Score comparability of short forms and computerized adaptive testing: Simulation study with the activity measure for post-acute care

The effect of post-acute rehabilitation setting on 90-day mobility after stroke: A difference-in-difference analysis

Background

After discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge.

Methods

In this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health.

Results

We included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services (β=-3.5 (1.4), p=0.01 and β=-8.2 (1.3), p=<0.001, respectively).

Conclusions

These findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.

Test-Retest Reliability and Responsiveness of the Computerized Adaptive Testing System of the Functional Assessment of Stroke

OBJECTIVE

To examine the test-retest reliability, responsiveness, and clinical utility of the Computerized Adaptive Testing System of the Functional Assessment of Stroke (CAT-FAS) in persons with stroke.

DESIGN

Repeated measurements design.

SETTING

A department of rehabilitation in a medical center.

PARTICIPANTS

30 persons with chronic stroke (for test-retest reliability) and 65 persons with subacute stroke (for responsiveness) were recruited. To examine the test-retest reliability, the participants received measurements twice at 1-month intervals. To examine the responsiveness, the data were collected at admission and discharge from hospital.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENT TOOL

CAT-FAS.

RESULTS

The intra-class correlation coefficients of the CAT-FAS were ≥0.82, indicating good to excellent test-retest reliability. The Kazis' effect size and standardized response mean of the CAT-FAS were ≥0.96, indicating good group-level responsiveness. For individual-level responsiveness, approximately two-thirds of the participants exceeded the conditional minimal detectable change. On average, the CAT-FAS was completed within 9 items and 3 minutes per administration.

CONCLUSIONS

Our results suggest the CAT-FAS is an efficient measurement tool with good to excellent test-retest reliability and responsiveness. In addition, the CAT-FAS can be used routinely in clinical settings to monitor progress of the crucial 4 domains for persons with stroke.

Benefits of an Early Mobility Program for Hospitalized Patients With Cancer

PURPOSE

Patients with cancer are often hospitalized with complications from cancer and cancer treatment. Many experience a decline in physical functioning, including loss of mobility, which likely contributes to increased length of stay (LOS) and increased readmissions. We aimed to determine whether a mobility program would improve quality of care and decrease health care utilization.

METHODS

We implemented a mobility aide program on an oncology unit in a large academic medical center for all patients without bedrest orders between October 1, 2018, and February 28, 2021. The program consisted of nursing evaluation using the Activity Measure for Post-Acute Care (AMPAC), an ordinal scale ranging from bed rest to ambulating ≥ 250 feet, to quantify mobility. Plan of care was determined in a multidisciplinary manner with physical therapy (PT), nursing, and a mobility aide, who is a medical assistant with enhanced rehabilitation training. Patients were then mobilized two times per day 7 days a week. Using descriptive statistics and mixed effects logistic regression, we evaluated the programs impact on LOS, readmissions, and changes in mobility during this time period compared with the 6-month interval before implementation.

RESULTS

A total of 1,496 hospitalized patients were identified. The odds of hospital readmission within 30 days of discharge was significantly less for those who received the intervention (OR, 0.53; 95% CI, 0.37 to 0.78; P = .001). The odds ratio (OR) of having a final AMPAC score at or above the median was significantly higher for those who received the intervention (OR, 1.60; 95% CI, 1.04 to 2.45; P < .05). There was no significant difference in LOS.

CONCLUSION

Use of this mobility program resulted in a significant decrease in readmissions and maintained or improved patients' mobility. This demonstrates that non-PT professionals can effectively mobilize hospitalized patients with cancer, thereby decreasing the burden on PT and nursing resources. Future work will evaluate the sustainability of the program and evaluate association with health care costs.

Computerized-adaptive testing versus short forms for pediatric inflammatory bowel disease patient-reported outcome assessment

Introduction

Computerized-adaptive testing (CAT) may increase reliability or reduce respondent burden for assessing patient-reported outcomes compared with static short forms (SFs). We compared CAT versus SF administration of the Patient-Reported Outcomes Measurement Information System® (PROMIS®) Pediatric measures in pediatric inflammatory bowel disease (IBD).

Methods

Participants completed 4-item CAT, 5- or 6-item CAT, and 4-item SF versions of the PROMIS Pediatric measures. We compared average T-scores, intra-class correlations (ICCs), floor and ceiling effects, and standard error of measurement (SEM) across forms, along with mean effect sizes between active versus quiescent IBD disease activity groups.

Results

Average PROMIS T-scores across forms were <3 points (minimally important difference) of each other. All forms correlated highly with each other (ICCs ≥0.90) and had similar ceiling effects, but the CAT-5/6 had lower floor effects. The CAT-5/6 had lower SEM than the CAT-4 and SF-4, and the CAT-4 had a lower SEM than the SF-4. Mean effect sizes were similar across forms when contrasting disease activity groups.

Conclusions

The CAT and SF forms produced similar score results, but the CAT had better precision and lower floor effects. Researchers should consider PROMIS pediatric CAT if they anticipate that their sample will skew toward symptom extremes.

Prognosis of Individual-Level Mobility and Daily Activities Recovery From Acute Care to Community, Part 2: A Proof-of-Concept Single Group Prospective Cohort Study

OBJECTIVE

To demonstrate a proof-of-concept for prognostic models of post-stroke recovery on activity level outcomes.

DESIGN

Longitudinal cohort with repeated measures from acute care, inpatient rehabilitation, and post-discharge follow-up to 6 months post-stroke.

SETTING

Enrollment from a single Midwest USA inpatient rehabilitation facility with community follow-up.

PARTICIPANTS

One-hundred fifteen persons recovering from stroke admitted to an acute rehabilitation facility (N=115).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Activity Measure for Post-Acute Care Basic Mobility and Daily Activities domains administered as 6 Clicks and patient-reported short forms.

RESULTS

The final Basic Mobility model defined a group-averaged trajectory rising from a baseline (pseudo-intercept) T score of 35.5 (P<.001) to a plateau (asymptote) T score of 56.4 points (P<.001) at a negative exponential rate of -1.49 (P<.001). Individual baseline scores varied by age, acute care tissue plasminogen activator, and acute care length of stay. Individual plateau scores varied by walking speed, acute care tissue plasminogen activator, and lower extremity Motricity Index scores. The final Daily Activities model defined a group-averaged trajectory rising from a baseline T score of 24.5 (P<.001) to a plateau T score of 41.3 points (P<.001) at a negative exponential rate of -1.75 (P<.001). Individual baseline scores varied by acute care length of stay, and plateau scores varied by self-care, upper extremity Motricity Index, and Berg Balance Scale scores.

CONCLUSIONS

As a proof-of-concept, individual activity-level recovery can be predicted as patient-level trajectories generated from electronic medical record data, but models require attention to completeness and accuracy of data elements collected on a fully representative patient sample.

Total knee arthroplasty is associated with greater immediate post-surgical pain and opioid use than total hip arthroplasty

BACKGROUND

As greater emphasis is being placed on opioid reduction strategies and implementation of multimodal analgesia, we sought to determine whether immediate post-surgical opioid consumption was different between THA and TKA.

METHODS

A single-institution total joint arthroplasty database was used to identify patients who underwent elective THA and TKA from 2016 to July 2019. Baseline demographic data, operative time (defined by incision time), and American Society of Anesthesiologist (ASA) class were collected. Morphine milligram equivalents (MME) were calculated and derived from prospectively documented nursing opioid administration events, while visual analog scale (VAS) scores represented pain levels, both of which were collected as part of our institution's standard protocols. Activity Measure for Post-Acute Care (AMPAC) was used to determine physical therapy progress.

RESULTS

A total of 11,693 cases were identified: 5,909 THA (50.53%) and 5784 (49.47%) TKA. THA patients tended to be slightly younger (63.38 years, SD 11.61 years, vs 65.72 years, SD 9.56 years; p < 0.01) and have lower BMIs (28.92 kg/m² vs 32.52 kg/m²; p < 0.01). THA patients had lower ASA scores in comparison to TKA patients (p < 0.01). Aggregate opioid consumption (93.76 MME vs 147.55 MME; p < 0.01) along with first 24-h and 48-h usage was significantly less for THA as compared to TKA. Similarly, mean pain scores (4.15 vs 5.08; p < 0.01) were lower for THA, while AMPAC mobilization scores were higher (20.88 vs 19.29; p < 0.01) when compared to TKA.

CONCLUSION

THA patients reported lower pain scores and were found to require less opioid medication in the immediate post-surgical period than TKA patients.

