Measuring patient-reported outcomes after discharge from inpatient rehabilitation settings

Linking the activity measure for post acute care and the quality of life outcomes in neurological disorders

OBJECTIVE

To use item response theory (IRT) methods to link physical functioning items in the Activity Measure for Post Acute Care (AM-PAC) and the Quality of Life Outcomes in Neurological Disorders (Neuro-QOL).

DESIGN

Secondary data analysis of the physical functioning items of AM-PAC and Neuro-QOL. We used a nonequivalent group design with 36 core items common to both instruments and a test characteristic curve transformation method for linking AM-PAC and Neuro-QOL scores. Linking was conducted so that both raw and scaled AM-PAC and Neuro-QOL scores (mean ± SD converted-logit scores, 50 ± 10) could be compared.

SETTING

AM-PAC items were administered to rehabilitation patients in post-acute care (PAC) settings. Neuro-QOL items were administered to a community sample of adults through the Internet.

PARTICIPANTS

PAC patients (N=1041) for the AM-PAC sample and community-dwelling adults (N=549) for the Neuro-QOL sample.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mobility (N=25) and activity of daily living (ADL) items (N=11) common to both instruments were included in analysis.

RESULTS

Neuro-QOL items were linked to the AM-PAC scale by using the generalized partial credit model. Mobility and ADL subscale scores from the 2 instruments were calibrated to the AM-PAC metric.

CONCLUSIONS

An IRT-based linking method placed AM-PAC and Neuro-QOL mobility and ADL scores on a common metric. This linking allowed estimation of AM-PAC mobility and ADL subscale scores based on Neuro-QOL mobility and ADL subscale scores and vice versa. The accuracy of these results should be validated in a future sample in which participants respond to both instruments.

Validity, responsiveness, and clinically important difference of the ABILHAND questionnaire in patients with stroke

OBJECTIVE

To investigate the criterion-related validity, responsiveness, and clinically important differences of the ABILHAND questionnaire in patients with stroke.

DESIGN

Validation and clinimetric study.

SETTING

Three medical centers.

PARTICIPANTS

Patients with stroke (N=51).

INTERVENTIONS

A total of 51 patients with stroke received 1 of 3 upper extremity rehabilitation programs for 4 weeks.

MAIN OUTCOME MEASURES

The ABILHAND and the criterion measures, including the Stroke Impact Scale (SIS), FIM, Nottingham Extended Activities of Daily Living (NEADL), and accelerometers, were administered at pretreatment and posttreatment. The score of the ABILHAND, given in logits, was based on the conversion of the ordinal score into a linear measure of ability.

RESULTS

Correlation coefficients (Pearson r) were moderate to large between the ABILHAND and SIS physical domains (.54-.66), fair to moderate between the ABILHAND and FIM-motor and NEADL (.28-.48), and moderate between the ABILHAND and accelerometer data (.45-.54). The responsiveness of the ABILHAND was large (standardized response mean=1.27). The minimal clinically important difference range for the ABILHAND was .26 to .35, and 51.0% of the patients showed a positive change that exceeded the lower bound of a clinically important difference after intervention.

CONCLUSIONS

The results support that the ABILHAND is an appropriate outcome measure for assessing upper extremity performance in daily activities in patients with stroke and is sensitive to detect change after rehabilitative interventions. The change score of a patient with stroke on the ABILHAND should reach .26 to .35 logits points to be regarded as a clinically important change.

Frailty Intervention Trial (FIT)

Background

Frailty is a term commonly used to describe the condition of an older person who has chronic health problems, has lost functional abilities and is likely to deteriorate further. However, despite its common use, only a small number of studies have attempted to define the syndrome of frailty and measure its prevalence. The criteria Fried and colleagues used to define the frailty syndrome will be used in this study (i.e. weight loss, fatigue, decreased grip strength, slow gait speed, and low physical activity). Previous studies have shown that clinical outcomes for frail older people can be improved using multi-factorial interventions such as comprehensive geriatric assessment, and single interventions such as exercise programs or nutritional supplementation, but no interventions have been developed to specifically reverse the syndrome of frailty.

We have developed a multidisciplinary intervention that specifically targets frailty as defined by Fried et al. We aim to establish the effects of this intervention on frailty, mobility, hospitalisation and institutionalisation in frail older people.

Methods and Design

A single centre randomised controlled trial comparing a multidisciplinary intervention with usual care. The intervention will target identified characteristics of frailty, functional limitations, nutritional status, falls risk, psychological issues and management of chronic health conditions. Two hundred and thirty people aged 70 and over who meet the Fried definition of frailty will be recruited from clients of the aged care service of a metropolitan hospital. Participants will be followed for a 12-month period.

