1. Communication Sciences and Disorders 2.Centers for Rehab Services, UPMC 3.Health Sciences Library System, University of Pittsburgh

Cavanaugh, Robert,1 Kravetz, Christina,2 Jarold, Lillian,1 Quique, Yina,1 Turner, Rose,3 Evans, William S1

Is there a research-practice dosage gap in aphasia rehabilitation?

INTRODUCTION

OBJECTIVES

MATERIALS & METHODS RESULTS CONCLUSIONS

REFERENCES

ACKNOWLEDGEMENTS

• Aphasia intervention research aims to improve communication and quality of life outcomes for people with aphasia.

• Few studies have evaluated the translation and implementation of evidence-based aphasia interventions to clinical practice.

• Treatment dosage is a critical element of aphasia interventions that may be especially challenging to translate from clinical research to clinical practice settings.

• Anecdotal evidence suggests that dosage is often reduced in clinical practice due to pragmatic constraints on access to care.

• Because estimates of the efficacy and ultimately the effectiveness of aphasia interventions are based on the dosage provided in clinical research, it is critical to evaluate whether the typical range of treatment dosage is attainable in current clinical practice settings.

• A mismatch between dosage in research and clinical practice threatens the external validity of aphasia intervention research and risks attenuating intervention effectiveness in clinical settings.

Estimating Clinical Rehabilitation Dosage:• We estimated clinical treatment dosage via

clinical utilization data extracted from the Centers for Rehabilitation Services (CRS) at the University of Pittsburgh Medical.

• Deidentified outpatient clinical utilization data was extracted in collaboration with the Health Record Research Request Service at the Clinical and Translational Science Institute.Estimating Research Dosage:

• We undertook a scoping review of aphasia interventions published from 2009-2019 to estimate the typical range of dosage in the current aphasia literature. Analysis:

• Permutation tests and descriptive statistics were utilized to compare the number of visits, number of treatment hours, weekly treatment intensity, and total treatment duration between clinical practice and aphasia rehabilitation research.

Estimating Clinical Rehabilitation Dosage:• From 2014-2019, a total of 683 patient records

from the CRS met inclusion criteria. • Outpatient episodes of care consisted of a

median 10 visits and mean 14.8 visits (interquartile range: 5-20 visits).

• Visits occurred 1-2 times/week over 4-14 weeks. • The median total hours of treatment was 7.5

hours (interquartile range: 3.75-15 hours). Estimating Research Dosage:• A total of 303 treatment studies met all scoping

review inclusion and exclusion criteria. • Published interventions administered a median

of 20 hours of treatment (interquartile range: 12-32 hours) over the course of 15 sessions (interquartile range: 10-24 sessions) approximately 3 times per week.

Analysis:• All permutation tests were significant, such that

dosage in clinical research was greater than clinical practice for all variables with the exception of total treatment duration. Only total treatment duration in clinical practice was greater than duration in clinical research .

• Results from this study demonstrate a meaningful research-practice dosage gap, particularly in total treatment hours and weekly treatment intensity.

• This dosage gap highlights a clear threat to the external validity of aphasia rehabilitation research in outpatient clinical settings and the potential for an attenuation of intervention effectiveness in outpatient settings.

• Future translational research should consider clinical dosage constraints and take steps to facilitate intervention implementation, particularly with regard to dosage.

• Conversely, healthcare advocacy and continued development of alternative delivery methods is necessary for successful implementation of treatments with dosage that is incompatible with current clinical contexts.

• Pragmatic, implementation-focused trials are recommended to evaluate and optimize treatment effectiveness in outpatient clinical settings.

Baker, E. (2012). Optimal intervention intensity in speech-language pathology: Discoveries, challenges, and unchartered territories. International Journal of Speech-Language Pathology, 14(5), 478–485. https://doi.org/10.3109/17549507.2012.717967Brogan, E., Ciccone, N., & Godecke, E. (2020). An exploration of aphasia therapy dosage in the first six months of stroke recovery. Neuropsychological Rehabilitation, 1–35. https://doi.org/10.1080/09602011.2020.1776135Harvey, S. R., Carragher, M., Dickey, M. W., Pierce, J. E., & Rose, M. L. (2020). Treatment dose in post-stroke aphasia: A systematic scoping review. Neuropsychological Rehabilitation, 1–32. https://doi.org/10.1080/09602011.2020.1786412Konietschke, F., & Pauly, M. (2014). Bootstrapping and permuting paired t-test type statistics. Statistics and Computing, 24(3), 283–296. https://doi.org/10.1007/s11222-012-9370-4Simmons-Mackie, N. (2018). Aphasia in North America. Aphasia Access.Skolarus, L. E., Feng, C., & Burke, J. F. (2017). No Racial Difference in Rehabilitation Therapy Across All Post-Acute Care Settings in the Year Following a Stroke. Stroke, 48(12), 3329–3335.https://doi.org/10.1161/STROKEAHA.117.017290

This work was supported by the National Center for Advancing Translational Sciences of the National Institute of Health under Award Number TL1TR001858. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Additionally, this research was supported through funding received from the SHRS Research Development Fund, School of Health and Rehabilitation Sciences, University of Pittsburgh. Finally, the Health Record Research Request Service is currently supported by the National Institute of Health (Grant Number UL1-TR001857).

The purpose of this study is to quantify a potential research-practice dosage gap in outpatient aphasia rehabilitation.

Hypotheses: Dosage in clinical research will be greater than dosage in clinical practice in terms of the number of treatment sessions, total treatment hours, weekly intensity, and treatment duration.

Figure 1. PRISMA Diagram describing identification, screening, eligibility, and inclusion.

Figure 2. Density plots of dosage parameter distributions for clinical and research dosage. Differences between distributions are significant in all cases (p <0.0001)

Dosage Variable Percent ReportedSessions 92.1%Hours 85.8%Hours per session 82.5%Hours per week 83.8%Sessions per week 87.5%Weeks 92.4%Study Characteristic Percent of StudiesIncluded group or dyad 13.1%Reported effect sizes 45.4%Used specific software or app 20.2%Required home practice 26.8%Utilized telehealth 6.3%

Table 2. Percent of studies providing sufficient information to calculate dosage parameter (top) and study characteristics of studies included in the scoping review (bottom).

Table 1.Schematic of dosage and intensity parameters. Reprinted from Baker (2012).

Simmons-Mackie, N. (2018). Aphasia in North America- Frequency, Demographics, Impact of Aphasia, Communication Access, Services and Service Gaps. http://www.aphasiaaccess.org file:///Users/wevans/OneDrive - University of Pittsburgh/Articles Sync 2.0/Simmons-Mackie - 2018 - Aphasia in North America- Frequency, Demographics, Impact of Aphasia, Communication Access, Services and Service.pdfSimmons-Mackie, N. (2018). Aphasia in North America- Frequency, Demographics, Impact of Aphasia, Communication Access, Services and Service Gaps. http://www.aphasiaaccess.org file:///Users/wevans/OneDrive - University of Pittsburgh/Articles Sync 2.0/Simmons-Mackie - 2018 - Aphasia in North America- Frequency, Demographics, Impact of Aphasia, Communication Access, Services and Service.pdfSimmons-Mackie, N. (2018). Aphasia in North America- Frequency, Demographics, Impact of Aphasia, Communication Access, Services and Service Gaps. http://www.aphasiaaccess.org file:///Users/wevans/OneDrive - University of Pittsburgh/Articles Sync 2.0/Simmons-Mackie - 2018 - Aphasia in North America- Frequency, Demographics, Impact of Aphasia, Communication Access, Services and Service.pdf