Activity Measure for Post-Acute Care “6-Clicks” Basic Mobility Scores Predict Discharge Destination After Acute Care Hospitalization in Select Patient Groups: A Retrospective, Observational Study

•

A standardized Basic Mobility score of 42.9 predicts home vs institution discharge.

•

Orthopedic diagnoses may have a cutoff score of 41.5 to predict home discharge.

•

Cutoff scores vary by diagnostic group and discharge destination.

•

Cutoff scores vary by time of assessment relative to admission for some diagnoses.

Objectives

To establish cutoff scores for the Activity Measure for Post-Acute Care “6-Clicks” standardized Basic Mobility scores (sBMSs) for predicting discharge destination after acute care hospitalization for diagnostic subgroups within an acute care population and to evaluate the need for a second score to improve predictive ability.

Design

Retrospective, observational design.

Setting

Major medical center in metropolitan area.

Participants

Electronic medical records of 1696 adult patients (>18 years) admitted to acute care from January to October 2018. Records were stratified by orthopedic, cardiac, pulmonary, stroke, and other neurological diagnoses (N=1696). Interventions: None

Main Outcome Measure

Physical therapists scored patients’ sBMSs after referral for physical therapy and prior to discharge. Receiver operating characteristic curves delineated sBMS cutoff scores distinguishing various pairings of home, home with services, inpatient rehabilitation, or skilled nursing facility discharges. First and second sBMSs were compared with percentage change of the area under the curve and inferential statistics.

Results

Home vs institution cutoff score was 42.88 for combined sample, pulmonary and neurological cases. The cutoff score for orthopedic diagnoses score was 41.46. Cardiac and stroke model quality invalidated cutoff scores. Home without services vs skilled nursing discharges and home with services vs skilled nursing discharges were predicted with varying cutoff scores per diagnosis. sBMS cutoff scores collected closer to discharge were either the same or higher than first cutoffs, with varying effects on predictive ability.

Conclusions

sBMSs can help decide institution vs home discharge and finer distinctions among discharge settings for some diagnostic groups. A single sBMS may provide sufficient assistance with discharge destination decisions but timing of scoring and diagnostic group may influence cutoff score selection.

Key Data Elements for Longitudinal Tracking of Physical Function: A Modified Delphi Consensus Study

OBJECTIVE

Physical function is associated with important outcomes, yet there is often a lack of continuity in routine assessment. The purpose of this study was to determine data elements and instruments for longitudinal measurement of physical function in routine care among patients transitioning from acute care hospital setting to home with home health care.

METHODS

A 4-round modified Delphi process was conducted with 13 participants with expertise in physical therapy, health care administration, health services research, physiatry/medicine, and health informatics. Three anonymous rounds identified important and feasible data elements. A fourth in-person round finalized the recommended list of individual data elements. Next, 2 focus groups independently provided additional perspectives from other stakeholders.

RESULTS

Response rates were 100% for online rounds 1, 3, and 4 and 92% for round 2. In round 1, 9 domains were identified: physical function, participation, adverse events, behavioral/emotional health, social support, cognition, complexity of illness/disease burden, health care utilization, and demographics. Following the fourth round, 27 individual data elements were recommended. Of these, 20 (74%) are "administrative" and available from most hospital electronic medical records. Additional focus groups confirmed these selections and provided input on standardizing collection methods. A website has been developed to share these results and invite other health care systems to participate in future data sharing of these identified data elements.

CONCLUSION

A modified Delphi consensus process was used to identify critical data elements to track changes in patient physical function in routine care as they transition from acute hospital to home with home health.

IMPACT

Expert consensus on comprehensive and feasible measurement of physical function in routine care provides health care professionals and institutions with guidance in establishing discrete medical records data that can improve patient care, discharge decisions, and future research.

Functional recovery following hospitalisation of patients diagnosed with COVID-19: a protocol for a longitudinal cohort study

INTRODUCTION

COVID-19 is an international public health crisis with more than 132 million infections worldwide. Beyond acute infection, emerging data indicate patients diagnosed with COVID-19 may experience persistent sequelae similar to survivors of sepsis or acute respiratory syndromes, including mobility limitations and fatigue. However, there is limited evidence on the trajectory of functional recovery in those hospitalised with COVID-19. The primary aim of the Coronavirus Registry Functional Recovery (COREG-FR) study is to understand the trajectory of functional recovery among individuals hospitalised for COVID-19 over the medium (up to 6 months) and longer term (6-12 months) that will guide clinical care and optimal management of serious COVID-19 illness and recovery.

METHODS AND ANALYSIS

COREG-FR is a multicentre longitudinal cohort study. We will enrol a minimum of 211 adults age 18 years and older with COVID-19 from five hospitals. Participants will be followed from admission to hospital as an inpatient, to hospital discharge, and at 3-month, 6-month, 9-month and up to 12-month post-hospital discharge. We will conduct telephone interviews at ward admission and discharge, and telephone interviews plus in-person assessments of physical function and lung function at all remaining follow-ups. Our primary outcome is the Activity Measure for Post-Acute Care mobility scale measured at all time points. We will conduct linear mixed effects regression analyses to explore determinants of functional outcomes after COVID-19 illness. Subgroup analyses based on age (≤65 vs >65 years), frailty status (Clinical Frailty Scale score ≤4 vs >5) and variants of concern will be conducted.

ETHICS AND DISSEMINATION

COREG-FR has been approved by Research Ethics Boards at participating sites. We will disseminate this work through peer-reviewed manuscripts, presentations at national and international meetings and through the established COREG website (www.coregontario.ca). COREG-FR is designed as a data platform for future studies evaluating COVID-19 recovery.

TRIAL REGISTRATION NUMBER

NCT04602260; Pre-results.

Linking AM-PAC Mobility and Daily Activity to the PROMIS Physical Function Metric

OBJECTIVE

The purpose of this study was to link Activity Measure for Post-Acute Care (AM-PAC) Mobility and Daily Activity scales to the PROMIS Physical Function (PF) allowing for a common metric across scales.

METHODS

Cross-sectional study of patients 18 years and older presenting to 1 of 8 outpatient rehabilitation clinics in southwestern Pennsylvania. Patients completed one survey with questions from the AM-PAC Daily Activity and Mobility short forms, and the PROMIS PF item bank. Using item response theory, 2 rounds of fixed-parameter calibration were performed. In the first, the AM-PAC Daily Activity and Mobility items were calibrated with 27 fixed item parameters from the PROMIS PF. Second, the AM-PAC Daily Activity items were calibrated with 11 PROMIS Upper Extremity fixed item parameters. This process uses the construct of physical function and equates AM-PAC items on the same underlying measurement scale for the PROMIS PF.

RESULTS

Both scales measured a wide range of functioning and demonstrated good calibration. Data were appropriate for a fixed-parameter item response theory-based crosswalk. AM-PAC Daily Activity and Mobility raw scores were mapped onto the PROMIS PF metric. AM-PAC Daily Activity scores were also mapped onto the PROMIS PF Upper Extremity metric.

CONCLUSION

Question items from the AM-PAC Daily Activity, AM-PAC Mobility, and PROMIS PF similarly measure the construct of physical function. This consistency allows for a crosswalk of AM-PAC scores onto the PROMIS PF metric.

IMPACT

Crosswalk tables developed in this study allow for converting scores from the AM-PAC Daily Activity and Mobility scales to the PROMIS PF metric. This will facilitate monitoring of longitudinal change in function over time and across settings.

Improving the utility of the European Health Literacy Survey Questionnaire: a computerized adaptive test for patients with stroke

PURPOSE

Health literacy among patients is crucial for effective stroke management. The European Health Literacy Survey Questionnaire is a theory-based measure that comprehensively captures 12 domains of health literacy. We aimed to develop a computerized adaptive test of the European Health Literacy Survey Questionnaire to efficiently assess health literacy among patients with stroke.

MATERIALS AND METHODS

The European Health Literacy Survey Questionnaire data of 311 patients and item parameters were retrieved from a Rasch validation study. Real data simulations were performed to develop a computerized adaptive test of the European Health Literacy Survey Questionnaire and explore its efficiency and reliability.

RESULTS

The computerized adaptive test of the European Health Literacy Survey Questionnaire displayed suitable reliability in all 12 domains (0.72-0.84) with a mean test length of 17 items (36.2% of the 47-item European Health Literacy Survey Questionnaire).