Discussion

This research is an important step in the examination of specifically targeted frailty interventions. This project will assess whether an intervention specifically targeting frailty can be implemented, and whether it is effective when compared to usual care. If successful, the study will establish a new approach to the treatment of older people at risk of further functional decline and institutionalisation. The strategies to be examined are readily transferable to routine clinical practice and are applicable broadly in the setting of aged care health services.

Trial Registration

Australian New Zealand Clinical Trails Registry: ACTRN12608000250336.

Adaptive short forms for outpatient rehabilitation outcome assessment

OBJECTIVE

To develop outpatient Adaptive Short Forms for the Activity Measure for Post-Acute Care item bank for use in outpatient therapy settings.

DESIGN

A convenience sample of 11,809 adults with spine, lower limb, upper limb, and miscellaneous orthopedic impairments who received outpatient rehabilitation in 1 of 127 outpatient rehabilitation clinics in the United States. We identified optimal items for use in developing outpatient Adaptive Short Forms based on the Basic Mobility and Daily Activities domains of the Activity Measure for Post-Acute Care item bank. Patient scores were derived from the Activity Measure for Post-Acute Care computerized adaptive testing program. Items were selected for inclusion on the Adaptive Short Forms based on functional content, range of item coverage, measurement precision, item exposure rate, and data collection burden.

RESULTS

Two outpatient Adaptive Short Forms were developed: (1) an 18-item Basic Mobility Adaptive Short Form and (2) a 15-item Daily Activities Adaptive Short Form, derived from the same item bank used to develop the Activity Measure for Post-Acute Care computerized adaptive testing program. Both Adaptive Short Forms achieved acceptable psychometric properties.

CONCLUSIONS

In outpatient postacute care settings where computerized adaptive testing outcome applications are currently not feasible, item response theory-derived Adaptive Short Forms provide the efficient capability to monitor patients' functional outcomes. The development of Adaptive Short Form functional outcome instruments linked by a common, calibrated item bank has the potential to create a bridge to outcome monitoring across postacute care settings and can facilitate the eventual transformation from Adaptive Short Forms to computerized adaptive testing applications easier and more acceptable to the rehabilitation community.

Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery

Background

The Medical Outcomes General Health Survey (SF-36) is a widely used health status measure; however, limited evidence is available for its performance in orthopedic settings. The aim of this study was to examine the magnitude and meaningfulness of change and sensitivity of SF-36 subscales following orthopedic surgery.

Methods

Longitudinal data on outcomes of total hip replacement (THR, n = 255), total knee replacement (TKR, n = 103), arthroscopic partial meniscectomy (APM, n = 74) and anterior cruciate ligament reconstruction (ACL, n = 62) were used to estimate the effect sizes (ES, magnitude of change) and minimal detectable change (sensitivity) at the group and individual level. To provide context for interpreting the magnitude of changes in SF-36 scores, we also compared patients' scores with age and sex-matched population norms. The studies were conducted in Sweden. Follow-up was five years in THR and TKR studies, two years in ACL, and three months in APM.

Results

On average, large effect sizes (ES≥0.80) were found after orthopedic surgery in SF-36 subscales measuring physical aspects (physical functioning, role physical, and bodily pain). Small (0.20–0.49) to moderate (0.50–0.79) effect sizes were found in subscales measuring mental and social aspects (role emotional, vitality, social functioning, and mental health). General health scores remained relatively unchanged during the follow-up. Despite improvements, post-surgery mean scores of patients were still below the age and sex matched population norms on physical subscales. Patients' scores on mental and social subscales approached population norms following the surgery. At the individual level, scores of a large proportion of patients were affected by floor or ceiling effects on several subscales and the sensitivity to individual change was very low.

Conclusion

Large to moderate meaningful changes in group scores were observed in all SF-36 subscales except General Health across the intervention groups. Therefore, in orthopedic settings, the SF-36 can be used to show changes for groups in physical, mental, and social dimensions and in comparison with population norms. However, SF-36 subscales have low sensitivity to individual change and so we caution against using SF-36 to monitor the health status of individual patients undergoing orthopedic surgery.

Analyzing change in recovery patterns in the year after acute hospitalization

OBJECTIVE

To examine trajectories of recovery and change in patterns of personal care and instrumental functional activity performance to determine whether different assessment interval designs within a 12-month period yield different estimates of improvement and decline after acute hospitalization and inpatient rehabilitation.

DESIGN

Secondary analysis of a 12-month prospective cohort study.

SETTING

Transition to the community.

PARTICIPANTS

Adults (N=419) admitted to acute care and receiving inpatient rehabilitation for a neurologic, lower-extremity musculoskeletal, or medically complex condition.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Improvement, no change, and decline as measured by the personal care and instrumental scale of the Activity Measure for Post-Acute Care.

