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Hayes HA, Mor V, Wei G, Presson A, McDonough C. Medicare Advantage Patterns of Poststroke Discharge to an Inpatient Rehabilitation or Skilled Nursing Facility: A Consideration of Demographic, Functional, and Payer Factors. Phys Ther 2023; 103:pzad009. [PMID: 37014280 PMCID: PMC10655208 DOI: 10.1093/ptj/pzad009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/19/2022] [Accepted: 12/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the factors influencing the discharge to an inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF) of people poststroke with Medicare Advantage plans. METHODS A retrospective cohort study was conducted with data from naviHealth, a company that manages postacute care discharge placement on behalf of Medicare Advantage organizations. The dependent variable was discharge destination (IRF or SNF). Variables included age, sex, prior living setting, functional status (Activity Measure for Post-Acute Care [AM-PAC]), acute hospital length of stay, comorbidities, and payers (health plans). Analysis estimated relative risk (RR) of discharge to SNF, while controlling for regional variation. RESULTS Individuals discharged to an SNF were older (RR = 1.17), women (RR = 1.05), lived at home alone or in assisted living (RR = 1.13 and 1.39, respectively), had comorbidities impacting their function "some" or "severely" (RR = 1.43 and 1.81, respectively), and had a length of stay greater than 5 days (RR = 1.16). Individuals with better AM-PAC Basic Mobility (RR = 0.95) went to an IRF, and individuals with better Daily Activity (RR = 1.01) scores went to an SNF. There was a substantial, significant variation in discharge of individuals to SNF by payer group (RR range = 1.12-1.92). CONCLUSIONS The results of this study show that individuals poststroke are more likely to be discharged to an SNF than to an IRF. This study did not find a different discharge decision-making picture for those with Medicare Advantage plans than previously described for other insurance programs. IMPACT Medicare Advantage payers have varied patterns in discharge placement to an IRF or SNF for patients poststroke.
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Affiliation(s)
- Heather A Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Providence Veteran’s Administration Medical Center, Providence, Rhode Island, USA
| | - Guo Wei
- Study Design and Biostatistics Center, University of Utah, Salt Lake City, Utah, USA
| | - Angela Presson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Christine McDonough
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Casey K, Sim E, Lavezza A, Iannuzzi K, Friedman LA, Hoyer EH, Young DL. Identifying Cognitive Impairment in the Acute Care Hospital Setting: Finding an Appropriate Screening Tool. Am J Occup Ther 2023; 77:24036. [PMID: 36764005 DOI: 10.5014/ajot.2023.050028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
IMPORTANCE Identifying cognitive impairment in adults in acute care is essential so that providers can address functional deficits and plan for safe discharge. Occupational therapy practitioners play an essential role in screening for, evaluating, and treating cognitive impairment. OBJECTIVE To test and compare the psychometrics and feasibility of three cognitive screens and select the ideal screen for use in acute care. DESIGN Prospective mixed methods. SETTING Acute care hospital. PARTICIPANTS Fifty adults. OUTCOMES AND MEASURES We examined the interrater reliability, administration time, and usability of the Brief Cognitive Assessment Tool Short Form (BCAT-SF), the Activity Measure for Post-Acute Care "6-Clicks" Applied Cognitive Inpatient Short Form (AM-PAC ACISF), and the Montreal Cognitive Assessment (MoCA). We compared the construct validity, sensitivity, and specificity of the BCAT-SF and AM-PAC ACISF with those of the MoCA. RESULTS Interrater reliability was good to excellent; ICCs were .98 for the MoCA, .97 for the BCAT-SF, and .86 for the AM-PAC ACISF. The BCAT-SF and the AM-PAC ACISF both had 100% sensitivity, and specificity was 74% for the BCAT-SF and 98% for the AM-PAC ACISF. The optimal cutoff score for cognitive impairment on the AM-PAC ACISF was <22. Administration time of the AM-PAC ACISF (1.0 min) was significantly less than that of the BCAT-SF (5.0 min) and the MoCA (13.3 min; p < .001). CONCLUSIONS AND RELEVANCE Each screen demonstrated acceptable reliability and construct validity. The AM-PAC ACISF had the optimum mix of performance and feasibility for the fast-paced acute care setting. What This Article Adds: Early identification of cognitive impairment using the AM-PAC ACISF can allow for timely occupational therapy intervention in acute care settings.
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Affiliation(s)
- Kelly Casey
- Kelly Casey, OTD, OTR/L, BCPR, ATP, CPAM, is Acute Care Therapy Services Team Leader, Johns Hopkins Hospital, Baltimore, MD;
| | - Erin Sim
- Erin Sim, OTD, OTR/L, PMP, is Acute Care Team Coordinator, Johns Hopkins Hospital, Baltimore, MD
| | - Annette Lavezza
- Annette Lavezza, OTR/L, is Director, Inpatient Therapy Services, Johns Hopkins Hospital, Baltimore, MD; Assistant Professor, Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD; and Member, Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kristen Iannuzzi
- Kristen Iannuzzi, OTD, OTR/L, BCPR, CPAM, is Occupational Therapist and Occupational Therapy Acute Care Fellow, Johns Hopkins Hospital, Baltimore, MD
| | - Lisa Aronson Friedman
- Lisa Aronson Friedman, ScM, is Senior Biostatistician, Division of Pulmonary and Critical Care Medicine, and Member, Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Erik H Hoyer
- Erik H. Hoyer, MD, is Assistant Professor and Vice Chair for Quality and Safety, Department of Physical Medicine and Rehabilitation, and Member, Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD
| | - Daniel L Young
- Daniel L. Young, PT, DPT, PhD, is Associate Professor, Department of Physical Therapy, University of Nevada; Member, Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University School of Medicine, Baltimore, MD; and Adjunct Associate Professor, Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD
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Schmerler J, Mo KC, Olson J, Kurian SJ, Skolasky RL, Kebaish KM, Neuman BJ. Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery. Spine J 2022; 23:746-753. [PMID: 36509380 DOI: 10.1016/j.spinee.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/12/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND CONTEXT Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients. PURPOSE To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery. DESIGN Retrospective review. PATIENT SAMPLE Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained. OUTCOME MEASURES The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute. METHODS Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM. RESULTS LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM. CONCLUSIONS Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jarod Olson
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shyam J Kurian
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Mo KC, Schmerler J, Olson J, Musharbash FN, Kebaish KM, Skolasky RL, Neuman BJ. AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery. Spine J 2022; 22:1884-1892. [PMID: 35870798 DOI: 10.1016/j.spinee.2022.07.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/26/2022] [Accepted: 07/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery. PURPOSE To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery. STUDY DESIGN Retrospective review PATIENT SAMPLE: Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included. OUTCOME MEASURES Non-home discharge disposition METHODS: Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify the optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold. RESULTS Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge. CONCLUSIONS First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.
