Disparities in Wheelchair Procurement by Payer Among People With Spinal Cord Injury

Falls in people with mobility limitations: a cross-sectional analysis of a US registry of assistive device users

Purpose of the Article: To (1) summarise the personal and clinical characteristics of persons with disabilities (PwDs) in the US who were evaluated for mobility assistive equipment (MAE) in the functional mobility assessment and uniform dataset (FMA/UDS) and (2) stratify subpopulations of PwD who reported falling versus those who do not report a fall.

Materials and Methods: This study was a retrospective, descriptive cohort analysis of adults with disabilities using the FMA/UDS. Data are collected during a user's initial evaluation for a new mobility device. The sample is intentionally general to be inclusive of all mobility device users. The primary variable of interest was a patient-reported fall within the 3 months leading up to their evaluation for a new mobility device. Subpopulation characteristics were stratified by this binary fall variable.

Results and Conclusions: This study provides descriptions of PwDs being evaluated for a new mobility device. There were 11,084 PwDs with 31 different primary diagnoses. During their new mobility device evaluation, 52.2% of PwDs reported at least one fall in the last 3 months. For those who reported a fall, 46.6% of PwDs were using a walking aid or no device at all before the new mobility device evaluation. Additionally, persons with progressively acquired disabilities (i.e., Parkinson's disease, osteoarthritis and cardiopulmonary disease) reported higher rates of falls than those with congenital disabilities (i.e., cerebral palsy and spina bifida). These findings will influence future studies comparing different types of devices and their influence on falls and user satisfaction.

Assistive technology in Korea: Findings from the 2017 National Disability Survey

PURPOSE

Explicitly monitoring the need, use and satisfaction of assistive product (AP) provision is essential to support population health and healthy longevity in ageing/aged countries, like Korea. We present findings from the 2017 Korea National Disability Survey (NDS) on AP access and compare them to international averages, introducing Korea's data into the wider coherence of global AP research.

MATERIALS AND METHODS

Using data from Korea's 2017 NDS, surveying 91,405 individuals, we extracted and calculated AP access indicators, including needing, having, using and being satisfied with 76 unique APs, by functional difficulty and product type. We compared satisfaction and unmet need between the National Health Insurance System (NHIS) and alternative provision services.

RESULTS

Prosthetics and orthotics had high rates of under-met need, and lower satisfaction rates, from 46.9% to 80.9%. Mobility APs overall had higher rates of under-met need. There was either low (<5%) or no reported need for most digital/technical APs. Among main products, those provided through the NHIS had lower unmet need (26.4%) than through alternative providers (63.1%), though satisfaction rates were similar (p < .001).

CONCLUSIONS

The Korean survey findings align with global averages calculated in the Global Report on Assistive Technology. Low reported needs for certain APs may reflect low awareness about how these products could benefit users, emphasizing the importance of data collection at each stage of the AP provision process. Recommendations to expand access to APs are given for people, personnel, provision, products, and policy.

Investigation of factors from assistive technology professionals that impact timeliness of wheelchair service delivery: a cross-sectional study

PURPOSE

The purpose of this study was to examine factors associated with variability in time from assessment to device delivery (cycle time). Our hypothesis was that device type and type of insurance would be the strongest predictor of cycle time.

MATERIALS AND METHODS

Data were extracted from the Functional Mobility Assessment/Uniform Dataset (FMA/UDS) Registry that at the time of analysis contained a sample of 2588 people with disabilities (PWD) who were provided with a wheeled mobility device (WMD) between 21 March 2016 and 29 June 2021. To examine the effect of individual factors on the variability in cycle time, a robust linear regression analysis was conducted.

RESULTS

The average national cycle time was 101.5 (SD = 59.9) d. Geographic area (Capital Metro [p < .001], Great Lakes [p = .016], and Northeast area [p < .001]), higher years since onset of disability (p < .001) and customizable devices (p = .021) were associated with higher cycle time. Non-customizable devices (p = .005), scooters (p < .001), Group 2 power wheelchairs (PWCs; p < .001), and funding source (Medicaid managed care (p < .001) and "other" (p = .028)) were associated with lower cycle time.

CONCLUSIONS

Longer cycle time is likely related to variations in clinical practice, insurance coverage criteria and the level of customizability of the device needed for a particular diagnosis, especially long-term disabilities.Implications for rehabilitationThe national average number of days between initial evaluation and device delivery (cycle time) to deliver a wheeled mobility device (WMD) varies based on specific variables such as type of WMD, diagnosis and payer source.Geographic area, years since onset of disability, device type, primary diagnosis and funding source significantly impact cycle times.Increased complexity of the WMD, both manual and power wheelchairs (PWCs), was associated with longer cycle times.As more service delivery models emerge, specific benefits and challenges need to be reported on how they impact cycle time.

