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Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries
  1. L Turner-Stokes1,2,
  2. S Paul1,
  3. H Williams1
  1. 1Regional Rehabilitation Unit, Northwick Park Hospital, UK
  2. 2Department of Palliative Care, Policy and Rehabilitation, King’s College London School of Medicine, UK
  1. Correspondence to:
 Professor L Turner-Stokes
 Regional Rehabilitation Unit, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK; lynne.turner-stokes{at}


Objectives: To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability.

Subjects and setting: Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury.

Methods: Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: “low” (NPDS<10 (n = 83)); “medium” (NPDS10–24 (n = 112)); “high” (NPDS >24 (n = 102)).

Results: Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in “weekly cost of care” was greatest in the high dependency group at £639 per week (95% CI 488 to 789)), as compared with the medium (£323/week (95% CI 217 to 428)), and low (£111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups.

Conclusions: The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

  • ABI, acquired brain injury
  • ADL, activities of daily living
  • FIM, Functional Independence Measure
  • LOS, length of stay
  • NPDS, Northwick Park Dependency Score
  • NPCNA, Northwick Park Care Needs Assessment
  • rehabilitation
  • outcome measurement
  • dependency
  • cost efficiency
  • brain injury

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  • * FIM is a trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

  • This older version of the FIM is applied only as part of the UK FIM+FAM with permission from the originators.

  • The lower unit cost in 2000/01 was due to unusually high turnover bed turnover that year.

  • § An alternative analysis using non-parametric statistics gave similar results and is available on the journal website (see

  • See Editorial Commentary, p 570

  • Competing interests: as employees of the NHS working within the Regional Rehabilitation Unit at the time the work was undertaken, the authors have a natural desire as professionals to ensure that the service is appropriately contracted for the nature of the work undertaken. Outcome measurement is a specific research interest of our centre. Both the NPDS, the NPCNA were developed through this department, but are disseminated free of charge. Professor Turner-Stokes is lead author on the papers which describe their initial development and validation, as well as that of the UK version of the FIM+FAM. However, none of the authors has any personal financial interests in the work undertaken or the findings reported.

  • Ethics approval: the Regional Rehabilitation Unit gathers this outcome data routinely in the course of clinical practice. Local research ethics committee permission has been obtained to report the data retrospectively for research and audit purposes.

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