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Affiliation(s)
- Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Jarod Olson
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 5241, Baltimore, MD 21287, USA.
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Combining the AM-PAC "6-Clicks" and the Morse Fall Scale to Predict Individuals at Risk for Falls in an Inpatient Rehabilitation Hospital. Arch Phys Med Rehabil 2021; 102:2309-2315. [PMID: 34407447 DOI: 10.1016/j.apmr.2021.07.800] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the effect of adding the Activity Measure for Post-Acute Care (AM-PAC) Inpatient '6-Clicks' Short Forms to the Morse Fall Scale (MFS) to assess fall risk. Falls that occur in a rehabilitation hospital result in increased morbidity and mortality, increased cost, and negatively affect reimbursement. Identifying individuals at high risk for falls would enable targeted fall prevention strategies and facilitate appropriate resource allocation to address this critical patient safety issue. DESIGN We used a retrospective observational design and repeated k-fold cross-validation (10 repeats and 10 folds) of logistic regression models with falls regressed onto: MFS alone, AM-PAC basic mobility and applied cognitive scales alone, and MFS and AM-PAC combined. SETTING Inpatient rehabilitation hospital. PARTICIPANTS After exclusions, 2007 patients from an inpatient setting (N=2007; 131 experienced a fall). Primary diagnoses included 602 individuals with stroke (30%), 502 with brain injury (25%), 321 with spinal cord injury (16%), and 582 with other diagnoses (29%). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Experience of a fall during inpatient stay. RESULTS The MFS at admission was associated with falls (area under the curve [AUC], 0.64). Above and beyond the MFS, AM-PAC applied cognitive and basic mobility at admission were also significantly associated with falls (combined model AUC, 0.70). Although MFS and applied cognition showed linear associations, there was evidence for a nonlinear association with AM-PAC basic mobility. CONCLUSIONS The AM-PAC basic mobility and AM-PAC applied cognitive scales showed associations with falls above and beyond the MFS. More work is needed to validate model predictions in an independent sample with truly longitudinal data; prediction accuracy would also need to be substantially improved. However, the current data do suggest that the AM-PAC has the potential to reduce the burden of fall management by focusing resources on a smaller cohort of patients identified as having a high fall risk.
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Abstract
Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.
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Hsieh CJ, DeJong G, Vita M, Zeymo A, Desale S. Effect of Outpatient Rehabilitation on Functional Mobility After Single Total Knee Arthroplasty: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2016571. [PMID: 32940679 PMCID: PMC7499127 DOI: 10.1001/jamanetworkopen.2020.16571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/26/2020] [Indexed: 11/16/2022] Open
Abstract
Importance Even without evidence, rehabilitation practitioners continue to introduce new interventions to enhance the mobility outcomes for the increasing population with a recent total knee arthroplasty (TKA). Objective To compare post-TKA functional mobility outcomes among 3 newly developed physical therapy protocols with a standard-of-care post-TKA rehabilitation protocol. Design, Setting, and Participants This randomized clinical trial included 4 study arms implemented in 15 outpatient clinics within a single health system in the Baltimore, Maryland, and Washington, District of Columbia, region from October 2013 to April 2017. Participants included patients who underwent elective unilateral TKA, were aged 40 years and older, and began outpatient physical therapy within 24 days after TKA. A total of 505 patients were screened and 386 participants were enrolled. Patients provided informed consent and were randomly assigned to 1 of 4 groups. Blinding patients and treating therapists was not feasible owing to the nature of the intervention. Analysis was conducted under the modified intent-to-treat principle from October 2017 to May 2019. Interventions The control group used a standard recumbent bike for 15 to 20 minutes each session. Interventions used 1 of 3 modalities for 15 to 20 minutes each session: (1) a body weight-adjustable treadmill, (2) a patterned electrical neuromuscular stimulation device, or (3) a combination of the treadmill and electrical neuromuscular stimulation. Main Outcomes and Measures Outcomes included the Activity Measure for Post-acute Care basic mobility score, a patient-reported outcome measure, and the 6-minute walk test. Outcomes were measured at baseline, monthly, and on discharge from outpatient therapy. Results Data from 363 patients (mean [SD] age, 63.4 [7.9] years; 222 [61.2%] women) were included in the final analysis, including 92 participants randomized to the control group, 91 participants randomized to the treadmill group, 90 participants randomized to the neuromuscular stimulation device group, and 90 participants randomized to the combination intervention group. Activity Measure for Post-acute Care scores at discharge were similar across groups, ranging from 61.1 to 61.3 (P = .99) with at least 9.0 points improvement (P = .80) since baseline. The distances as measured by the 6-minute walking test were not statistically different across groups (range, 382.9-404.5 m; P = .60). Conclusions and Relevance This randomized clinical trial found no statistically or clinically significant differences in outcomes across the 4 arms. Because outcomes were similar among arms, clinicians should instead consider relative cost in tailoring TKA rehabilitation. Trial Registration ClinicalTrials.gov Identifier: NCT02426190.