A descriptive analysis of wheelchair repair registry data

Wheeled mobility and seating (WMS) devices allow users to achieve greater mobility independence. Previous studies determined that 53% of wheelchair users required one or more repairs over a 6-month period; however, there are a limited number of studies that have evaluated types of repairs. The purpose of this study was to describe the types of manual wheelchair, power wheelchair, and scooter repairs within the Wheelchair Repair Registry (WRR) and examine the association between WMS devices and the frequency of repairs. A dataset of 4,645 devices distributed in the United States was collected from equipment suppliers who performed and logged community-based wheelchair repair services. The results demonstrated common repairs found across devices were within the wheels/tires/forks and batteries/cables categories. Device type was the most significant predictor of variance in the number of repairs. Customizable manual wheelchairs, tilt-in-space, Groups 2 & 3 power wheelchairs, and scooters were associated with higher number of repairs compared to non-customizable manual wheelchairs, pediatric, heavy-duty manual wheelchairs, and Group 4 power wheelchairs. The higher failure rate found in specific devices may be associated with a population of more active users, environment/conditions where equipment is used, time spent in equipment, additional features on device, or lower durability.

Service delivery for complex rehabilitation technology: a scoping review

PURPOSE

Complex rehabilitation technologies (CRT) support independence for individuals with disabilities by enabling mobility for function, employment, education, and independent living. CRT service delivery is evolving, with changes to funding, provider qualifications, consumer needs, and technological advances. This scoping review investigated service delivery processes for individuals with disabilities who have a mobility impairment, while specifically identifying best practices, barriers, and unique features of health delivery policies and practices.

METHODS

We used a framework described by Colquhoun et. al. for conducting scoping reviews, a six-step process that includes: 1) identifying the research question, 2) identifying studies, 3) selecting studies 4) data charting, 5) reporting results and 6) consultation. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was also used for reporting results of the review.

RESULTS

Common categories were identified and organised into a hierarchical structure of four categories and 16 sub-categories. The primary categories included "policy", "consumer", "service delivery", and "wheeled mobility devices". The sub-categories described funding sources, consumer and professional populations, service delivery guidelines, and types of mobility devices. Analysis indicated the data were from 21 countries and 14 combinations of funding sources, and the articles were primarily descriptive studies.

CONCLUSION

This scoping review identified evidence from various countries, health systems, and stakeholder. Currently, this process does not proactively address the needs of individuals with mobility disabilities. The scoping review provides the foundation for the development of a novel policy on the provision of CRT services and devices to address these needs.Implications for RehabilitationExamination of national and international service delivery practices in diverse clinical and funding environments indicate various challenges and opportunities for improvement.CRT consumers are negatively impacted by current service delivery practices, including long wait times, lack of specialised clinical expertise, and limited consumer education opportunities.More consistent and widespread research is needed within the CRT provision industry to grow evidence-based practice related to complex rehabilitation technology and individuals with disabilities.

Disparities in Morbidity After Spinal Cord Injury Across Insurance Types in the United States

OBJECTIVE

To compare the prevalence and incidence of, and adjusted hazards for comorbidities among adults with traumatic spinal cord injuries (TSCIs) across insurance types (private vs governmental insurance) in the United States.

PATIENTS AND METHODS

Privately insured (N=9081) and Medicare (N=7645) beneficiaries with a diagnosis of TSCI were included. Prevalence and incidence estimates of common psychological, cardiometabolic, and musculoskeletal morbidities were compared at baseline and at 4-years after index diagnosis, respectively. Survival models were used to quantify hazard ratios (HRs) for outcomes, controlling for insurance type, sociodemographic characteristics, and other comorbidities. Sensitivity analyses were conducted to determine the effects of insurance and race/ethnicity.

RESULTS

Adults with TSCIs on Medicare had a higher prevalence of any psychological (54.7% vs 35.4%), cardiometabolic (74.7% vs 70.1%), and musculoskeletal (72.8% vs 66.3%) morbidity than privately insured adults with TSCIs. Similarly, the 4-year incidences of most psychological (eg, depression: 37.6% [Medicare] vs 24.2% [private]), cardiometabolic (eg, type 2 diabetes: 22.5% [Medicare] vs 12.9% [private], and musculoskeletal (eg, osteoarthritis: 42.1% [Medicare] vs 34.6% [private]) morbidities were considerably higher among adults with TSCIs on Medicare. Adjusted survival models found that adults with TSCIs on Medicare had a greater hazard for developing psychological (HR, 1.40; 95% CI, 1.31-1.50) and cardiometabolic (HR, 1.21; 95% CI, 1.10-1.33) morbidities compared with privately insured adults with TSCI. There was evidence of both insurance and racial disparities.

CONCLUSION

Adults with TSCIs on Medicare had significantly higher prevalence and risk for developing common physical and mental health comorbidities, compared with privately insured adults with TSCIs.

