Dataset Information

Post-fracture rehabilitation pathways and association with mortality among adults with cerebral palsy.

ABSTRACT:

Objective

Rehabilitation may mitigate the high mortality rates and health declines post-fracture for adults with cerebral palsy, but this is understudied. The objectives were to characterize the post-fracture rehabilitation pathways and identify their association with 1-year survival among adults with cerebral palsy.

Methods

A retrospective cohort study of adults with cerebral palsy with a fragility fracture with continuous health plan enrollment ≥1-year prior to and ≥1 day after their fracture date was performed using a random 20% Medicare fee-for-service dataset. Participants were categorized as a home discharge or inpatient rehabilitation admission post-fracture. For the home discharge cohort, weekly exposure to outpatient physical/occupational therapy (PT/OT) was examined up to 6-month post-fracture. Cox regression examined the association between time-varying PT/OTuse within 6-month post-fracture and mortality from 30 days to 1-year post-fracture before and after adjusting for confounders (e.g. medical complexity).

Results

Of 3598 adults with cerebral palsy with an incident fragility fracture, 74% were discharged home without inpatient rehabilitation; they were younger, but more medically complex compared to the 26% admitted to inpatient rehabilitation. Among the home discharge cohort (n = 2662), 43.1% initiated PT/OTwithin 6-month post-fracture, and cumulative PT/OTexposure post-fracture was associated with improved survival; for example, per 3 weeks of PT/OTexposure, the adjusted mortality rate was 40% lower (95% confidence interval (CI) = 0.41-0.89).

Conclusions

Most adults with cerebral palsy with a fragility fracture were discharged home rather than to inpatient rehabilitation, and only 43.1% of that group initiated outpatient PT/OTwithin 6 months post-fracture. Receiving outpatient PT/OTwas associated with improved 1-year survival.

SUBMITTER: Whitney DG

PROVIDER: S-EPMC10150496 | biostudies-literature | 2023 Jan

REPOSITORIES: biostudies-literature

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Publications

Post-fracture rehabilitation pathways and association with mortality among adults with cerebral palsy.

Whitney Daniel G DG Xu Tao T Ryan Dayna D Whibley Daniel D Caird Michelle S MS Hurvitz Edward A EA Haapala Heidi H

Clinical rehabilitation 20220829 1

<h4>Objective</h4>Rehabilitation may mitigate the high mortality rates and health declines post-fracture for adults with cerebral palsy, but this is understudied. The objectives were to characterize the post-fracture rehabilitation pathways and identify their association with 1-year survival among adults with cerebral palsy.<h4>Methods</h4>A retrospective cohort study of adults with cerebral palsy with a fragility fracture with continuous health plan enrollment ≥1-year prior to and ≥1 day after ...[more]

PMID: 36039504

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Project description:BackgroundIndividuals with cerebral palsy (CP) manifest skeletal fragility problems early in life, are vulnerable to non-trauma fracture (NTFx), and have a high burden of premature mortality. No studies have examined the contribution of NTFx to mortality among adults with CP. The purpose of this study was to determine if NTFx is a risk factor for mortality among adults with CP and if NTFx exacerbates mortality risk compared to adults without CP.MethodsData from 2011 to 2016 Optum Clinformatics® Data Mart and a random 20% sample Medicare fee-for-service were used for this retrospective cohort study. Diagnosis codes were used to identify adults (18+ years) with and without CP, NTFx, and pre-NTFx comorbidities. Crude mortality rates per 100 person years were estimated. Cox regression estimated hazard ratios (HR and 95% confidence interval [CI]) for mortality, comparing: (1) CP and NTFx (CP + NTFx; n = 1777); (2) CP without NTFx (CP w/o NTFx; n = 12,933); (3) without CP and with NTFx (w/o CP + NTFx; n = 433,560); and (4) without CP and without NTFx (w/o CP w/o NTFx; n = 6.8 M) after adjusting for demographics and pre-NTFx comorbidities.ResultsThe 3-, 6-, and 12-month crude mortality rates were highest among CP + NTFx (12-month mortality rate = 6.80), followed by w/o CP + NTFx (12-month mortality rate = 4.91), CP w/o NTFx (12-month mortality rate = 2.15), and w/o CP w/o NTFx (12-month mortality rate = 0.49). After adjustments, the mortality rate was elevated for CP + NTFx for all time points compared to CP w/o NTFx (e.g., 12-month HR = 1.61; 95%CI = 1.29-2.01), w/o CP + NTFx (e.g., 12-month HR = 1.49; 95%CI = 1.24-1.80), and w/o CP w/o NTFx (e.g., 12-month HR = 5.33; 95%CI = 4.42-6.44). There were site-specific effects (vertebral column, lower extremities) on 12-month mortality.ConclusionsNTFx is associated with an increase of 12-month mortality risk among adults with CP and compared to adults without CP. Findings suggest that NTFx may be a robust risk factor for mortality among adults with CP.

