D EVELOPMENT ALTERNATIVES , INC

Staff at TNTR received a daily email from a clerk responsible for entering ICD- 10 codes (World Health Organization, 1990), listing all persons who had presented over the previous 24 hours to the RHH’s ED, with a code for TBI. Additionally, research assistants, including a registered nurse employed by TNTR, regularly checked patients on the neurosurgery, orthopaedic, and surgical wards to ensure that cases of

TBI who were hospitalised for other-system injuries were not overlooked, as has been shown to occur in other settings (Moss & Wade, 1996).

Research staff at TNTR initially interviewed these people on the wards of the RHH, or by telephone, if they had not been admitted to hospital or had been discharged. If a person’s eligibility for the project was confirmed during that interview, they were invited to participate in the research project. Details of the numbers of TBI patients invited to participate are displayed in table 6.2 together with those who refused, were not contactable, were prisoners, or had died.

Table 6.2 Details of TNTR Recruitment n Cumulative % Recruited to TNTR 1,226 51% Unable to contact 516 23% Refused 538 22% Overseas 50 2% Prisoners 33 1% Deaths 19 1% Sub Total 1,156 1,156 Total 2,382 100%

All participants were provided with an Information Sheet and Consent Form (see Appendix B) and were given a full explanation of the nature and aims of the study, and the voluntary nature of their involvement. They were informed that they could

withdraw from the project at any time, without prejudice to their future health care. If a potential participant was unconscious, consent was obtained from a relative until they regained consciousness and any period of PTA ended, at which time the procedure described above was followed. Participants confirmed their consent to take part in the

study by signing the consent form. The consent form for all participants less than 18 years of age was signed by a parent or guardian.

Participants were seen for an initial assessment, as soon as possible after their TBI, and then invited to attend follow-up assessments at one-month, three-months, six- months, one-year, and then annually to a maximum of five-years post-injury.

PTA was assessed by subjective estimation at the first interview using a standard interview. For inpatients, the Westmead PTA Scale (Shores, et al., 1986) was

administered by occupational therapists as part of the hospital’s routine procedures, and the first interview was delayed until the participant had scored twelve out of twelve on three consecutive days, indicating the end of PTA.

Demographic and injury-related data were collected at the first assessment (median = 7 days), and tests and questionnaires assessing a range of cognitive, physical and psychosocial variables were completed at all assessments. The data reported in this study on psychological, physical and cognitive status were collected at each

participant’s first assessment at TNTR. At each assessment, all participants were asked about the medical and rehabilitation services they had accessed post-injury. Although referral to rehabilitation services was not one of the aims of the project, TNTR research assistants began to refer some participants for rehabilitation, to the Community

Rehabilitation Unit (CRU), only a few weeks after the research project’s inception, in response to what was perceived as a gap in services. As described in chapter 5, CRU is a service of the Tasmanian DHHS, which provides outpatient rehabilitation and is the single point of referral for all adults in Tasmania who require access to public outpatient multidisciplinary rehabilitation services. Other participants were referred to CRU by medical and allied health professionals independently from TNTR. A third group of

participants accessed rehabilitation services in the private sector, while a large sample received no rehabilitation.

For the group referred for rehabilitation in the private sector information about the date of their referral was not collected. For those referred to CRU however this information was later collected from CRU clinical files: 65% were referred in the first three months post-injury and 90% in the first nine months.

For the purpose of this study the whole sample of TNTR participants was divided, according to rehabilitation status, into the following groups:

CRU-TNTR (n = 121) - referred to CRU by TNTR research assistants

CRU-Other (n = 54) - referred to CRU by hospital and community services Private (n = 247) - received rehabilitation in the private sector

No-Rehab (n = 804) - no rehabilitation

The four groups were compared on the following variables: Demographic variables

 Gender  Age-at-injury  Years of education

 Estimated pre-morbid IQ (NART, WAIS Vocab.) Injury-related variables:

 Previous TBI  Cause of TBI

 Severity of injury (PTA)

 Hospital admission following injury Post-Injury physical variables:

 Pain (VAS)  Fatigue (VAS)

 Functional independence (FIM)  Disability (DRS)

Post-injury psychological variables:  Anxiety (HADS anxiety scale)  Depression (HADS depression scale) Post-injury cognitive variables:

 Executive function (COWAT, Trails B, Digits F/B)  Working memory (Digit Span)

 Information processing speed (AMIPB) Employment status:

 Employed/Not employed

6.2.5 Analyses.

Differences between the four groups (CRU-TNTR, CRU-Other, Private and No- Rehab) on continuous variables listed were investigated using a one-way between groups analyses of variance (ANOVA), followed by Tukey post-hoc tests where appropriate.

For each dichotomous categorical variable, a global chi-square test was

performed to determine whether, overall, there was a significant difference between the four groups. If this chi-square test was significant, post-hoc tests were performed between the six pairs to determine which pairs differed significantly on the variable in question—for example, percentages of hospitalised cases in each group. For cause of injury, analyses were performed using only the three main causes of injury (transport,

assault and falls) which together accounted for 88% of cases. As the resulting variable had three categories, separate chi-square tests were performed comparing each category with all others causes combined, followed by pair-wise tests if the initial test was significant.

The results of this study, and all subsequent studies in this thesis, were analysed using the Statistical Package for the Social Sciences (SPSS). For t-tests, when Levine’s test indicated that the assumption of homogeneity of variances had been violated, the alternative t-value was used, and Welch’s procedure was used for ANOVAs in the same circumstances, as recommended by Tomarken and Serline (1986).

Because of the probability of finding one analysis in twenty significant due to chance, given the large number of analyses performed in this study (and also in

subsequent ones reported in this thesis), a statistical significance of p <.01 was adopted. Some data were missing on some of the variables in this and subsequent studies. This was due to the refusal or inability of a proportion of participants to complete some or all of the tests and questionnaires at TNTR, often due to the participant feeling unwell. Efforts were always made to continue the assessment at another time, but this was not always possible.

6.3 Results

The results of this study are presented in two sections. The first section gives further details of the demographic and injury-related characteristics of the whole sample; the second section looks at differences in the four groups characterised by rehabilitation status (CRU-TNTR, CRU-Other, Private, No-Rehab).

6.3.1 Demographic and injury-related characteristics of whole sample.