CONCLUSIONS

Our findings indicate that the computerized adaptive test of the European Health Literacy Survey Questionnaire, which assesses 12 domains of health literacy among patients with stroke in a timely and precise fashion, is efficient and reliable.Implications for rehabilitationThe computerized adaptive test of the European Health Literacy Survey Questionnaire assesses the subjective fit of personal health literacy competencies to environmental demands, providing insight into patient strengths and weaknesses when dealing with health tasks and interacting with health systems.The computerized adaptive test of the European Health Literacy Survey Questionnaire assesses the 12 domains of health literacy among patients with stroke in a timely and precise manner.Our study has demonstrated the utility of the computerized adaptive test of the European Health Literacy Survey Questionnaire in reducing the assessment burden of patients in clinical practice.Developing of the computerized adaptive test of the European Health Literacy Survey Questionnaire provided findings that may benefit researchers and clinicians interested in developing efficient outcome measures.

Validation of the Mandarin Version of the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" Among Patients in Acute Rehabilitation

IMPORTANCE

A standardized functional measure that can be used across rehabilitation care settings in Taiwan is urgently needed.

OBJECTIVE

To generate a Mandarin version of the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" for patients in acute care.

DESIGN

Mixed-methods study with a cross-sectional design.

SETTING

Acute care wards of three teaching hospitals in Taiwan.

PARTICIPANTS

A sample of 231 neurological patients in acute care (62.3% female; mean age = 63.2 yr, standard deviation = 14.6).

OUTCOMES AND MEASURES

The 6-Clicks consist of three subscales: Basic Mobility, Daily Activity, and Applied Cognition. They were translated into Mandarin, and their internal consistency, test-retest reliability, interrater reliability, and convergent validity were tested.

RESULTS

All subscales of the Mandarin version of the 6-Clicks showed good internal consistency (α = .97-.98). Test-retest and interrater reliabilities were excellent for all subscales (intraclass correlation coefficients >.8). Convergent validity was supported by strong correlations of the Basic Mobility and Daily Activity subscales with the Barthel Index (r = .73 and .72, respectively) and between the Applied Cognition subscale and the Montreal Cognitive Assessment (r = .82).

CONCLUSION

Our results provide psychometric evidence supporting the use of the Mandarin version of the 6-Clicks in acute care settings in Taiwan.

WHAT THIS ARTICLE ADDS

This study confirms the appropriateness of the use of the Mandarin version of the AM-PAC "6-Clicks" with patients in acute rehabilitation, making it a valuable addition to validated measures available for use by occupational therapists in Taiwan.

Physical Function in the Hospital Is Associated With Patient-Centered Outcomes in an Inpatient Rehabilitation Facility

OBJECTIVE

Poor knowledge of the relationships between physical function (PF) in the hospital and patient outcomes in an inpatient rehabilitation facility (IRF) limits the identification of patients most appropriate for discharge to an IRF. This study aimed to test for independent associations between PF measured via the AM-PAC "6-clicks" basic mobility short form in the hospital and outcomes in an IRF.

METHODS

This was a retrospective cohort study. Primary data were collected from an acute hospital and IRF at 1 academic medical center. Associations were tested between PF at hospital admission or discharge and PF improvement in the IRF, discharge from the IRF to the community, and 30-day hospital events by estimating adjusted relative risk (aRR) using modified Poisson regression and the relative difference in IRF length of stay (LOS) using Gamma regression.

RESULTS

A total of 1323 patients were included. Patients with moderately low, (aRR = 1.50; 95% CI = 1.15-1.93), moderately high (aRR = 1.52; 95% CI = 1.16-2.01), or high (aRR = 1.37; 95% CI = 1.02-1.85) PF at hospital discharge were more likely than those with very low PF to improve their PF while in the IRF. These same patients were more likely to discharge from IRF to the community and had significantly shorter IRF LOS. Hospital-measured PF did not differentiate risk for 30-day hospital events.

CONCLUSION

Patients with moderate-but not very low or very high-PF measured near the time of acute hospital discharge were likely to achieve meaningful PF improvement in an IRF. They also had a shorter IRF LOS so may be ideal candidates for discharge to IRF. Prospective studies with larger samples are necessary to test this assertion.

IMPACT

Providers in the hospital should identify patients with moderate PF near the time of hospital discharge as those who may benefit most from post-acute rehabilitation in an IRF.

The Concerns About Pain (CAP) Scale: A Patient-Reported Outcome Measure of Pain Catastrophizing

Pain catastrophizing has been recognized as an important and consistent psychosocial predictor of nearly every key pain-related outcome. The purpose of this study was to develop a new measure of pain catastrophizing using modern psychometric methodology. People with chronic pain (N = 795) responded to thirty items. Data were analyzed using item response theory, including assessment of differential item functioning and reliability. Sensitivity to change and validity were examined using data collected from patients undergoing spinal fusion surgery (n = 184) and participating in an ongoing longitudinal aging with a disability survey study (n = 1,388). The final 24-item bank had no items with significant local dependence, misfit, or differential item functioning. Results provided strong evidence of reliability and validity. Six- and 2-item short forms were developed for use when computer adaptive testing is not feasible or desirable. The item bank was named the University of Washington Concerns About Pain scale because the term "catastrophizing" was considered stigmatizing by people with chronic pain. Guidance for score interpretation was developed with extensive feedback from individuals with chronic pain. The Concerns About Pain item bank, short forms, and user manuals are free and publicly available to all users and can be accessed online at https://uwcorr.washington.edu/measures/. PERSPECTIVE: This article presents the development of the University of Washington Concerns About Pain scale, the first item response theory-based item bank of pain catastrophizing. The measure is intended for clinicians interested in improving outcomes of patients with chronic pain and for researchers who study impact of and treatment interventions aimed at reducing pain catastrophizing.

Effect of Collaborative Telerehabilitation on Functional Impairment and Pain Among Patients With Advanced-Stage Cancer: A Randomized Clinical Trial

Importance

Most patients with advanced-stage cancer develop impairment and pain-driven functional losses that jeopardize their independence.

Objective

To determine whether collaborative telerehabilitation and pharmacological pain management improve function, lessen pain, and reduce requirements for inpatient care.

Design, Setting, and Patients

The Collaborative Care to Preserve Performance in Cancer (COPE) study was a 3-arm randomized clinical trial conducted at 3 academic medical centers within 1 health care system. Patient recruitment began in March 2013 and follow-up concluded in October 2016. Participants (N = 516) were low-level community or household ambulators with stage IIIC or IV solid or hematologic cancer.

Interventions

Participants were randomly assigned to the (1) control arm, (2) telerehabilitation arm, or (3) telerehabilitation with pharmacological pain management arm. All patients underwent automated function and pain monitoring with data reporting to their care teams. Participants in arms 2 and 3 received 6 months of centralized telerehabilitation provided by a physical therapist-physician team. Those in arm 3 also received nurse-coordinated pharmacological pain management.

Main Outcomes and Measures

Blinded assessment of function using the Activity Measure for Postacute Care computer adaptive test, pain interference and average intensity using the Brief Pain Inventory, and quality of life using the EQ-5D-3L was performed at baseline and months 3 and 6. Hospitalizations and discharges to postacute care facilities were recorded.

Results

The study included 516 participants (257 women and 259 men; mean [SD] age, 65.6 [11.1] years), with 172 randomized to 1 of 3 arms. Compared with the control group, the telerehabilitation arm 2 had improved function (difference, 1.3; 95% CI, 0.08-2.35; P = .03) and quality of life (difference, 0.04; 95% CI, 0.004-0.071; P = .01), while both telerehabilitation arms 2 and 3 had reduced pain interference (arm 2, -0.4; 95% CI, -0.78 to -0.09; P = .01 and arm 3, -0.4; 95% CI, -0.79 to -0.10; P = .01), and average intensity (arm 2, -0.4; 95% CI, -0.78 to -0.07; P = .02 and arm 3, -0.5; 95% CI, -0.84 to -0.11; P = .006). Telerehabilitation was associated with higher odds of home discharge in arms 2 (odds ratio [OR], 4.3; 95% CI, 1.3-14.3; P = .02) and 3 (OR, 3.8; 95% CI, 1.1-12.4; P = .03) and fewer days in the hospital in arm 2 (difference, -3.9 days; 95% CI, -2.4 to -4.6; P = .01).

Conclusions and Relevance

Collaborative telerehabilitation modestly improved function and pain, while decreasing hospital length of stay and the requirement for postacute care, but these outcomes were not enhanced with the addition of pharmacological pain management.

Trial Registration

ClinicalTrials.gov identifier: NCT01721343.

Reduced version of the Activity Measure for Post-Acute Care (AM-PAC) for inpatients, "6-clicks": Brazilian-Portuguese cross-cultural adaptation and measurement properties

BACKGROUND

The "6-clicks" is the reduced version of the Activity Measure for Post-Acute Care for inpatients that assesses limitations in basic mobility, daily activity, and applied cognitive, simply and quickly.

