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136 Musculoskeletal & Neurological Rehabilitation KCE reports 57 In all pathways, physical and occupational therapy is starting in the post-operative phase, in an inpatient setting. One pathway mentions rehabilitation therapy activities performed by nurses. All post-acute and maintenance phases contain pain control, stump modelling and march training as most important goals. A multidisciplinary team is taking care of the medical and paramedical follow-up. The phases after the post-operative phase are performed in an inpatient and/or an outpatient setting. 7.2.2.9 Expected outcomes and the use of outcome measurement tools The main outcome for the pre-amputation phase is having an informed and wellprepared patient, who is fit for surgery. On the day of the intervention, all critical pathways include pain control and stump modelling as the main goals. Patient’s physical and mental status are continuously monitored. One program indicates that day of discharge may depend on wound-healing and stump status. Another pathway lets the day of discharge depend on the patient’s progression based on a physical assessment. 7.2.3 Conclusion In literature, many descriptions of the use clinical pathways or rehabilitation programs for lower extremity amputations, were detected. Only four pathways were obtained for analysis and comparison. All pathways start in the pre-operative phase. All pathways make use of a multidisciplinary team, consisting in all programs of physicians, physical therapists, occupational therapists and nurses. Social workers and dieticians are also teammembers, but not in all pathways. Physical therapy is given daily during inpatient rehabilitation, but the exact amount of time of therapy is not explicitly noted in all pathways. The duration and content of the rehabilitation process described in the 4 clinical pathways differs. But this can be explained by the fact that each pathway only covers a part of the disease trajectory. Acute, post-acute and maintenance post-acute phases differ between the 4 pathways, as do the outcome measurements. Only 1 program included long-term follow-up until 18 months post-operatively. In only 1 pathway, prosthetic training is included, without giving concrete details. In the other 3 pathways, there is no report on prosthetic training or adaptation of prostheses. Perhaps, they only provide the prosthetic training in an outpatient setting. 7.3 MULTIPLE SCLEROSIS (MS) 7.3.1 Methodology The objective of the search was to find clinical pathways for rehabilitation in case of multiple sclerosis, used in different countries. The search algorithm on the website of the American Academy of Physical Medicine and Rehabilitation was performed by the subheadings Legislative, Business and Clinical Pathways and Multiple Sclerosis (N=23). In the PubMed search the keywords rehabilitation, multiple sclerosis, critical pathway, clinical pathway, integrated care pathway and care map were used. (See Appendix to chapter 7) Cochrane library search algorithms contained the keywords clinical care pathway, multiple sclerosis, critical care pathway and care pathway. (See Appendix to chapter 7)
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 137 7.3.2 Results Search on the website of the national library of health of the U.K. was performed through ‘protocols & care pathways’ and ‘multiple sclerosis’ (N=0). Different experts were contacted to ask whether they had a clinical pathway for rehabilitation in multiple sclerosis, and were willing to provide it. E-mail addresses were obtained trough the publications found by the literature search (N=9), through the website of RIMS (rehabilitation of multiple sclerosis - Europe) (N=22), the website of the department of health of the UK (N=3), and through the website of the National multiple sclerosis society of the USA (N=1). Personal contact with professionals in Belgium took place (N=1). Results of the searches were screened by title and/or abstract. The search algorithms were double checked by a second reader to avoid selection bias, and results were discussed with professionals of the CZVand department of PMR. During the search on the website of the American Academy of Physical Medicine and Rehabilitation, 4 publications (see Appendix to chapter 7) were considered as relevant. Full text of all articles was scanned. In the PubMed search 7 articles (see Appendix to chapter 7) were identified as relevant. Full text of all articles was scanned. In the Cochrane library and on the website of the national library of health in the U.K., no relevant publications were detected. Through contact with professionals, both by e-mail or personal contact, only 2 clinical pathways for rehabilitation for multiple sclerosis were received. Only the two clinical pathways obtained via expert contact were apt to be analysed and compared. 7.3.2.1 Patient characteristics Both pathways describe a multidisciplinary path for inpatients, for acute/post-acute or maintenance therapy. 7.3.2.2 Delay after onset of MS Delay after onset of pathology wasn’t described in either of them. 7.3.2.3 Method of identification of patient needs The pathways are different related to the methods of identification of patient needs; one pathway uses a psychological questionnaire, composed by the local team members, concerning expectations/satisfaction. The other uses functional tests (Barthel, FIM, ESS) and consultation of the patient to discuss feasible objectives. 7.3.2.4 Conditions to start rehabilitation Conditions to start the clinical pathway were rather functional in one pathway (identification of areas of potential functional improvement involving 2 or more disciplines, patients must be able to undertake an intensive therapy, definition of a clearly defined set of functional objectives which aim at reducing their degree of disability and/or handicap), and rather time-based in the other (minimum 3 weeks of admission). 7.3.2.5 Duration of rehabilitation Length of stay was 3 weeks, and every single week was described separately in both clinical pathways.
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Dépôt légal : D/2007/10.273/19
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35. Etude relative aux coûts poten
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