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Affiliation(s)
- Chinghui Jean Hsieh
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, Maryland
| | - Gerben DeJong
- MedStar National Rehabilitation Hospital, Washington, District of Columbia
- Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, District of Columbia
| | - Michele Vita
- MedStar National Rehabilitation Network, Washington, District of Columbia
| | | | - Sameer Desale
- MedStar Health Research Institute, Hyattsville, Maryland
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Campo M, Toglia J, Batistick-Aufox H, O'Dell MW. Standardized Outcome Measures in Stroke Rehabilitation and Falls After Discharge: A Cohort Study. PM R 2020; 13:265-273. [PMID: 32358887 DOI: 10.1002/pmrj.12396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/14/2020] [Accepted: 04/22/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Individuals with stroke discharged from inpatient rehabilitation units (IRUs) are at increased risk for falls. In IRUs, standardized outcome measures (SOMs) have been used to predict falls, but the results have been mixed. OBJECTIVE To examine the relationship between SOMs and the risk of falls in individuals with stroke within 6 months of discharge from an IRU. DESIGN Prospective cohort study with 6-month follow-up. SETTING IRU that was part of a large, urban academic medical center. PARTICIPANTS Individuals with stroke who underwent rehabilitation. MAIN OUTCOME MEASURES Self-reported falls within 6 months of discharge. RESULTS The study included 105 participants who were discharged to their homes after inpatient rehabilitation and who responded to a 6-month follow-up (57% response rate) phone call. Twenty-nine participants (28%) reported falling. Significant odds ratios (ORs), adjusted for age, sex, and stroke severity, were found for the following measures: Berg Balance Scale (OR 0.95, 95% confidence interval [CI] 0.92-0.99), Activity Measure for Post-Acute Care basic mobility (OR 0.89, 95% CI 0.81-0.97), Motricity Index (OR 0.96, 95% CI 0.94-0.98), Functional Independence Measure mobility subscale (OR 0.89, 95% CI 0.80-0.98), and Trunk Control Test (OR 0.97, 95% CI 0.95-0.99). Areas under the curve ranged from .64 to .71. In samples of 82 to 90 patients who could complete the tests, gait speed, the Functional Reach Test, the 6-minute Walk Test, and Timed Up and Go did not result in significant ORs. CONCLUSIONS At discharge, SOMs were associated with the odds of falls within 6 months. The multifactorial nature of falls will continue to make prediction challenging but SOMs can be helpful. Lower extremity strength deserves more attention as a risk factor.
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Affiliation(s)
- Marc Campo
- School of Health and Natural Sciences, Mercy College, Dobbs Ferry, NY
| | - Joan Toglia
- School of Health and Natural Sciences, Mercy College, Dobbs Ferry, NY
| | | | - Michael W O'Dell
- Clinical Rehabilitation Medicine, Weill Cornell Medicine, New York City, NY
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Borges PRT, Sampaio RF, Kirkwood RN, Souza MAPD, Mancini MC, Furtado SRC. Reduced version of the Activity Measure for Post-Acute Care (AM-PAC) for inpatients, "6-clicks": Brazilian-Portuguese cross-cultural adaptation and measurement properties. Braz J Phys Ther 2019; 24:231-239. [PMID: 30850214 DOI: 10.1016/j.bjpt.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 02/11/2019] [Accepted: 02/15/2019] [Indexed: 10/27/2022] Open
Abstract
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 (ICC2.1=0.81, 0.83 and 0.82, respectively), good to moderate for daily activity (ICC2.1=0.78 and ICC3.1=0.71 and 0.82, respectively) and moderate to poor for applied cognitive (ICC2.1=0.64, 0.36 and ICC3.1=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.
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Affiliation(s)
| | - Rosana Ferreira Sampaio
- Graduate Program in Rehabilitation Science, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Physical Therapy Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Renata Noce Kirkwood
- Graduate Program in Rehabilitation Science, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | | | - Marisa Cotta Mancini
- Graduate Program in Rehabilitation Science, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Occupation Therapy Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Sheyla Rossana Cavalcanti Furtado
- Graduate Program in Rehabilitation Science, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Physical Therapy Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
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Ulrich CM, Himbert C, Boucher K, Wetter DW, Hess R, Kim J, Lundberg K, Ligibel JA, Barnes CA, Rushton B, Marcus R, Finlayson SRG, LaStayo PC, Varghese TK. Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: rationale and design of the PEP study trial. BMJ Open 2018; 8:e024672. [PMID: 30559162 PMCID: PMC6303592 DOI: 10.1136/bmjopen-2018-024672] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/05/2018] [Accepted: 09/26/2018] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Lung cancer is a significant burden on societies worldwide, and the most common cause of death in patients with cancer overall. Exercise intervention studies in patients with lung cancer have consistently shown benefits with respect to physical and emotional functioning. However, to date, exercise training has not been consistently implemented into clinical practice given that interventions have been costly and not aligned with clinical care. METHODS/DESIGN The Precision-Exercise-Prescription (PEP) study is a prospective randomised controlled trial comparing the effectiveness and feasibility of a personalised intervention exercise programme among patients with lung cancer undergoing surgery. Two-hundred patients who are diagnosed with stage primary or secondary lung cancer and are eligible to undergo surgical treatment at Huntsman Cancer Institute comprise the target population. Patients are randomised to either the (1) outpatient precision-exercise intervention group or (2) delayed intervention group. The intervention approach uses Motivation and Problem Solving, a hybrid behavioural treatment based on motivational interviewing and practical problem solving. The dosage of the exercise intervention is personalised based on the individual's Activity Measure for Post-Acute-Care outpatient basic mobility score, and incorporates four exercise modes: mobility, callisthenics, aerobic and resistance. Exercise is implemented by physical therapists at study visits from presurgery until 6 months postsurgery. The primary endpoint is the level of physical function assessed by 6 min walk distance at 2 months postsurgery. Secondary outcomes include patient-reported outcomes (eg, quality of life, fatigue and self-efficacy) and other clinical outcomes, including length of stay, complications, readmission, pulmonary function and treatment-related costs up to 6 months postsurgery. ETHICS/DISSEMINATION The PEP study will test the clinical effectiveness and feasibility of a personalised exercise intervention in patients with lung cancer undergoing surgery. Outcomes of this clinical trial will be presented at national and international conferences and symposia and will be published in international, peer-reviewed journals. Ethics approval was obtained at the University of Utah (IRB 00104671). TRIAL REGISTRATION NUMBER NCT03306992.