OBJECTIVE

Cross-culturally adapt the "6-clicks" into Brazilian-Portuguese and verify its measurement properties.

METHODS

Cross-cultural adaptation followed recommendations from international guidelines. Reliability indices, standard error of measurement and minimum detectable difference were calculated. Participants included 13 professionals, 13 patients and 13 companions. Test of measurement properties involved 101 patients' of both sexes, hospitalized in the infirmary, under physical therapy care, able to understand and respond to commands and with no discharge expectation. Their 30 companions were also included.

RESULTS

Minor changes implemented to the original version. The three domains showed adequate internal consistency (α>0.65). Inter-rater reliability (n=50) and test-retest reliability, when administer to patients (n=51) and to companions (n=30), showed good for basic mobility domain (ICC_2.1=0.81, 0.83 and 0.82, respectively), good to moderate for daily activity (ICC_2.1=0.78 and ICC_3.1=0.71 and 0.82, respectively) and moderate to poor for applied cognitive (ICC_2.1=0.64, 0.36 and ICC_3.1=0.63), respectively. The highest agreements among patients/companions were also in basic mobility. Standard error of measurement ranged from 2.03 to 2.64 while the minimum detectable difference ranged from 5.63 to 7.32.

CONCLUSION

Translated and adapted Brazilian version of the "6-clicks" showed acceptable measurement properties. The functional data provided by the instrument could be used to enhance care and help treatment follow-up.

A comparison of computerized adaptive testing and fixed-length short forms for the Prosthetic Limb Users Survey of Mobility (PLUS-MTM)

BACKGROUND

New health status instruments can be administered by computerized adaptive test or short forms. The Prosthetic Limb Users Survey of Mobility (PLUS-MTM) is a self-report measure of mobility for prosthesis users with lower limb loss. This study used the PLUS-M to examine advantages and disadvantages of computerized adaptive test and short forms.

OBJECTIVES

To compare scores obtained from computerized adaptive test to scores obtained from fixed-length short forms (7-item and 12-item) in order to provide guidance to researchers and clinicians on how to select the best form of administration for different uses.

STUDY DESIGN

Cross-sectional, observational study.

METHODS

Individuals with lower limb loss completed the PLUS-M by computerized adaptive test and short forms. Administration time, correlations between the scores, and standard errors were compared.

RESULTS

Scores and standard errors from the computerized adaptive test, 7-item short form, and 12-item short form were highly correlated and all forms of administration were efficient. Computerized adaptive test required less time to administer than either paper or electronic short forms; however, time savings were minimal compared to the 7-item short form.

CONCLUSION

Results indicate that the PLUS-M computerized adaptive test is most efficient, and differences in scores between administration methods are minimal. The main advantage of the computerized adaptive test was more reliable scores at higher levels of mobility compared to short forms. Clinical relevance Health-related item banks, like the Prosthetic Limb Users Survey of Mobility (PLUS-MTM), can be administered by computerized adaptive testing (CAT) or as fixed-length short forms (SFs). Results of this study will help clinicians and researchers decide whether they should invest in a CAT administration system or whether SFs are more appropriate.

Construct validity and inter-rater reliability of the Dutch activity measure for post-acute care "6-clicks" basic mobility form to assess the mobility of hospitalized patients

To evaluate the construct validity and the inter-rater reliability of the Dutch Activity Measure for Post-Acute Care "6-clicks" Basic Mobility short form measuring the patient's mobility in Dutch hospital care. First, the "6-clicks" was translated by using a forward-backward translation protocol. Next, 64 patients were assessed by the physiotherapist to determine the validity while being admitted to the Internal Medicine wards of a university medical center. Six hypotheses were tested regarding the construct "mobility" which showed that: Better "6-clicks" scores were related to less restrictive pre-admission living situations (p = 0.011), less restrictive discharge locations (p = 0.001), more independence in activities of daily living (p = 0.001) and less physiotherapy visits (p < 0.001). A correlation was found between the "6-clicks" and length of stay (r= -0.408, p = 0.001), but not between the "6-clicks" and age (r= -0.180, p = 0.528). To determine the inter-rater reliability, an additional 50 patients were assessed by pairs of physiotherapists who independently scored the patients. Intraclass Correlation Coefficients of 0.920 (95%CI: 0.828-0.964) were found. The Kappa Coefficients for the individual items ranged from 0.649 (walking stairs) to 0.841 (sit-to-stand). The Dutch "6-clicks" shows a good construct validity and moderate-to-excellent inter-rater reliability when used to assess the mobility of hospitalized patients. Implications for Rehabilitation Even though various measurement tools have been developed, it appears the majority of physiotherapists working in a hospital currently do not use these tools as a standard part of their care. The Activity Measure for Post-Acute Care "6-clicks" Basic Mobility is the only tool which is designed to be short, easy to use within usual care and has been validated in the entire hospital population. This study shows that the Dutch version of the Activity Measure for Post-Acute Care "6-clicks" Basic Mobility form is a valid, easy to use, quick tool to assess the basic mobility of Dutch hospitalized patients.

Minimally Clinically Important Change in the Activity Measure for Post-Acute Care (AM-PAC), a Generic Patient-Reported Outcome Tool, in People With Low Back Pain

BACKGROUND

The Activity Measure for Post-Acute Care (AM-PAC) is a generic metric of patient-reported functional status. The minimal clinically important difference (MCID) in the AM-PAC score has not been determined.

OBJECTIVE

The study objective was to determine the MCID for AM-PAC in people with low back pain.

DESIGN

This was a retrospective cohort study.

METHODS

Anchor-based and distribution-based methods were used to estimate the MCID. The Modified Low Back Pain Disability Questionnaire was used as the anchor. Adults who had a primary ICD-9 code for low back pain in at least 1 outpatient physical therapist visit during an episode of care and who completed both the AM-PAC and the Modified Low Back Pain Disability Questionnaire in at least 2 visits during the care episode were included. The MCID was calculated for the AM-PAC basic mobility version as well its adapted version, which the Cleveland Clinic uses for patients 65 years old or older.

RESULTS

A total of 1,271 participants were eligible for study. For the AM-PAC basic mobility version, anchor-based methods yielded MCID estimates of between 3.4 and 5.1, whereas distribution-based methods yielded estimates of 1.7 to 4.2. The minimal detectable change (MDC) for the AM-PAC basic mobility version was 3.3. For the adapted AM-PAC basic mobility version, the MCID was estimated to be between 2.9 and 4.0 via anchor-based methods and between 1.2 to 3.5 via distribution-based methods. The MDC for the adapted AM-PAC basic mobility version was 3.5.

LIMITATIONS

The estimated MCID was designed for people with low back pain only.

CONCLUSIONS

The MCID ranged from 3.3 to 5.1 for the AM-PAC basic mobility version and 3.5 to 4 for the adapted version, with the MDC as the lower limit. Changes in the AM-PAC for people with low back pain may be interpreted using the estimated MCID. Future studies are needed to determine the AM-PAC MCID for populations other than those with low back pain.

FIM-Minimum Data Set Motor Item Bank: Short Forms Development and Precision Comparison in Veterans

OBJECTIVE

To improve the practical use of the short forms (SFs) developed from the item bank, we compared the measurement precision of the 4- and 8-item SFs generated from a motor item bank composed of the FIM and the Minimum Data Set (MDS).

DESIGN

The FIM-MDS motor item bank allowed scores generated from different instruments to be co-calibrated. The 4- and 8-item SFs were developed based on Rasch analysis procedures. This article compared person strata, ceiling/floor effects, and test SE plots for each administration form and examined 95% confidence interval error bands of anchored person measures with the corresponding SFs. We used 0.3 SE as a criterion to reflect a reliability level of .90.

SETTING

Veterans' inpatient rehabilitation facilities and community living centers.

PARTICIPANTS

Veterans (N=2500) who had both FIM and the MDS data within 6 days during 2008 through 2010.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Four- and 8-item SFs of FIM, MDS, and FIM-MDS motor item bank.

RESULTS

Six SFs were generated with 4 and 8 items across a range of difficulty levels from the FIM-MDS motor item bank. The three 8-item SFs all had higher correlations with the item bank (r=.82-.95), higher person strata, and less test error than the corresponding 4-item SFs (r=.80-.90). The three 4-item SFs did not meet the criteria of SE <0.3 for any theta values.

CONCLUSIONS

Eight-item SFs could improve clinical use of the item bank composed of existing instruments across the continuum of care in veterans. We also found that the number of items, not test specificity, determines the precision of the instrument.