Project description:BackgroundFor adults with cerebral palsy (CP), fragility fractures may be a risk factor for pneumonia, a leading cause of death for this population; yet, the timing and complications are unknown. The objectives were to determine the 30-day pneumonia rate post-fracture and its association with mortality and incident cardiovascular events among adults with CP.MethodsThis retrospective cohort study used nationwide administrative claims data from 01/01/2012-12/31/2017 from a random 20% sample of the Medicare fee-for-service and Optum Clinformatics® Data Mart. Cohorts included ≥18 years of age with CP with an incident fragility fracture (CP + Fx) and comparison cohorts: CP without fractures (CPw/oFx) and without CP with an incident fragility fracture (w/oCP + Fx). Incidence rate (IR) of pneumonia 30-days post-fracture and IR ratios were estimated by age group: 18-40, 41-64, and ≥ 65 years. For CP + Fx, Cox regression examined the association between time-varying pneumonia (within 30-days post-fracture) with mortality and incidence of cardiovascular events 0-30-days and 31-365-days post-fracture.ResultsThere were 3688 CP + Fx (mean [SD] age, 58.2 [14.9]; 56.4% women), 29,429 CPw/oFx (50.3 [15.8]; 45.9% women), and 363,995 w/oCP + Fx (65.9 [18.3]; 65.5% women). The IR of 30-day pneumonia for CP + Fx was similar across age groups (IR per 100 person-months, 8.4-11.0) and 1.77-16.18-fold higher (all P < 0.05) than comparison cohorts. Peri/post-fracture pneumonia was associated with an increased rate of mortality (30-day-adjusted HR [aHR] = 5.89, 95%CI = 3.54-9.81; 31-365-day aHR = 2.89, 95%CI = 2.13-3.92), congestive heart failure 0-30-days (aHR = 3.64, 95%CI = 2.01-6.57) and 31-365-days (time-dependent), myocardial infarction 31-365-days (aHR = 2.03, 95%CI = 1.11-3.71), and cerebrovascular disease 0-30-days (time-dependent), without evidence of effect modification by age, sex, or fracture site.ConclusionsAdults with CP are particularly vulnerable to 30-day risk of post-fracture pneumonia and its complications across the adult lifespan and not just in the elderly years.