Factors Influencing Incidence of Wheelchair Repairs and Consequences Among Individuals with Spinal Cord Injury

OBJECTIVE

To investigate the frequency and consequences of wheelchair repairs, looking at the relationship to usage, components, out-of-pocket costs, number of days affecting the user, and factors associated with the need for repairs or consequences.

DESIGN

Survey, cross-sectional.

SETTING

Nine spinal cord injury (SCI) Model Systems centers.

PARTICIPANTS

Wheelchair users with SCI (N=533).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Cost and incidence of wheelchair repairs and consequences and wheelchair usage within the past 6 months.

RESULTS

A total of 310 participants (56%) reported repairs, 127 (42%) of whom experienced at least 1 adverse consequence lasting a median of 5 days (interquartile range [IQR], 2-17.3 days). Repair rates were highest for the seating system, electronics, and tires. Participants were most often stranded at home or forced to use a backup chair. Median out-of-pocket costs were $150 (IQR, $50-$620). Active users, based on type of mobility and terrain, experienced more repairs and consequences than less active users. Repairs were more common among those who were Black (odds ratio [OR], 2.42) or power wheelchair (PWC) users (OR, 1.84), whereas consequences were more common among those who were Black (OR, 2.27), PWC (OR, 2.08) or power assist users (OR, 2.76), and those who had public insurance (OR, 1.70).

CONCLUSIONS

Wheelchair repairs continue to affect more than 50% of wheelchair users with significant financial and personal cost. High repair rates limited participation inside and outside of the home. Consequences lasted longer than 2 weeks for many and may be minimized by a working backup chair. Disparities exist based on participant and wheelchair factors; repairs and adverse consequences appear to hit those most vulnerable with the least financial resources. Costs may be a barrier to repair completion for some individuals. This ongoing problem of high repair rates and their associated effects requires action such as higher standards, access to quicker service, and better training of users on wheelchair maintenance and repair.

Retrospective Chart Review Examining Differences and Timelines in Delivered Wheelchair Equipment in a Midwestern Dedicated Seating Department

OBJECTIVE

This study compares recommended wheeled mobility equipment to delivered equipment, excluding custom seats and backs, considering demographic factors such as sex, age, and funding source, as well as the timeline of the procurement process.

DESIGN

Retrospective chart review.

SETTING

Dedicated wheelchair seating department within a Midwestern rehabilitation hospital and associated complex rehabilitation technology durable medical equipment suppliers.

SAMPLE

Wheelchair recommendations (n = 546) made between January 1, 2017 and December 31, 2017.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Recommended and delivered wheelchair equipment type and length of time between recommendation and delivery.

RESULTS

Differences were found between the recommended and delivered equipment in manual wheelchairs, power mobility devices, seat backs, cushions, and power option equipment groups (p = ≤.001). Delivered manual wheelchairs were 7% more likely to be different than recommended for each year decrease in age (p = ≤.001), although the model lacked sufficient predictive accuracy for clinical application. Average length of time from equipment recommendation to delivery was about 6 months (M = 176 days). Standard and complex power mobility devices were associated with longer timelines (Mdn = 137, 173 days respectively; p = .001); although, only complex power mobility device timelines were significantly associated with public funding sources (p = .02).

CONCLUSIONS

Wheelchair bases, positioning accessories, and power options may be delivered differently than originally recommended, and the process for procuring complex power mobility devices with public funding sources should be further studied. Health care professionals should consistently follow-up on delivered equipment to ensure expectations and needs of the wheelchair user are met. Reducing systemic barriers to interdisciplinary communication post-recommendation may improve patient outcomes.

Demographics and Durable Medical Equipment Needs of Persons With Disabilities in a Charitable Rehabilitation Clinic

ABSTRACT

This study characterizes the demographics and durable medical equipment needs of persons with disabilities to improve utilization and management of resources at a philanthropic rehabilitation clinic. Paper charts from all encounters between 2013 and 2018 were reviewed. Data collected include sex, age, ethnicity, insurance status, diagnoses, and durable medical equipment requested/received. Paper charts that were incomplete or illegible were excluded. Among 763 individuals, there were 1157 encounters for durable medical equipment requests. Forty-six percent of individuals were uninsured. Thirty-seven percent had federal insurance such as Medicare or Medicaid, and 6% private insurance. Fifty-five percent of individuals were Hispanic, 28% African American, and 14% White. Fifty-six percent of encounters were with individuals with a neurological diagnosis, 18% medical diagnosis, 17% musculoskeletal/autoimmune diagnosis, 6% amputation diagnosis, and 3% cancer diagnosis. Of the 2680 items distributed, 34% were wheelchair parts and repair, 30% personal hygiene/incontinence supplies, 25% mobility equipment, and 11% bathroom equipment. Of the 513 unmet items requested, 49% were mobility equipment, 24% wheelchair parts and repair, 17% personal hygiene/incontinence supplies, and 11% bathroom equipment. More than a third (43%) of durable medical equipment requests were from individuals with either private insurance or federal payers, which implies lack of adequate coverage on durable medical equipment to maintain mobility and independence.