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Affiliation(s)
- Cornelia M Ulrich
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Caroline Himbert
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Kenneth Boucher
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - David W Wetter
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Rachel Hess
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
- Division of General Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jaewhan Kim
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Health and Kinesiology, University of Utah, Salt Lake City, Utah, USA
| | - Kelly Lundberg
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, USA
| | - Jennifer A Ligibel
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Barnes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | | | - Robin Marcus
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | | | - Paul C LaStayo
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Thomas K Varghese
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah, USA
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Bagraith KS, Strong J, Meredith PJ, McPhail SM. Self-reported disability according to the International Classification of Functioning, Disability and Health Low Back Pain Core Set: Test-retest agreement and reliability. Disabil Health J 2017; 10:621-626. [DOI: 10.1016/j.dhjo.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 12/22/2016] [Accepted: 01/02/2017] [Indexed: 12/12/2022]
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Toglia J, Askin G, Gerber LM, Taub MC, Mastrogiovanni AR, O'Dell MW. Association Between 2 Measures of Cognitive Instrumental Activities of Daily Living and Their Relation to the Montreal Cognitive Assessment in Persons With Stroke. Arch Phys Med Rehabil 2017; 98:2280-2287. [PMID: 28478128 DOI: 10.1016/j.apmr.2017.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/28/2017] [Accepted: 04/08/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To explore the relation between a computer adaptive functional cognitive questionnaire and a performance-based measure of cognitive instrumental activities of daily living (C-IADL) and to determine whether the Montreal Cognitive Assessment (MoCA) at admission can identify those with C-IADL difficulties at discharge. DESIGN Prospective cohort study. SETTING Acute inpatient rehabilitation unit of an academic medical center. PARTICIPANTS Inpatients (N=148) with a diagnosis of stroke (mean age, 68y; median, 13d poststroke) who had mild cognitive and neurological deficits. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Admission cognitive status was assessed by the MoCA. C-IADL at discharge was assessed by the Executive Function Performance Test (EFPT) bill paying task and Activity Measure of Post-Acute Care (AM-PAC) Applied Cognition scale. RESULTS Greater cognitive impairment on the MoCA was associated with more assistance on the EFPT bill paying task (ρ=-.63; P<.01) and AM-PAC Applied Cognition scale (ρ=-.43; P<.01). This relation was nonsignificant for higher MoCA scores and EFPT bill paying task scores. The AM-PAC Applied Cognition scale and the EFPT bill paying task had low agreement in classifying functional performance (Cohen's κ=.20). A receiver operating characteristic curve identified optimal MoCA cutoff scores of 20 and 21 for classifying EFPT bill paying task status and AM-PAC Applied Cognition scale status, respectively. For values above 20 and 21, sensitivity increased whereas specificity decreased for classifying functional deficits. Approximately one third of the participants demonstrated C-IADL deficits on at least 1 C-IADL measure at discharge despite having a MoCA score of ≥26 at admission. CONCLUSIONS Questionnaire and performance-based methods of assessment appear to yield different estimates of C-IADL. Low MoCA scores (<20) are more likely to identify those with C-IADL deficits on the EFPT bill paying task. The results suggest that C-IADL should be assessed in those who have mild or no cognitive difficulties at admission.
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Affiliation(s)
- Joan Toglia
- School of Health and Natural Sciences, Mercy College, Dobbs Ferry, NY; Department of Rehabilitation Medicine, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY.
| | - Gulce Askin
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY
| | - Linda M Gerber
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY
| | | | - Andrea R Mastrogiovanni
- Department of Rehabilitation Medicine, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY
| | - Michael W O'Dell
- Department of Rehabilitation Medicine, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY; Weill Cornell Medicine, New York, NY
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Oncology EDGE Task Force on Prostate Cancer Outcomes: A Systematic Review of Outcome Measures for Functional Mobility. REHABILITATION ONCOLOGY 2016. [DOI: 10.1097/01.reo.0000000000000029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Hill JN, Balbale S, Lones K, LaVela SL. Starting a new conversation: Engaging Veterans with spinal cord injury in discussions of what function means to them, the barriers/facilitators they encounter, and the adaptations they use to optimize function. Disabil Health J 2016; 10:114-122. [PMID: 27424945 DOI: 10.1016/j.dhjo.2016.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 05/17/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Assessments of function in persons with spinal cord injury (SCI) often utilize pre-defined constructs and measures without consideration of patient context, including how patients define function and what matters to them. OBJECTIVES/HYPOTHESIS We utilized photovoice to understand how individuals define function, facilitators and barriers to function, and adaptations to support functioning. METHODS Veterans with SCI were provided with cameras and guidelines to take photographs of things that: (1) help with functioning, (2) are barriers to function, and (3) represent adaptations used to support functioning. Interviews to discuss photographs followed and were audio-recorded, transcribed, and analyzed using grounded-thematic coding. Nvivo 8 was used to store and organize data. RESULTS Participants (n = 9) were male (89%), Caucasian (67%), had paraplegia (75%), averaged 64 years of age, and were injured, on average, for 22 years. Function was described in several ways: the concept of 'normalcy,' aspects of daily living, and ability to be independent. Facilitators included: helpful tools, physical therapy/therapists, transportation, and caregivers. Barriers included: wheelchair-related issues and interior/exterior barriers both in the community and in the hospital. Examples of adaptations included: traditional examples like ramps, and also creative examples like the use of rubber bands on a can to help with grip. CONCLUSION(S) Patient-perspectives elicited in-depth information that expanded the common definition of function by highlighting the concept of "normality," facilitators and barriers to function, and adaptations to optimize function. These insights emphasize function within a patient-context, emphasizing a holistic definition of function that can be used to develop personalized, patient-driven care plans.