Project description:ObjectiveThe objective of this study was to assess the rehabilitation status and factors associated with rehabilitation service utilisation among children with cerebral palsy (CP) in Bangladesh.Materials and methodsThis is a population-based surveillance study conducted among children with CP registered in the Bangladesh CP Register (BCPR), the first population-based register of children with CP aged <18 years (y) in Bangladesh. Children with CP were identified from the community using the key informant method and underwent a detailed neurodevelopmental assessment. Socio-demographic, clinical and rehabilitation status were documented. Unadjusted and adjusted analyses with a 95% confidence interval (CI) were used to identify potential predictors of rehabilitation service uptake.ResultsBetween January 2015 and December 2019, 2852 children with CP were registered in the BCPR (mean (standard deviation, SD) age: 7 y 8 months (mo) (4 y 7 mo), 38.5% female). Of these, 50.2% had received rehabilitation services; physiotherapy was the most common type of service (90.0%). The mean (SD) age at commencement of rehabilitation services was 3 y 10 mo (3 y 1 mo). The odds of not receiving rehabilitation was significantly higher among female children (adjusted odds ratio (aOR) 1.3 [95% CI: 1.0-1.7], children whose mothers were illiterate and primary level completed (aOR 2.1 [95% CI: 1.4-3.1] and aOR 1.5 [95% CI: 1.1-2.1], respectively), fathers were illiterate (aOR 1.9 [95% CI: 1.3-2.8]), had a monthly family income ~US$ 59-118 (aOR: 1.8 [95% CI: 1.2-2.6]), had hearing impairment (aOR: 2.3 [95% CI: 1.5-3.5]) and motor severity (i.e. Gross Motor Function Classification System level III (aOR: 0.6 [95% CI: 0.3-0.9]) and level V (aOR: 0.4 [95% CI: 0.2-0.7])).ConclusionsRehabilitation status was poor among the majority of the children with CP in the BCPR cohort, limiting their opportunities for functional improvement. A community-based rehabilitation model focusing on socio-demographic and clinical characteristics should be a public health priority in Bangladesh.

Project description:AIM:To compare mortality rates for cardiovascular disease, cancer, and respiratory disease between adults with cerebral palsy (CP) and the general population. METHOD:A cohort study was conducted using data from adults with CP in England, identified through a primary care data set (the Clinical Practice Research Datalink), with linked data on death registrations from the Office for National Statistics. Cause of death was categorized according to International Classification of Diseases codes. Standardized mortality ratios (SMRs) were calculated to compare mortality rates between adults with CP and the general population, adjusted for age, sex, and calendar year. RESULTS:Nine hundred and fifty-eight adults with CP were identified (52.5% males, 47.5% females; median age at start of follow-up 31y [interquartile range 22-43y]) and followed for a total of 7693 person-years. One hundred and forty-two patients (15%) died during follow-up. Adults with CP had an increased risk of death due to cardiovascular disease (SMR: 3.19, 95% confidence interval [CI] 2.20-4.62) and respiratory disease (SMR: 13.59, 95% CI 9.89-18.67), but not from malignant neoplasms (SMR: 1.42, 95% CI 0.83-2.45). INTERPRETATION:We found that adults with CP in England have increased risk of death due to diseases of the circulatory and respiratory systems, supporting findings from two studies that compared cause-specific mortality rates between adults with CP in the USA and the general population. Further research is required into primary and secondary prevention of cardiovascular and respiratory disease in people with CP worldwide. WHAT THIS PAPER ADDS:Adults with cerebral palsy (CP) in England have 14-fold increased risk of mortality due to diseases of the respiratory system. They have a 3-fold increased risk of mortality due to diseases of the circulatory system. Adults with CP had an increased risk of death due to cerebrovascular disease and ischaemic heart disease. The elevated risk of ischaemic heart disease, however, did not reach statistical significance at the 5% per cent level.