Adaptation of the Activity Measure Post-Acute Care (AM-PAC) from English to Mandarin using the dual-panel translation approach

PURPOSE

The aims of this study were to translate and adapt the Activity Measure Post-Acute Care (AM-PAC) from US English to Mandarin using the dual-panel method, and to assess its psychometric properties in an outpatient rehabilitation setting.

METHODS

The AM-PAC outpatient short forms were translated using the dual-panel method. The translated AM-PAC was tested in 550 Chinese-speaking rehabilitation outpatients. Floor and ceiling effects were evaluated and internal consistency was assessed using Cronbach's alpha. Spearman correlation was used to assess the concurrent validity of the AM-PAC with the Barthel Index and the Mini-Mental State Examination. Test-retest reliability was determined by administering the AM-PAC twice to 57 participants within a 2-7 day interval.

RESULTS

Some ceiling effects (>20%) were observed in the Applied Cognition subscale. All subscales exhibited good internal consistency (α > 0.70). Supportive evidence for concurrent validity was found in strong correlations between Basic Mobility subscale and Barthel Index (r = 0.68), and Daily Activity subscale and Barthel Index (r = 0.70); and moderate correlations between Applied Cognition subscale and Mini-Mental State Examination (r = 0.50). Test-retest reliability for all subscales was high (intraclass correlation coefficient =0.89-0.98).

CONCLUSIONS

The dual-panel approach was successfully used to translate the AM-PAC from English to Mandarin. Adequate reliability and validity in rehabilitation outpatients in Taiwan were established. Implications for Rehabilitation The dual-panel method is a modern translation technique, which was successfully used to adapt the Activity Measure Post-Acute Care from English to Mandarin. The Mandarin version of Activity Measure Post-Acute Care demonstrates adequate internal consistency, concurrent validity, and test-retest reliability in rehabilitation outpatients. The Activity Measure Post-Acute Care is superior to existing functional measures used to monitor activity performance for rehabilitation patients in Taiwan.

Exercise and fall prevention self-management to reduce mobility-related disability and falls after fall-related lower limb fracture in older people: protocol for the RESTORE (Recovery Exercises and STepping On afteR fracturE) randomised controlled trial

BACKGROUND

Lasting disability and further falls are common and costly problems in older people following fall-related lower limb and pelvic fractures. Exercise interventions can improve mobility after fracture and reduce falls in older people, however the optimal approach to rehabilitation after fall-related lower limb and pelvic fracture is unclear. This randomised controlled trial aims to evaluate the effects of an exercise and fall prevention self-management intervention on mobility-related disability and falls in older people following fall-related lower limb or pelvic fracture. Cost-effectiveness of the intervention will also be investigated.

METHODS/DESIGN

A randomised controlled trial with concealed allocation, assessor blinding for physical performance tests and intention-to-treat analysis will be conducted. Three hundred and fifty people aged 60 years and over with a fall-related lower limb or pelvic fracture, who are living at home or in a low care residential aged care facility and have completed active rehabilitation, will be recruited. Participants will be randomised to receive a 12-month intervention or usual care. The intervention group will receive ten home visits from a physiotherapist to prescribe an individualised exercise program with motivational interviewing, plus fall prevention education through individualised advice from the physiotherapist or attendance at the group based "Stepping On" program (seven two-hour group sessions). Participants will be followed for a 12-month period. Primary outcome measures will be mobility-related disability and falls. Secondary outcomes will include measures of balance and mobility, falls risk, physical activity, walking aid use, frailty, pain, nutrition, falls efficacy, mood, positive and negative affect, quality of life, assistance required, hospital readmission, and health-system and community-service contact.

DISCUSSION

This study will determine the effect and cost-effectiveness of this exercise self management intervention on mobility-related disability and falls in older people who have recently sustained a fall-related lower limb or pelvic fracture. The results will have implications for the design and implementation of interventions for older people with fall related lower limb fractures. The findings of this study will be disseminated in peer-reviewed journals and through professional and scientific conferences.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12610000805077.

Video and computer-based interactive exercises are safe and improve task-specific balance in geriatric and neurological rehabilitation: a randomised trial

QUESTION

Does adding video/computer-based interactive exercises to inpatient geriatric and neurological rehabilitation improve mobility outcomes? Is it feasible and safe?

DESIGN

Randomised trial.

PARTICIPANTS

Fifty-eight rehabilitation inpatients.

INTERVENTION

Physiotherapist-prescribed, tailored, video/computer-based interactive exercises for 1 hour on weekdays, mainly involving stepping and weight-shifting exercises.

OUTCOME MEASURES

The primary outcome was the Short Physical Performance Battery (0 to 3) at 2 weeks. Secondary outcomes were: Maximal Balance Range (mm); Step Test (step count); Rivermead Mobility Index (0 to 15); activity levels; Activity Measure for Post Acute Care Basic Mobility (18 to 72) and Daily Activity (15 to 60); Falls Efficacy Scale (10 to 40), ED5D utility score (0 to 1); Reintegration to Normal Living Index (0 to 100); System Usability Scale (0 to 100) and Physical Activity Enjoyment Scale (0 to 126). Safety was determined from adverse events during intervention.

RESULTS

At 2 weeks the between-group difference in the primary outcome (0.1, 95% CI -0.2 to 0.3) was not statistically significant. The intervention group performed significantly better than usual care for Maximal Balance Range (38mm difference after baseline adjustment, 95% CI 6 to 69). Other secondary outcomes were not statistically significant. Fifty-eight (55%) of the eligible patients agreed to participate, 25/29 (86%) completed the intervention and 10 (39%) attended > 70% of sessions, with a mean of 5.6 sessions (SD 3.3) attended and overall average duration of 4.5hours (SD 3.1). Average scores were 62 (SD 21) for the System Usability Scale and 62 (SD 8) for the Physical Activity Enjoyment Scale. There were no adverse events.

CONCLUSION

The addition of video/computer-based interactive exercises to usual rehabilitation is a safe and feasible way to increase exercise dose, but is not suitable for all. Adding the exercises to usual rehabilitation resulted in task-specific improvements in balance but not overall mobility.

REGISTRATION

ACTRN12613000610730.

Interrater Reliability of AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms

BACKGROUND

The interrater reliability of 2 new inpatient functional short-form measures, Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" basic mobility and daily activity scores, has yet to be established.

OBJECTIVE

The purpose of this study was to examine the interrater reliability of AM-PAC "6-Clicks" measures.

DESIGN

A prospective observational study was conducted.

METHODS

Four pairs of physical therapists rated basic mobility and 4 pairs of occupational therapists rated daily activity of patients in 1 of 4 hospital services. One therapist in a pair was the primary therapist directing the assessment while the other therapist observed. Each therapist was unaware of the other's AM-PAC "6-Clicks" scores. Reliability was assessed with intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa.

RESULTS

The ICCs for the overall reliability of basic mobility and daily activity were .849 (95% confidence interval [CI]=.784, .895) and .783 (95% CI=.696, .847), respectively. The ICCs for the reliability of each pair of raters ranged from .581 (95% CI=.260, .789) to .960 (95% CI=.897, .983) for basic mobility and .316 (95% CI=-.061, .611) to .907 (95% CI=.801, .958) for daily activity. The weighted kappa values for item agreement ranged from .492 (95% CI=.382, .601) to .712 (95% CI=.607, .816) for basic mobility and .251 (95% CI=.057, .445) to .751 (95% CI=.653, .848) for daily activity. Mean differences between raters' scores were near zero.

LIMITATIONS

Raters were from one health system. Each pair of raters assessed different patients in different services.

CONCLUSIONS

The ICCs for AM-PAC "6-Clicks" total scores were very high. Levels of agreement varied across pairs of raters, from large to nearly perfect for physical therapists and from moderate to nearly perfect for occupational therapists. Levels of agreement for individual item scores ranged from small to very large.

Effectiveness of a multifactorial intervention on preventing development of frailty in pre-frail older people: study protocol for a randomised controlled trial

INTRODUCTION

Frailty is a major concern due to its costly and widespread consequences, yet evidence of effective interventions to delay or reduce frailty is lacking. Our previous study found that a multifactorial intervention was feasible and effective in reducing frailty in older people who were already frail. Identifying and treating people in the pre-frail state may be an effective means to prevent or delay frailty. This study describes a randomised controlled trial that aims to evaluate the effectiveness of a multifactorial intervention on development of frailty in older people who are pre-frail.

