraction instruments
MAStARI data extraction instrument