A Cross-Sectional Study to Investigate the Effects of Perceived Discrimination in the Health Care Setting on Pain and Depressive Symptoms in Wheelchair Users With Spinal Cord Injury

OBJECTIVES

In a sample of wheelchair users with spinal cord injury (SCI), the objectives were to investigate which participant characteristics are associated with greater perceived discrimination in the health care setting, and how such discrimination relates to health outcomes of pain and depressive symptoms.

DESIGN

Survey, cross-sectional.

SETTING

Spinal Cord Injury Model Systems (SCIMS) Center.

PARTICIPANTS

Full-time wheelchair users with SCI from 9 SCIMS centers (N=410), with data collected between 2011 and 2016.

INTERVENTIONS

N/A.

MAIN OUTCOMES

A 7-item questionnaire inquiring about perceived discrimination by hospital staff, self-reported pain severity over the past month using a 0-10 Numeric Rating Scale, and depressive symptoms using the 2-question Patient Health Questionnaire screener.

RESULTS

Participants who were black or from the lowest income group were more likely to report experiencing more discrimination than those who were white or from the highest income group, respectively (incidence rate ratio=2.2-2.6, P<.01). Those who reported more perceived discrimination had greater risk of severe pain compared to no pain (relative risk [RR]=1.11; 95% confidence interval [95% CI], 1.01-1.23; P<.05), mild depressive symptoms (RR=1.09; 95% CI, 1.02-1.17; P<.05), and severe depressive symptoms (RR=1.12; 95% CI, 1.04-1.21; P<.05) compared to no symptoms.

CONCLUSIONS

Wheelchair users with SCI who were from more disadvantaged groups (black, lower income levels) reported experiencing more discrimination in their health care setting. Furthermore, those who reported more discrimination were more likely to report worse mental and physical health outcomes. Attempts to reduce discrimination in health care settings may lead to better outcomes for people with SCI. These observations were correlational and not causal; a prospective analysis is necessary to prove causation. Future investigations should further explore the effect of discrimination on the many facets of living with an SCI.

Manual Wheelchair Skills Training for Community-Dwelling Veterans with Spinal Cord Injury: A Randomized Controlled Trial

OBJECTIVES

To test the hypotheses that community-dwelling veterans with spinal cord injury (SCI) who receive the Wheelchair Skills Training Program (WSTP) in their own environments significantly improve their manual wheelchair-skills capacity, retain those improvements at one year and improve participation in comparison with an Educational Control (EC) group.

METHODS

We carried out a randomized controlled trial, studying 106 veterans with SCI from three Veterans Affairs rehabilitation centers. Each participant received either five one-on-one WSTP or EC sessions 30-45 minutes in duration. The main outcome measures were the total and subtotal percentage capacity scores from the Wheelchair Skills Test 4.1 (WST) and Craig Handicap Assessment and Reporting Technique (CHART) scores.

RESULTS

Participants in the WSTP group improved their total and Advanced-level WST scores by 7.1% and 30.1% relative to baseline (p < 0.001) and retained their scores at one year follow-up. The success rates for individual skills were consistent with the total and subtotal WST scores. The CHART Mobility sub-score improved by 3.2% over baseline (p = 0.021).

CONCLUSIONS

Individualized wheelchair skills training in the home environment substantially improves the advanced and total wheelchair skills capacity of experienced community-dwelling veterans with SCI but has only a small impact on participation.

Assistive device use and mobility-related factors among adults aged≥65years

INTRODUCTION

Examining how assistive device (cane, walker) use relates to other mobility factors can provide insight into older adults' future mobility needs.

METHODS

Data come from the Second Injury Control and Risk Survey, Phase 2 (ICARIS2-P2), conducted from March 2007 to May 2008. Prevalence estimates were calculated for older adults (aged ≥65) and multivariable logistic regression was used to explore associations between assistive device use and mobility-related characteristics.

RESULT

Compared with non-users, assistive device users were more likely to report a recent fall (AOR 12.0; 95% CI 4.9-29.3), limit walking outside due to concerns about falling (AOR 7.1; 95% CI 2.6-19.1), be unable to walk outside for 10min without resting (AOR 3.3; 95% CI 1.1-9.3), and be no longer driving (AOR 6.7; 95% CI 2.0-22.3).

CONCLUSION

Assistive device users have limited mobility and an increased risk for fall injury compared with non-users.

PRACTICAL APPLICATION

Effective fall prevention interventions, and innovative transportation options, are needed to protect the mobility of this high-risk group.