METHODS AND ANALYSIS

A single centre randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Two hundred and thirty people aged above 70 who meet the Cardiovascular Health Study frailty criteria for pre-frailty, reside in the community and are without severe cognitive impairment will be recruited. Participants will be randomised to receive a multifactorial intervention or usual care. The intervention group will receive a 12-month interdisciplinary intervention targeting identified characteristics of frailty and problems identified during geriatric assessment. Participants will be followed for a 12-month period. Primary outcome measures will be degree of frailty measured by the number of Cardiovascular Health Study frailty criteria present, and mobility measured with the Short Physical Performance Battery. Secondary outcomes will include measures of mobility, mood and use of health and community services.

ETHICS AND DISSEMINATION

The study was approved by the Northern Sydney Local Health District Health Research Ethics Committee (1207-213M). The findings will be disseminated through scientific and professional conferences, and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN12613000043730.

Development and initial psychometric evaluation of the Mobility Activities Measure for Inpatient Rehabilitation Settings (Mobam-in)

OBJECTIVE

To describe the development and the initial psychometric evaluation of a mobility measure for inpatient postacute rehabilitation settings—the Mobility Activities Measure for Inpatient Rehabilitation Settings (Mobam-in).

DESIGN

Self-report-based psychometric study.

SETTING

Postacute rehabilitation unit of a public hospital.

PARTICIPANTS

A consecutive sample of inpatients (N=239) receiving postacute rehabilitation care.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We developed a 30-item mobility measure, using the Mobility Activities Measure (Mobam) framework, to assess functioning across 5 mobility activity domains classified within the International Classification of Functioning, Disability and Health. These were (1) changing and maintaining body position involving only sitting and/or lying (4 items); (2) changing and maintaining body position involving standing up (6 items); (3) carrying and moving objects using the hand and shoulder (6 items); (4) handling objects using only the hand and/or forearm (7 items); and (5) walking and moving (7 items). Psychometric analyses were conducted to test assumptions underlying the scaling and scoring of Mobam-in scales, and to test both the reliability and validity.

RESULTS

Multitrait scaling and confirmatory factor analyses (with Tucker-Lewis Index median, .99; root mean square error of approximation median, .025) supported the assumption of unidimensionality concerning each domain. Five dimensions appeared to be stable across diverse diagnostic groups (the percentage of items with discriminant validity ranged from 93% to 100%, Cronbach coefficient ranged from .859 to .966). Rasch model (Masters' partial credit) showed that all items could be located along a continuum in each dimension, with goodness-of-fit criteria of infit and outfit mean-square values between 0.6 and 1.4. Test-retest reliability was excellent (intraclass correlation coefficients median, .98). Groups with more severe conditions and lower functional independence scored lower on Mobam-in scales, as hypothesized.

CONCLUSIONS

Mobam-in covers 5 dimensions of mobility activities. The Mobam framework is an effective reference for building outcome instruments.

Validity of the AM-PAC "6-Clicks" inpatient daily activity and basic mobility short forms

BACKGROUND

Standardized assessment of patients' activity limitations in acute care settings can provide valuable information. Existing measures have not been widely implemented.

OBJECTIVES

The aim of this study was to provide evidence for validity of scores on Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measures of basic mobility and daily activity in acute care.

DESIGN

A retrospective measurement study was conducted.

METHODS

The study used a database from one health system containing "6-Clicks" scores from first and last physical therapist and occupational therapist visits for 84,446 patients. Validity was analyzed by examining differences in "6-Clicks" scores across categories of patient characteristics; the ability of "6-Clicks" scores to predict patients' having more than one therapy visit; correlation of "6-Clicks" scores with Functional Independence Measure (FIM) scores; and internal responsiveness over the episode of care. Internal consistency reliability also was determined.

RESULTS

The "6-Clicks" scores differed across patients' age, preadmission living situation, and number of therapy visits. The areas under receiver operating characteristic curves derived using "6-Clicks" scores at the first visit to predict patients receiving more than one visit were 0.703 and 0.652 using basic mobility and daily activity scores, respectively. The "6-Clicks" scores at the final visit were correlated with scores on subscales of the FIM completed on admission to inpatient rehabilitation facilities (r=.65 and .69). Standardized response means were 1.06 and 0.95 and minimal detectable changes with 90% confidence level (MDC90) were 4.72 and 5.49 for basic mobility and daily activity scores, respectively. Internal consistency reliability of basic mobility and daily activity scores was .96 and .91, respectively.

LIMITATIONS

Using clinical databases for research purposes has limitations, including missing data, misclassifications, and selection bias. Rater reliability is not known.

CONCLUSIONS

This study provides evidence for the validity of "6-Clicks" scores for assessing patients' activity limitations in acute care settings.

Symptom burden and comorbidities impact the consistency of responses on patient-reported functional outcomes

OBJECTIVE

To assess the influence of symptom intensity, mood, and comorbidities on patient-clinician agreement and the consistency of responses to functional patient-reported outcomes (PROs).

DESIGN

Two data sources were used. The first, a cross-sectional database of patients with breast cancer who completed functional PROs and were administered the FIM, was used to examine whether average pain intensity (as measured with an 11-point numeric rating scale [NRS]) and Rand Mental Health inventory scores differed among those rating their functional independence as different than clinicians. The second, a longitudinal database of 311 adults with late-stage lung cancer who completed the Activity Measure for Post Acute Care Computer Adaptive Test (AM PAC CAT) with differences between their expected and actual responses as reflected in their AM PAC CAT SEs.

SETTING

Two tertiary medical centers.

PARTICIPANTS

Data source #1, 163 women with stage IV breast cancer; data source #2, 311 adults with late-stage lung cancer.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Data source #1, FIM, pain NRS, Older Americans Resource Study activities of daily living subscale, Physical Function-10, Mental Health Inventory-17. Data source #2, AM PAC CAT and NRS symptom ratings.

RESULTS

Pain intensity was significantly higher when clinicians and patients disagreed regarding a patient's independence in the ability to transfer (NRS pain severity, 3.78 vs 2.40; P=.014), groom (3.71 vs 2.36, P=.009), bathe (3.76 vs 2.40, P=.016), and dress (3.09 vs 2.44, P=.034). The magnitude of AM PAC CAT SEs was significantly associated with the severity of participants' pain, dyspnea, and fatigue, as well as the presence of musculoskeletal disorders and coronary artery disease. Neither mood nor emotional distress was associated with clinician-patient agreement or AM PAC CAT SE.

CONCLUSIONS

Pain intensity is associated with disagreement between patients and clinicians about the patient's level of functioning. Moreover, physical symptoms (pain, dyspnea, fatigue) as well as specific medical comorbidities (musculoskeletal disorders, coronary artery disease), but not mood, are associated with inconsistency in patients' assessment of their functional abilities.

A phase IIA randomized, placebo-controlled clinical trial to study the efficacy and safety of the selective androgen receptor modulator (SARM), MK-0773 in female participants with sarcopenia

BACKGROUND

Sarcopenia, the age-related loss of muscle mass [defined as appendicular LBM/Height2 (aLBM/ht2) below peak value by>1SD], strength and function, is a major contributing factor to frailty in the elderly. MK-0773 is a selective androgen receptor modulator designed to improve muscle function while minimizing effects on other tissues.

OBJECTIVES

The primary objective of this study was to demonstrate an improvement in muscle strength and lean body mass (LBM) in sarcopenic frail elderly women treated with MK-0773 relative to placebo.

DESIGN

This was a randomized, double-blind, parallel-arm, placebo-controlled, multicenter, 6-month study. Participants were randomized in a 1:1 ratio to receive either MK-0773 50mg b.i.d. or placebo; all participants received Vitamin D and protein supplementation.

SETTING

General community.

PARTICIPANTS

170 Women aged ≥65 with sarcopenia and moderate physical dysfunction.

MEASUREMENTS

Dual energy X-ray absorptiometry, muscle strength and power, physical performance measures.

RESULTS

Participants receiving MK-0773 showed a statistically significant increase in LBM from baseline at Month 6 vs. placebo (p<0.001). Participants receiving both MK-0773 and placebo showed a statistically significant increase in strength from baseline to Month 6, but the mean difference between the two groups was not significant (p=0.269). Both groups showed significant improvement from baseline at Month 6 in physical performance measures, but there were no statistically significant differences between participants receiving MK-0773 and placebo. A greater number of participants experienced elevated transaminases in the MK-0773 group vs. placebo, which resolved after discontinuation of study therapy. MK-0773 was generally well-tolerated with no evidence of androgenization.

CONCLUSIONS

The MK-0773-induced increase in LBM did not translate to improvement in strength or function vs. placebo. The improvement of strength and physical function in the placebo group could be at least partly attributed to protein and vitamin D supplementation.