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Affiliation(s)
- Jennifer N Hill
- Department of Veterans Affairs (VA), Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center of Innovation for Complex Chronic Health Care (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Edward Hines Jr. VA Hospital, Hines, IL, USA.
| | - Salva Balbale
- Department of Veterans Affairs (VA), Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Keshonna Lones
- Department of Veterans Affairs (VA), Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center of Innovation for Complex Chronic Health Care (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Sherri L LaVela
- Department of Veterans Affairs (VA), Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center of Innovation for Complex Chronic Health Care (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Edward Hines Jr. VA Hospital, Hines, IL, USA; Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University, Chicago, IL, USA
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Are CMS G-Code Functional Limitation Severity Modifiers Responsive to Change Across an Episode of Outpatient Rehabilitation? Phys Ther 2015; 95:1650-9. [PMID: 26294681 DOI: 10.2522/ptj.20150003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 08/04/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services has mandated rehabilitation professionals to document patients' impairment levels. There is no evidence of responsiveness to change of functional limitation severity modifier codes. OBJECTIVE The purpose of this study was to assess the validity of G-code functional limitation severity modifier codes in determining change in function. DESIGN This was a retrospective observational study. METHODS Patients completed the Activity Measure for Post-Acute Care (AM-PAC) and were assigned G-codes, with severity modifiers based on AM-PAC scores at initial and follow-up visits. Patients were classified as having AM-PAC scores in the upper or lower range for each severity modifier, and sensitivity, specificity, and positive and negative predictive values for change in severity modifier level and odds of changing by one severity modifier level using a change in AM-PAC score of at least 1 minimal detectable change at the 95% confidence interval (MDC95) as the standard were determined. RESULTS Sensitivity and specificity of change in severity modifier in determining change in function were dependent on patients' initial AM-PAC scores. Improvement in severity modifier level was 2.2 to 4.5 times more likely with scores at the higher end of the range within a severity modifier level than with scores in the lower end of the range. Decline in severity modifier level was 2.7 to 4.8 times more likely with scores at the lower end of the range within a severity modifier than with scores in the higher end of the range. LIMITATIONS Data were from one health care system, and most patients had orthopedic conditions. The MDC95 for AM-PAC tool may not be the best standard for defining functional change. CONCLUSIONS The G-code functional limitation severity modifier system may not be valid for determining change in function and is not recommended for determining if patients have changed over the course of outpatient therapy.
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Interrater Reliability of AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms. Phys Ther 2015; 95:758-66. [PMID: 25504489 DOI: 10.2522/ptj.20140174] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 11/25/2014] [Indexed: 02/07/2023]
Abstract
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.
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Marino ME, Meterko M, Marfeo EE, McDonough CM, Jette AM, Ni P, Bogusz K, Rasch EK, Brandt DE, Chan L. Work-related measures of physical and behavioral health function: Test-retest reliability. Disabil Health J 2015; 8:652-7. [PMID: 25991419 DOI: 10.1016/j.dhjo.2015.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/31/2015] [Accepted: 04/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Work Disability Functional Assessment Battery (WD-FAB), developed for potential use by the US Social Security Administration to assess work-related function, currently consists of five multi-item scales assessing physical function and four multi-item scales assessing behavioral health function; the WD-FAB scales are administered as Computerized Adaptive Tests (CATs). OBJECTIVE The goal of this study was to evaluate the test-retest reliability of the WD-FAB Physical Function and Behavioral Health CATs. METHODS We administered the WD-FAB scales twice, 7-10 days apart, to a sample of 376 working age adults and 316 adults with work-disability. Intraclass correlation coefficients were calculated to measure the consistency of the scores between the two administrations. Standard error of measurement (SEM) and minimal detectable change (MDC90) were also calculated to measure the scales precision and sensitivity. RESULTS For the Physical Function CAT scales, the ICCs ranged from 0.76 to 0.89 in the working age adult sample, and 0.77-0.86 in the sample of adults with work-disability. ICCs for the Behavioral Health CAT scales ranged from 0.66 to 0.70 in the working age adult sample, and 0.77-0.80 in the adults with work-disability. The SEM ranged from 3.25 to 4.55 for the Physical Function scales and 5.27-6.97 for the Behavioral Health function scales. For all scales in both samples, the MDC90 ranged from 7.58 to 16.27. CONCLUSION Both the Physical Function and Behavioral Health CATs of the WD-FAB demonstrated good test-retest reliability in adults with work-disability and general adult samples, a critical requirement for assessing work related functioning in disability applicants and in other contexts.
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Affiliation(s)
- Molly Elizabeth Marino
- Boston University School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston MA 02118, USA.
| | - Mark Meterko
- Boston University School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston MA 02118, USA; VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
| | - Elizabeth E Marfeo
- Boston University School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston MA 02118, USA
| | - Christine M McDonough
- Boston University School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston MA 02118, USA
| | - Alan M Jette
- Boston University School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston MA 02118, USA
| | - Pengsheng Ni
- Boston University School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston MA 02118, USA
| | - Kara Bogusz
- Boston University School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston MA 02118, USA
| | - Elizabeth K Rasch
- National Institutes of Health, Rehabilitation Medicine Department, Mark O. Hatfield Clinical Research Center, Bethesda, MD, USA
| | - Diane E Brandt
- National Institutes of Health, Rehabilitation Medicine Department, Mark O. Hatfield Clinical Research Center, Bethesda, MD, USA
| | - Leighton Chan
- National Institutes of Health, Rehabilitation Medicine Department, Mark O. Hatfield Clinical Research Center, Bethesda, MD, USA
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Does activity limitation predict discharge destination for postacute care patients? Am J Phys Med Rehabil 2015; 93:782-90. [PMID: 24800717 DOI: 10.1097/phm.0000000000000097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aimed to examine the ability of different domains of activity limitation to predict discharge destination (home vs. nonhome settings) 1 mo after hospital discharge for postacute rehabilitation patients. DESIGN A secondary analysis was conducted using a data set of 518 adults with neurologic, lower extremity orthopedic, and complex medical conditions followed after discharge from a hospital into postacute care. Variables collected at baseline include activity limitations (basic mobility, daily activity, and applied cognitive function, measured by the Activity Measure for Post-Acute Care), demographics, diagnosis, and cognitive status. The discharge destination was recorded at 1 mo after being discharged from the hospital. RESULTS Correlational analyses revealed that the 1-mo discharge destination was correlated with two domains of activity (basic mobility and daily activity) and cognitive status. However, multiple logistic regression and receiver operating characteristic curve analyses showed that basic mobility functioning performed the best in discriminating home vs. nonhome living. CONCLUSIONS This study supported the evidence that basic mobility functioning is a critical determinant of discharge home for postacute rehabilitation patients. The Activity Measure for Post-Acute Care-basic mobility showed good usability in discriminating home vs. nonhome living. The findings shed light on the importance of basic mobility functioning in the discharge planning process.