Project description:ObjectiveFragility fractures are associated with an increased risk of pneumonia, which is a leading cause of death in adults with intellectual disabilities; however, the timing and complications of post-fracture pneumonia are underinvestigated. The objectives of this study were to determine the 30-day pneumonia rate post-fracture and the association of post-fracture pneumonia with mortality and cardiovascular events among adults with intellectual disabilities.MethodsThis retrospective cohort study was conducted using Medicare and commercial claims from 01 January 2011 to 31 December 2016. Incidence of pneumonia 30 days after a fragility fracture among adults ≥18 years old with intellectual disabilities (Fx cohort) was compared to the incidence among matched adults with intellectual disabilities without fractures (w/oFx cohort) and the general population of patients with an incident fragility fracture (GP+Fx). For the Fx cohort, Cox regression was used to examine the adjusted association of time-varying pneumonia (within 30 days post-fracture) with mortality and incidence of cardiovascular events 0-30, 31-365, and 366-730 days post-fracture.ResultsThere was a high-early rate of pneumonia within 30 days post-fracture for young, middle-aged, and elderly adults with intellectual disabilities (n = 6,183); this rate was 2.2- to 6.1-fold higher than the rate among the w/oFx (n = 12,366) and GP+Fx (n = 363,995) cohorts (all P < 0.05). For the Fx cohort, post-fracture 30-day incidence of pneumonia was associated with an increased 30-day rate of mortality (adjusted HR [aHR] = 5.19; 95% confidence interval [CI] = 3.68-7.32), heart failure (aHR = 2.96; 95% CI = 1.92-4.56), and cerebrovascular disease (aHF = 1.48; 95% CI = 0.93-2.35; P = 0.098), with sustained effects to 1 year for heart failure (aHR = 1.61; 95% CI = 1.19-2.17) and 2 years for mortality (aHR = 1.39; 95% CI = 1.06-1.83), and without evidence of effect modification by age.DiscussionAdults with intellectual disabilities are vulnerable to post-fracture pneumonia within 30 days, and complications arising from this, across the adult lifespan, and not only during the elderly years.

Project description:ObjectiveFragility fractures are common among adults with cerebral palsy (CP), but clinical rehabilitation use after fracture and its effect on long-term health outcomes have not been sufficiently studied. The objectives of this study were to identify patterns of the use of physical therapy, occupational therapy, or both in the 6-month postfracture period and the association with 3-year mortality in adults with CP.MethodsThis retrospective cohort study included adults who were ≥18 years old, had CP, and had sustained an incident fragility fracture between January 1, 2014, and December 31, 2016, as identified from a random 20% Medicare fee-for-service dataset. Six-month outpatient physical therapy or occupational therapy use patterns after fracture were identified using group-based trajectory modeling. Cox regression determined the association between physical therapy or occupational therapy use trajectory patterns and mortality from 6 months to 3 years after fracture, adjusting for confounders. Effect modification by key characteristics was tested, including age, sex, and the modified Whitney Comorbidity Index (mWCI), which is a CP-specific comorbidity index that better captures overall medical complexity.ResultsOf the 2429 participants included, the majority (73.2%) were characterized as having little to no probability of physical therapy or occupational therapy use, whereas 16.0 and 10.7% were characterized as having early initiation and later initiation, respectively. Compared to the mortality rate for the little to no physical therapy or occupational therapy group, the mortality rates were 26% lower for the early physical therapy or occupational therapy initiation group (hazard ratio [HR] = 0.74; 95% CI = 0.55-1.00) and were 20% lower for the later initiation group (HR = 0.80; 95% CI = 0.57-1.12). There was effect modification by the mWCI. The mortality rate was lower when the early initiation and later initiation groups were compared to the little to no initiation group across all mWCI values examined (median and interquartile range), but the effect was stronger (ie, lower mortality rate) for lower mWCI values for both early initiation and later initiation groups.ConclusionMost adults with CP underutilize outpatient physical therapy or occupational therapy services within 6 months postfracture. Early or later initiation versus little to no physical therapy or occupational therapy use was associated with a lower HR of mortality, although the effect was stronger and statistically significant among those with less medical complexity.ImpactThroughout their lives, the use of rehabilitation services in individuals with CP, including physical therapy and occupational therapy, dramatically declines despite the need for continued rehabilitation across their lifespans. This study characterized longitudinal physical therapy or occupational therapy use patterns in the 6 months following a fragility fracture among adults with CP and found that nearly 3 in 4 adults with CP had little to no physical therapy or occupational therapy use during this critical window to optimize postfracture health and function. Further, those who more regularly used physical therapy or occupational therapy services, regardless of the timing of initiation (early vs later), had significantly improved survival up to 3 years after fracture, suggesting the need for greater access to and delivery of clinical rehabilitation services.

Dataset Information

Post-fracture rehabilitation pathways and association with mortality among adults with cerebral palsy.

Objective

Methods

Results

Conclusions

Publications

Post-fracture rehabilitation pathways and association with mortality among adults with cerebral palsy.

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