Effect of a multifactorial interdisciplinary intervention on mobility-related disability in frail older people: randomised controlled trial

BACKGROUND

Interventions that enhance mobility in frail older people are needed to maintain health and independence, yet definitive evidence of effective interventions is lacking. Our objective was to assess the impact of a multifactorial intervention on mobility-related disability in frail older people.

METHODS

We conducted a randomised, controlled trial with 241 frail community-dwelling older people in Sydney, Australia. Participants were classified as frail using the Cardiovascular Health Study definition, did not have severe cognitive impairment and were recently discharged from an aged care and rehabilitation service. The experimental group received a 12 month multifactorial, interdisciplinary intervention targeting identified frailty components. Two physiotherapists delivered a home exercise program targeting mobility, and coordinated management of psychological and medical conditions with other health professionals. The control group received usual care. Disability in the mobility domain was measured at baseline and at 3 and 12 months using the International Classification of Functioning, Disability and Health framework. Participation (involvement in life situations) was assessed using the Life Space Assessment and the Goal Attainment Scale. Activity (execution of mobility tasks) was measured using the 4-metre walk and self-report measures.

RESULTS

The mean age of participants was 83.3 years (SD: 5.9 years). Of the participants recruited, 216 (90%) were followed-up at 12 months. At this time point, the intervention group had significantly better scores than the control group on the Goal Attainment Scale (odds ratio 2.1; 95% confidence interval (CI) 1.3 to 3.3, P = 0.004) and Life Space Assessment (4.68 points, 95% CI 1.4 to 9.9, P = 0.005). There was no difference between groups on the global measure of participation or satisfaction with ability to get out of the house. At the activity level, the intervention group walked 0.05 m/s faster over 4 m (95% CI 0.0004 to 0.1, P = 0.048) than the control group, and scored higher on the Activity Measure for Post Acute Care (P < 0.001).

CONCLUSIONS

The intervention reduced mobility-related disability in frail older people. The benefit was evident at both the participation and activity levels of mobility-related disability.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ANZCTRN12608000507381.

Development of the computer-adaptive version of the Late-Life Function and Disability Instrument

BACKGROUND

Having psychometrically strong disability measures that minimize response burden is important in assessing of older adults.

METHODS

Using the original 48 items from the Late-Life Function and Disability Instrument and newly developed items, a 158-item Activity Limitation and a 62-item Participation Restriction item pool were developed. The item pools were administered to a convenience sample of 520 community-dwelling adults 60 years or older. Confirmatory factor analysis and item response theory were employed to identify content structure, calibrate items, and build the computer-adaptive testings (CATs). We evaluated real-data simulations of 10-item CAT subscales. We collected data from 102 older adults to validate the 10-item CATs against the Veteran's Short Form-36 and assessed test-retest reliability in a subsample of 57 subjects.

RESULTS

Confirmatory factor analysis revealed a bifactor structure, and multi-dimensional item response theory was used to calibrate an overall Activity Limitation Scale (141 items) and an overall Participation Restriction Scale (55 items). Fit statistics were acceptable (Activity Limitation: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.03; Participation Restriction: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.05). Correlation of 10-item CATs with full item banks were substantial (Activity Limitation: r = .90; Participation Restriction: r = .95). Test-retest reliability estimates were high (Activity Limitation: r = .85; Participation Restriction r = .80). Strength and pattern of correlations with Veteran's Short Form-36 subscales were as hypothesized. Each CAT, on average, took 3.56 minutes to administer.

CONCLUSIONS

The Late-Life Function and Disability Instrument CATs demonstrated strong reliability, validity, accuracy, and precision. The Late-Life Function and Disability Instrument CAT can achieve psychometrically sound disability assessment in older persons while reducing respondent burden. Further research is needed to assess their ability to measure change in older adults.

The impact of cataract surgery questionnaire: re-evaluation using Rasch analysis

PURPOSE

The Impact of Cataract Surgery (ICS) questionnaire was designed to assess cataract surgery outcomes. The aim of this study was to describe the psychometric properties of the ICS questionnaire using the Rasch model in a cataract population.

METHODS

Ninety-one patients waiting to undergo cataract surgery in the first or second eye at the Flinders Medical Centre, Adelaide, South Australia self-administered the four-item ICS questionnaire. Rasch analysis was performed to assess behaviour of response categories, ability to differentiate between participants' visual abilities (person separation; minimum acceptable 2.0), if items measure a single underlying construct [i.e. unidimensionality assessed by fit statistics and further by principal components analysis (PCA)] and matching of item difficulty to participant ability (targeting; ideal < 0.5 logits). Adequate person separation was defined as basic requirement for a measure, failing which further assessment such as PCA was not performed.

RESULTS

The four-item ICS questionnaire did not meet the required measurement properties (person separation zero). Response categories did not behave as intended, requiring the collapsing of categories for one item (read ordinary newspaper-size print). One item misfit (estimating distance) indicating that it was not measuring the same construct as other items. However, person separation failed to improve following the deletion of this item. Targeting was -0.46 logits, indicating that the item difficulty was well suited to the visual abilities of the participants.

CONCLUSION

In its present form, the ICS is unsuitable for visual disability assessment in patients awaiting cataract surgery. Other, better visual function questionnaires are available and preferred.

Translating shoulder computerized adaptive testing generated outcome measures into clinical practice

STUDY DESIGN

Prospective longitudinal cohort study.

INTRODUCTION

Increased use of computerized adaptive tests (CATs) to generate outcome measures during rehabilitation has stimulated questions concerning score interpretation.

PURPOSE OF THE STUDY

The purpose of the study was to describe meaningful interpretations of scores from patient self-report shoulder functional status (FS) outcome measures estimated using a shoulder CAT (score range=0-100).

METHODS

We applied four approaches to the clinical interpretation of outcomes data from 30,987 patients with shoulder impairments receiving outpatient rehabilitation in 518 clinics in 30 states (United States) between August 2007 and July 2009. First, we used standard error of estimates to construct 95% confidence intervals for each CAT estimated score. Second, we estimated the percentile rank (PR) of FS scores. Third, we used two threshold approaches to define individual patient-level change: statistically reliable change (i.e., minimal detectable change or MDC) and clinically important change. Fourth, we developed and applied a functional staging model, the Shoulder Function Classification System (SFCS).

RESULTS

Precision of a single score was estimated by FS score ±4. Based on score distribution, 25th, 50th, and 75th PRs corresponded to intake FS scores of 43, 52, and 59 and discharge FS scores of 59, 68, and 80, respectively. MDC calculations indicated that changes in FS scores of 11 or more units represented statistically reliable change. FS score increments of eight or more units were estimated to represent minimal clinically important improvement based on receiver operating characteristic. The five-level SFCS was judged to be clinically logical and provide insight for clinical interpretation of patient progress.

CONCLUSIONS

Results may improve clinical interpretation of CAT-generated outcome measures and assist clinicians using patient-reported outcomes during clinical practice.

LEVEL OF EVIDENCE

Therapy level 2c.

Computerized adaptive test for patients with lumbar spine impairments produced valid and responsive measures of function

STUDY DESIGN

Outcomes instrument validation study.

OBJECTIVE

We evaluated administrative efficiency and psychometric adequacy of a computerized adaptive test (CAT) for patients with lumbar spine impairments seeking rehabilitation in outpatient therapy clinics.

SUMMARY OF BACKGROUND DATA

CATs promise efficient outcomes data collection in clinical applications with little loss of measurement precision compared to paper and pencil surveys. The lumbar CAT has been developed and simulated and is currently used routinely in therapy clinics. The CAT has not been assessed for administrative efficiency, and the outcomes measures estimated using the CAT have not been assessed using prospective data collection for validity, sensitivity to change, or responsiveness.

METHODS

Data from 17,439 patients with lumbar spine impairments receiving outpatient rehabilitation in 377 clinics in 30 states (United States) were analyzed. We evaluated efficiency of routine CAT administration and assessed construct validity, sensitivity to change, and responsiveness of CAT measures of lumbar functional status (FS).

RESULTS

On average, patients took less than 2 minutes (standard deviation <1 minute) to answer 7 CAT items (standard deviation, 3), which produced precise estimates of FS that adequately covered the content range with negligible floor and ceiling effects. Patients who were older had more chronic symptoms, had more surgeries, had more comorbidities, and did not exercise before receiving rehabilitation reported worse discharge FS. A total of 66% of patients obtained statistically significant change (95% confidence interval minimal detectable change) at discharge. Change of 5 FS units (scale, 0-100) represented minimal clinically important improvement, which 70% of patients obtained. Minimal detectable change and minimal clinically important improvement were associated with intake FS.

CONCLUSION

We concluded the lumbar CAT administration was efficient, and CAT FS measures were precise, valid, sensitive, and responsive, supporting lumbar CAT use in clinical and research applications.