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Abstract
BACKGROUND Physical therapists and occupational therapists practicing in acute care hospitals play a crucial role in discharge planning. A standardized assessment of patients' function could be useful for discharge recommendations. OBJECTIVES The study objective was to determine the accuracy of "6-Clicks" basic mobility and daily activity measures for predicting discharge from an acute care hospital to a home or institutional setting. DESIGN The study was retrospective and observational. METHODS "6-Clicks" scores obtained at initial visits by physical therapists or occupational therapists and patients' discharge destinations were used to develop and validate receiver operating characteristic curves for predicting discharge destination. Positive predictive values (PPV), negative predictive values (NPV), and likelihood ratios were calculated. RESULTS Areas under the receiver operating characteristic curves for basic mobility scores were 0.857 (95% confidence interval [CI]=0.852, 0.862) and 0.855 (95% CI=0.850, 0.860) in development and validation samples, respectively. Areas under the curves for daily activity scores were 0.846 (95% CI=0.841, 0.851) and 0.845 (95% CI=0.840, 0.850) in development and validation samples, respectively. Cutoff scores providing the best accuracy for determining discharge destination were 42.9 for basic mobility and 39.4 for daily activity. For basic mobility, the PPV was 0.748 and the NPV was 0.801 in both development and validation samples. For daily activity, the PPVs were 0.787 and 0.784 and the NPVs were 0.748 and 0.746 in development and validation samples, respectively. LIMITATIONS Limitations included lack of information on the rater reliability of "6-Clicks" instruments, use of surrogate data for some discharge designations, and use of a clinical database for research purposes. CONCLUSIONS This study provides evidence of the accuracy of "6-Clicks" scores for predicting destination after discharge from an acute care hospital.
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Chan L, Sandel ME, Jette AM, Appelman J, Brandt DE, Cheng P, Teselle M, Delmonico R, Terdiman JF, Rasch EK. Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke. Arch Phys Med Rehabil 2013; 94:622-9. [PMID: 23124133 PMCID: PMC3584186 DOI: 10.1016/j.apmr.2012.09.033] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 09/12/2012] [Accepted: 09/30/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the impact of postacute care site on stroke outcomes. DESIGN Prospective cohort study. SETTING Four northern California hospitals that are part of a single health maintenance organization. PARTICIPANTS Patients with stroke (N=222) enrolled between February 2008 and July 2010. INTERVENTION Not applicable. MAIN OUTCOME MEASURE Baseline and 6-month assessments were performed using the Activity Measure for Post Acute Care (AM-PAC), a test of self-reported function in 3 domains: Basic Mobility, Daily Activities, and Applied Cognition. RESULTS Of the 222 patients analyzed, 36% went home with no treatment, 22% received home health/outpatient care, 30% included an inpatient rehabilitation facility (IRF) in their care trajectory, and 13% included a skilled nursing facility (but not IRF) in their care trajectory. At 6 months, after controlling for important variables such as age, functional status at acute care discharge, and total hours of rehabilitation, patients who went to an IRF had functional scores that were at least 8 points higher (twice the minimally detectable change for the AM-PAC) than those who went to a skilled nursing facility in all 3 domains and in 2 of 3 functional domains compared with those who received home health/outpatient care. CONCLUSIONS Patients with stroke may make more functional gains if their postacute care includes an IRF. This finding may have important implications as postacute care delivery is reshaped through health care reform.
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Affiliation(s)
- Leighton Chan
- National Institutes of Health, Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department, Bethesda, MD 20892, USA.
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Samita FN, Sandjo LP, Ndiege IO, Hassanali A, Lwande W. Zanthoxoaporphines A-C: Three new larvicidal dibenzo[de,g]quinolin-7-one alkaloids from Zanthoxylum paracanthum (Rutaceae). Beilstein J Org Chem 2013; 9:447-52. [PMID: 23504306 PMCID: PMC3596013 DOI: 10.3762/bjoc.9.47] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 02/06/2013] [Indexed: 11/25/2022] Open
Abstract
The bioassay-guided purification of Zanthoxylum paracanthum (Rutaceae) extracts led to the isolation of three new alkaloids, namely 1-hydroxy-10-methoxy-7H-dibenzo[de,g]quinolin-7-one (zanthoxoaporphine A, 2), 1-hydroxy-7H-dibenzo[de,g]quinolin-7-one (zanthoxoaporphine B, 3) and 1,8-dihydroxy-9-methoxy-7H-dibenzo[de,g]quinolin-7-one (zanthoxaporphine C, 4), and a known lignan identified as sesamin (1). Isolation and purification of the constituent compounds was achieved through conventional chromatographic methods. The chemical structures of the isolated compounds were determined on the basis of UV, IR, NMR and MS data, and confirmed by comparison with those reported in the literature. The larvicidal activity of some of the isolated compounds was investigated by using third-instar Anopheles gambiae larvae.
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Affiliation(s)
- Fidelis N Samita
- Department of Chemistry, Maseno University, P.O. Private Bag Maseno, Kenya ; Department of Chemistry, Kenyatta University, P.O. Box 43844, Nairobi 00100, Kenya
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Abstract
The primary focus of this review is on the cost-effectiveness of critical care. The rapid growth in health care expenditures has engendered careful scrutiny of the practice of medicine with regard not only to effectiveness but also to efficiency. This shift necessitates that physicians understand the effectiveness of their interventions and the cost at which this effectiveness is obtained. Cost-effectiveness and cost-utility analyses have become crucial evaluative tools in medicine. Explicit articulation of comparative cost-effectiveness facilitates the allocation of limited resources. Physicians and policy-makers must evaluate such studies with caution, skepticism, and attention to the methods used.
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Jette AM, Ni P, Rasch EK, Appelman J, Sandel ME, Terdiman J, Chan L. Evaluation of patient and proxy responses on the activity measure for postacute care. Stroke 2012; 43:824-9. [PMID: 22343646 DOI: 10.1161/strokeaha.111.619643] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Our objective was to examine the agreement between adult patients with stroke and family member or clinician proxies in activity measure for postacute care (AM-PAC) summary scores for daily activity, basic mobility, and applied cognitive function. METHODS This study involved 67 patients with stroke admitted to a hospital within the Kaiser Permanente of Northern California system and were participants in a parent study on stroke outcomes. Each participant and proxy respondent completed the AM-PAC by personal or telephone interview at the point of hospital discharge or during ≥1 transitions to different postacute care settings. RESULTS The results suggest that for patients with a stroke proxy, AM-PAC data are robust for family or clinician proxy assessment of basic mobility function and clinician proxy assessment of daily activity function, but less robust for family proxy assessment of daily activity function and for all proxy groups' assessments of applied cognitive function. The pattern of disagreement between patient and proxy was, on average, relatively small and random. There was little evidence of systematic bias between proxy and patient reports of their functional status. The degree of concordance between patient and proxy was similar for those with moderate to severe strokes compared with mild strokes. CONCLUSIONS Patient and proxy ratings on the AM-PAC achieved adequate agreement for use in stroke research when using proxy respondents could reduce sample selection bias. The AM-PAC data can be implemented across institutional as well as community care settings while achieving precision and reducing respondent burden.