RESULTS

Assessment at the end of a single 12-month follow-up assessment interval showed that over 60% of the participants improved. In contrast, analysis of 2 fixed-length 6-month assessment intervals revealed an almost 40% decrease in the proportion who improved from 6 to 12 months. Fewer participants continued to improve in the time periods further from the acute hospitalization and the proportion of subjects who declined increased from 21.4% to 31.2% to 38.0% over the 3 consecutive assessment intervals (baseline to 1 mo, 1-6 mo, 6-12 mo). Only 58 (19.7%) participants continued on the same path of recovery from baseline to 12 months (9.8% improved over all 3 consecutive time periods, 3.1% made no change, 6.8% declined).

CONCLUSIONS

Examination of change over shorter compared with longer assessment intervals revealed considerable variability in the trajectories of recovery. Research is needed to determine the appropriate frequency and timing for measuring and monitoring function and recovery after an acute hospitalization.

An exploratory analysis of functional staging using an item response theory approach

OBJECTIVES

To develop and explore the feasibility of a functional staging system (defined as the process of assigning subjects, according to predetermined standards, into a set of hierarchic levels with regard to their functioning performance in mobility, daily activities, and cognitive skills) based on item response theory (IRT) methods using short forms of the Activity Measure for Post-Acute Care (AM-PAC) and to compare the criterion validity and sensitivity of the IRT-based staging system to a non-IRT-based staging system developed for the FIM instrument.

DESIGN

Prospective, longitudinal cohort study of patients interviewed at hospital discharge and 1, 6, and 12 months after inpatient rehabilitation.

SETTING

Follow-up interviews conducted in patients' homes.

PARTICIPANTS

Convenience sample of 516 patients (47% men; sample mean age, 68.3y) at baseline (retention at the final follow-up, 65%) with neurologic, lower-extremity orthopedic, or complex medical conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

AM-PAC basic mobility, daily activity, and applied cognitive activity stages; FIM executive control, mobility, activities of daily living, and sphincter stages. Stages refer to the hierarchic levels assigned to patients' functioning performances.

RESULTS

We were able to define IRT-based staging definitions and create meaningful cut scores based on the 3 AM-PAC short forms. The IRT stages correlated as well or better to the criterion items than the FIM stages. Both the IRT-based stages and the FIM stages were sensitive to changes throughout the 6-month follow-up period. The FIM stages were more sensitive in detecting changes between baseline and 1-month follow-up visits. The AM-PAC stages were more discriminant in the follow-up visits.

CONCLUSIONS

An IRT-based staging approach appeared feasible and effective in classifying patients throughout long-term follow-up. Although these stages were developed from short forms, this staging methodology could also be applied to improve the meaning of scores generated from IRT-based computerized adaptive testing in future work.

A method to provide a more efficient and reliable measure of self-report physical work capacity for patients with spinal pain

Self-report measures of functional ability are commonly used in occupational rehabilitation to measure the current status of an individual and his or her progress in response to intervention. Most of these measures have been developed using classical test theory that does not provide calibration of the items. Methods of test development that originated in the field of Education have been applied recently to healthcare measures, providing item calibration and allowing proportional evaluation of total scores. The purpose of this article is to demonstrate the application of these methods in the revision of an existing self-report measure. The potential value of these methods to improve established measures is demonstrated.

Prospective evaluation of the AM-PAC-CAT in outpatient rehabilitation settings

BACKGROUND AND PURPOSE

The purpose of this study was to prospectively evaluate the practical and psychometric adequacy of the Activity Measure for Post-Acute Care (AM-PAC) "item bank" and computerized adaptive testing (CAT) assessment platform (AM-PAC-CAT) when applied within orthopedic outpatient physical therapy settings.

METHOD

This was a prospective study with a convenience sample of 1,815 patients with spine, lower-extremity, or upper-extremity impairments who received outpatient physical therapy in 1 of 20 outpatient clinics across 5 states. The authors conducted an evaluation of the number of items used and amount of time needed to complete the CAT assessment; evaluation of breadth of content coverage, item exposure rate, and test precision; as well as an assessment of the validity and sensitivity to change of the score estimates.

RESULTS

Overall, the AM-PAC-CAT's Basic Mobility scale demonstrated excellent psychometric properties while the Daily Activity scale demonstrated less adequate psychometric properties when applied in this outpatient sample. The mean length of time to complete the Basic Mobility scale was 1.9 minutes, using, on average, 6.6 items per CAT session, and the mean length of time to complete the Daily Activity scale was 1.01 minutes, using on average, 6.8 items. BACKGROUND AND CONCLUSION: Overall, the findings are encouraging, yet they do reveal several areas where the AM-PAC-CAT scales can be improved to best suit the needs of patients who are receiving outpatient orthopedic physical therapy of the type included in this study.

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: I. Activity outcomes

OBJECTIVE

To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home.

DESIGN

Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit.

SETTING

Follow-up visits conducted in patients' home setting.

PARTICIPANTS

Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66).

RESULTS

AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77-.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval.

CONCLUSIONS

Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.