Weighted index explained more variance in physical function than an additively scored functional comorbidity scale

OBJECTIVE

1) examine association between the Functional Comorbidity Index (FCI) and discharge functional status (FS); 2) examine impact of FCI on FS when added to comprehensive models; and 3) compare additive FCI with weighted FCI and list of condition variables (list).

STUDY DESIGN AND SETTING

Patients were drawn from Focus On Therapeutic Outcomes, Inc. (FOTO) database (1/1/06-12/31/07). FS collected using computer adaptive tests. Linear regression examined association between FCI and FS. Three methods of including functional comorbidities (FC) were compared.

RESULTS

Relationship between FCI and FS varied by group (range, 0.02-0.9). Models with weighted index or list had similar R². Weighted FCI or list increased R² of crude models by <0.01 for cervical, shoulder, and lumbar; by 0.01 for wrist/hand, knee, and foot/ankle; by 0.02 for hip; by 0.03 for elbow; and by 0.08 for neurological. Addition of FCI to comprehensive models added <0.01 to R² (all groups). Weighted FCI increased R² by <0.01 for cervical, lumbar, and shoulder; by 0.01 for wrist/hand, hip, knee, and foot/ankle; by 0.02 for elbow; and by 0.04 for neurological; whereas list increased R² by <0.01 for cervical, shoulder, and lumbar; by 0.01 for knee and foot/ankle; by 0.02 for elbow, wrist/hand, and hip; and by 0.05 for neurological.

CONCLUSION

List of comorbidities or weighted FCI is preferable to using additive FCI.

A computerized adaptive test for patients with shoulder impairments produced responsive measures of function

BACKGROUND

Computerized adaptive tests (CATs) promise efficient outcomes data collection with little loss of measurement precision. The shoulder CAT has not been assessed for administrative efficiency, nor have prospective studies been completed to evaluate the sensitivity to change or the responsiveness of CAT-based functional status (CAT-FS) measures.

OBJECTIVE

The purpose of this study was to evaluate the efficiency and responsiveness of the shoulder CAT.

DESIGN

This was a secondary analysis of prospectively collected data.

METHODS

Data were analyzed from patients with shoulder impairments who received outpatient rehabilitation in 518 clinics in 30 US states. Over the testing time, 30,987 patients completed the shoulder CAT at intake, and of these, 13,805 completed the CAT at discharge (45% completion rate). The efficiency of routine CAT administration was evaluated, and the sensitivity to change and responsiveness of CAT-FS measures were assessed.

RESULTS

On average, patients took about 1.5 minutes (SD <2 minutes) to answer 6 CAT items (SD=2), which produced precise estimates of CAT-FS measures that adequately covered the content range and had negligible floor and minimal ceiling effects. Ninety-four percent of the patients had CAT-FS scores between 20 and 80, where upper-level 95% confidence interval (CI) standard errors were between 3.2 and 4.6 (out of 100). Of patients with both intake and discharge data, 79% had CAT-FS change scores greater than minimal detectable change, and 76% had changes greater than minimal clinically important improvement.

LIMITATIONS

Because this study was a secondary analysis, the results may have been affected by patient selection bias. Future studies would benefit from more complete data.

CONCLUSIONS

The results indicate the shoulder CAT was efficient and support the precision, sensitivity, and responsiveness of CAT-FS measures.

Development of symptom assessments utilising item response theory and computer-adaptive testing--a practical method based on a systematic review

Assessment of individual patients' distress is a cornerstone of clinical care for advanced cancer. Patients' ability to fill out lengthy questionnaires is compromised by many factors. Computer-adaptive tests (CAT) offer a promising approach to developing tailored instruments, that administer only items relevant to the individual patient. A systematic review of the literature about CATs in medical databases was conducted. Based on the results, a method for developing a CAT was designed that requires nine steps: (1) build an item pool; (2) administer the items to a predefined sample in a calibration study; (3) eliminate inappropriate items; (4) examine whether all items are influenced by a single dominant trait; (5) calibrate the items to the best-fitting item response theory (IRT) model; (6) evaluate items' parameter equivalence across subgroups; (7) build an item bank with the calibrated items; (8) develop the CAT; and (9) pilot test the developed CAT. CAT offers the chance to extend the usefulness of patient-reported outcome (PRO) measurements from clinical studies to daily clinical practice.

Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice

OBJECTIVE

To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake.

DESIGN

Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes.

SETTING

Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel.

PARTICIPANTS

A consecutive sample of 22,019 adult patients (mean age 51.2 y, standard deviation=15.7, range 18-96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status at discharge.

RESULTS

Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs.

CONCLUSIONS

The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice.

Replenishing a computerized adaptive test of patient-reported daily activity functioning

PURPOSE

Computerized adaptive testing (CAT) item banks may need to be updated, but before new items can be added, they must be linked to the previous CAT. The purpose of this study was to evaluate 41 pretest items prior to including them into an operational CAT.

METHODS

We recruited 6,882 patients with spine, lower extremity, upper extremity, and nonorthopedic impairments who received outpatient rehabilitation in one of 147 clinics across 13 states of the USA. Forty-one new Daily Activity (DA) items were administered along with the Activity Measure for Post-Acute Care Daily Activity CAT (DA-CAT-1) in five separate waves. We compared the scoring consistency with the full item bank, test information function (TIF), person standard errors (SEs), and content range of the DA-CAT-1 to the new CAT (DA-CAT-2) with the pretest items by real data simulations.

RESULTS

We retained 29 of the 41 pretest items. Scores from the DA-CAT-2 were more consistent (ICC = 0.90 versus 0.96) than DA-CAT-1 when compared with the full item bank. TIF and person SEs were improved for persons with higher levels of DA functioning, and ceiling effects were reduced from 16.1% to 6.1%.

CONCLUSIONS

Item response theory and online calibration methods were valuable in improving the DA-CAT.

A computerized adaptive test for patients with hip impairments produced valid and responsive measures of function

OBJECTIVES

To describe the use of a computerized adaptive test (CAT) in routine clinical practice and evaluate content coverage and construct validity, sensitivity to change, and responsiveness of hip CAT functional status (FS) measures.

DESIGN

Longitudinal, prospective observational cohort study.

SETTING

Two hundred fifty-seven outpatient rehabilitation clinics in 31 states (United States).

PARTICIPANTS

Two samples were examined: intake and discharge rehabilitation FS data from patients (N=8714) treated for hip impairments between January 2005 and June 2007 and data from patients (N=444) used to develop the hip CAT were examined for comparison (2002-2004).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Hip functional status and global rating of change.

RESULTS

The CAT used on average 7 items to produce precise estimates of FS that adequately covered the content range with negligible floor and slight ceiling effects. Test information functions and SEs supported FS measure precision. FS measures discriminated patients in clinically logical ways. Sixty-one percent of patients obtained discharge FS measures greater than or equal to minimal detectable change (95% confidence intervals). Change of 6 FS units (scale: 0-100) represented minimal clinically important improvement, which 64% of patients obtained.

CONCLUSIONS

The hip CAT was efficient; produced valid, responsive measures of FS for patients receiving therapy for hip impairments; and functioned well in routine clinical application but would benefit from more difficult items.

Creating a computer adaptive test version of the late-life function and disability instrument

BACKGROUND

This study applied item response theory (IRT) and computer adaptive testing (CAT) methodologies to develop a prototype function and disability assessment instrument for use in aging research. Herein, we report on the development of the CAT version of the Late-Life Function and Disability Instrument (Late-Life FDI) and evaluate its psychometric properties.

METHODS

We used confirmatory factor analysis, IRT methods, validation, and computer simulation analyses of data collected from 671 older adults residing in residential care facilities. We compared accuracy, precision, and sensitivity to change of scores from CAT versions of two Late-Life FDI scales with scores from the fixed-form instrument. Score estimates from the prototype CAT versus the original instrument were compared in a sample of 40 older adults.

RESULTS

Distinct function and disability domains were identified within the Late-Life FDI item bank and used to construct two prototype CAT scales. Using retrospective data, scores from computer simulations of the prototype CAT scales were highly correlated with scores from the original instrument. The results of computer simulation, accuracy, precision, and sensitivity to change of the CATs closely approximated those of the fixed-form scales, especially for the 10- or 15-item CAT versions. In the prospective study, each CAT was administered in <3 minutes and CAT scores were highly correlated with scores generated from the original instrument.

CONCLUSIONS

CAT scores of the Late-Life FDI were highly comparable to those obtained from the full-length instrument with a small loss in accuracy, precision, and sensitivity to change.

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.