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Affiliation(s)
- Alan M Jette
- Boston University Medical Campus, School of Public Health, Health & Disability Research Institute, 715 Albany Street, T5W, Boston, MA 02118-2526, USA.
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Participation in community walking following stroke: subjective versus objective measures and the impact of personal factors. Phys Ther 2011; 91:1865-76. [PMID: 22003172 DOI: 10.2522/ptj.20100216] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mobility, specifically community walking, is important, but often limited among survivors of stroke. The factors that influence the recovery of community walking are not clearly understood. OBJECTIVE The purpose of this research was to examine mobility disability following stroke, specifically: (1) the association between subjective and objective measures of participation in community walking and (2) the association between personal factors and participation in community walking. DESIGN A cross-sectional study design was used. METHODS Fifty community-dwelling survivors of stroke, aged 50 to 79 years, were enrolled in the study. Participation in community walking was measured subjectively (perceived difficulty and satisfaction) and objectively using self-report data (number of trips and walking-related activities) and step data (pedometer). The association between subjective and objective measures of participation was analyzed using Pearson correlation. The association of personal factors (age, sex, number of comorbidities, fatigue, depression, balance and fall self-efficacy, and importance of walking) with measures of participation was analyzed using multiple linear regression. RESULTS Subjective and objective measures of participation were weakly associated. Self-efficacy was the only personal factor that was strongly associated with both subjective and objective measures of participation. Personal factors explained 27% to 55% of the variability in participation in community walking. LIMITATIONS Limitations included a small sample size and limited diversity among participants. Reliability of the pedometer used in this study has not been established in the stroke population. CONCLUSIONS Subjective and objective measures of participation in community walking were only weakly correlated, suggesting that they measure different aspects of mobility; thus, to fully capture participation, it is critical to measure both. Personal factors were associated with subjective and objective measures of participation and are important in explaining variability in community walking following stroke.
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Prvu Bettger JA, Coster WJ, Latham NK, Keysor JJ. Analyzing change in recovery patterns in the year after acute hospitalization. Arch Phys Med Rehabil 2008; 89:1267-75. [PMID: 18586128 DOI: 10.1016/j.apmr.2007.11.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Revised: 10/18/2007] [Accepted: 11/09/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine trajectories of recovery and change in patterns of personal care and instrumental functional activity performance to determine whether different assessment interval designs within a 12-month period yield different estimates of improvement and decline after acute hospitalization and inpatient rehabilitation. DESIGN Secondary analysis of a 12-month prospective cohort study. SETTING Transition to the community. PARTICIPANTS Adults (N=419) admitted to acute care and receiving inpatient rehabilitation for a neurologic, lower-extremity musculoskeletal, or medically complex condition. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Improvement, no change, and decline as measured by the personal care and instrumental scale of the Activity Measure for Post-Acute Care. RESULTS Assessment at the end of a single 12-month follow-up assessment interval showed that over 60% of the participants improved. In contrast, analysis of 2 fixed-length 6-month assessment intervals revealed an almost 40% decrease in the proportion who improved from 6 to 12 months. Fewer participants continued to improve in the time periods further from the acute hospitalization and the proportion of subjects who declined increased from 21.4% to 31.2% to 38.0% over the 3 consecutive assessment intervals (baseline to 1 mo, 1-6 mo, 6-12 mo). Only 58 (19.7%) participants continued on the same path of recovery from baseline to 12 months (9.8% improved over all 3 consecutive time periods, 3.1% made no change, 6.8% declined). CONCLUSIONS Examination of change over shorter compared with longer assessment intervals revealed considerable variability in the trajectories of recovery. Research is needed to determine the appropriate frequency and timing for measuring and monitoring function and recovery after an acute hospitalization.
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Affiliation(s)
- Janet A Prvu Bettger
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA, USA.
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An exploratory analysis of functional staging using an item response theory approach. Arch Phys Med Rehabil 2008; 89:1046-53. [PMID: 18503798 DOI: 10.1016/j.apmr.2007.11.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 11/01/2007] [Accepted: 11/04/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To develop and explore the feasibility of a functional staging system (defined as the process of assigning subjects, according to predetermined standards, into a set of hierarchic levels with regard to their functioning performance in mobility, daily activities, and cognitive skills) based on item response theory (IRT) methods using short forms of the Activity Measure for Post-Acute Care (AM-PAC) and to compare the criterion validity and sensitivity of the IRT-based staging system to a non-IRT-based staging system developed for the FIM instrument. DESIGN Prospective, longitudinal cohort study of patients interviewed at hospital discharge and 1, 6, and 12 months after inpatient rehabilitation. SETTING Follow-up interviews conducted in patients' homes. PARTICIPANTS Convenience sample of 516 patients (47% men; sample mean age, 68.3y) at baseline (retention at the final follow-up, 65%) with neurologic, lower-extremity orthopedic, or complex medical conditions. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES AM-PAC basic mobility, daily activity, and applied cognitive activity stages; FIM executive control, mobility, activities of daily living, and sphincter stages. Stages refer to the hierarchic levels assigned to patients' functioning performances. RESULTS We were able to define IRT-based staging definitions and create meaningful cut scores based on the 3 AM-PAC short forms. The IRT stages correlated as well or better to the criterion items than the FIM stages. Both the IRT-based stages and the FIM stages were sensitive to changes throughout the 6-month follow-up period. The FIM stages were more sensitive in detecting changes between baseline and 1-month follow-up visits. The AM-PAC stages were more discriminant in the follow-up visits. CONCLUSIONS An IRT-based staging approach appeared feasible and effective in classifying patients throughout long-term follow-up. Although these stages were developed from short forms, this staging methodology could also be applied to improve the meaning of scores generated from IRT-based computerized adaptive testing in future work.
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Latham NK, Jette AM, Ngo LH, Soukup J, Iezzoni LI. Did the 1997 balanced budget act reduce use of physical and occupational therapy services? Arch Phys Med Rehabil 2008; 89:807-14. [PMID: 18452725 DOI: 10.1016/j.apmr.2008.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate whether use of physical therapy (PT) and occupational therapy (OT) services decreased after the passage of the 1997 Balanced Budget Act (BBA). DESIGN Data from the nationally representative Medicare Current Beneficiary Survey (MCBS) were merged with Medicare claims data. We conducted cross-sectional analyses of data from 1995 (n=7978), 1999 (n=7863), and 2001 (n=7973). All analyses used MCBS sampling weights to provide estimates that can be generalized to the Medicare population with 5 common conditions. SETTINGS Skilled nursing facilities (SNFs), home health agencies, inpatient rehabilitation facilities (IRFs), and outpatient rehabilitation settings. PARTICIPANTS Medicare beneficiaries who participated in the MCBS survey in each of the study years and had 1 or more of the following conditions: acute stroke, acute myocardial infarction, chronic obstructive pulmonary disease, arthritis or degenerative joint disease, or mobility problems. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Percentage of persons meeting our inclusion criteria who received PT or OT in each setting, and total units of PT and OT received in each setting. RESULTS Multivariable logistic regression revealed no statistically significant differences in the proportion of people who met our inclusion criteria who used PT or OT from home health agencies across the 3 time points. For SNFs, an increase in the odds of receiving PT was statistically significant from 1995 to 1999 (odds ratio [OR]=1.42; 95% confidence interval [CI], 1.19-1.69) and 1995 to 2001 (OR=1.69; 95% CI, 1.39-2.05). For IRF and outpatient settings, a significant increase was observed between 1995 and 2001 (OR=1.71, OR=1.27, respectively). For OT, a statistically significant increase was observed for IRF and outpatient rehabilitation settings from 1995 to 2001. For SNF, the increase was statistically significant from 1995 to 1999 and 1995 to 2001. Mean total PT and OT units received also increased across all settings from 1995 to 2001 except for IRFs. CONCLUSIONS Despite BBA mandates restricting postacute care expenditures, this nationally representative study showed no decreases in the percentage of Medicare beneficiaries with 5 common diagnoses receiving PT and/or OT across all settings and no decreases in units of PT and/or OT services received between 1995 and 2001 except for those in IRFs. This study suggests that the delivery of PT and OT services did not decline among persons with conditions for which rehabilitation services are often clinically indicated.
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Affiliation(s)
- Nancy K Latham
- Health and Disability Research Institute, School of Public Health, Boston University, Boston, MA 02118-2639, USA.
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Coster W, Haley SM, Jette A, Tao W, Siebens H. Predictors of basic and instrumental activities of daily living performance in persons receiving rehabilitation services. Arch Phys Med Rehabil 2007; 88:928-35. [PMID: 17601476 DOI: 10.1016/j.apmr.2007.03.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine the relations among cognitive and emotional function and other patient impairment and demographic variables and the performance of daily activities. DESIGN Cohort. SETTING Acute inpatient rehabilitation, skilled nursing facilities, home care, and outpatient clinics. PARTICIPANTS Adults (N=534) receiving services for neurologic (32.3%), lower-extremity orthopedic (42.7%), or complex medical (24.9%) conditions. Mean age was 63.8 years; 55% were women; 88.6% were white; and the time since condition onset ranged from 0.2 to 3.9 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Activity Measure for Post-Acute Care: applied cognitive, personal care and instrumental, and physical and movement scales; Mental Health Inventory-5 (MHI-5); and patient-identified problems (vision, grasp). RESULTS Path analyses resulted in good model fit both for the total sample and 3 patient subgroups (chi(2) test, P>.05; comparative fit index >.95). There was a significant (P<.05) direct relation between the applied cognitive, grasp, and personal care and instrumental variables in all patient groups. There were also significant indirect relations between the MHI-5, visual impairment, and grasp problems with the personal care and instrumental scale through an association with the applied cognitive scale. Strength and significance of associations between age, sex, and physical and movement and personal care and instrumental scales varied more across patient groups. The model R(2) for the personal care and instrumental scale for the total sample was .60, with R(2) values of .10, .72, and .62 for the lower-extremity orthopedic, neurologic, and complex medical groups, respectively. CONCLUSIONS Results suggest that variations in cognitive function, along with visual impairment and lower perceived well-being are associated with a patient's ability to complete daily activities. Rehabilitation professionals should consider cognitive and emotional factors as well as physical performance when planning treatment programs to restore daily activity function.
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Affiliation(s)
- Wendy Coster
- Department of Occupational Therapy and Rehabilitation Counseling, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA 02215, USA.
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Jette AM, Haley SM, Tao W, Ni P, Moed R, Meyers D, Zurek M. Prospective evaluation of the AM-PAC-CAT in outpatient rehabilitation settings. Phys Ther 2007; 87:385-98. [PMID: 17311888 DOI: 10.2522/ptj.20060121] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to prospectively evaluate the practical and psychometric adequacy of the Activity Measure for Post-Acute Care (AM-PAC) "item bank" and computerized adaptive testing (CAT) assessment platform (AM-PAC-CAT) when applied within orthopedic outpatient physical therapy settings. METHOD This was a prospective study with a convenience sample of 1,815 patients with spine, lower-extremity, or upper-extremity impairments who received outpatient physical therapy in 1 of 20 outpatient clinics across 5 states. The authors conducted an evaluation of the number of items used and amount of time needed to complete the CAT assessment; evaluation of breadth of content coverage, item exposure rate, and test precision; as well as an assessment of the validity and sensitivity to change of the score estimates. RESULTS Overall, the AM-PAC-CAT's Basic Mobility scale demonstrated excellent psychometric properties while the Daily Activity scale demonstrated less adequate psychometric properties when applied in this outpatient sample. The mean length of time to complete the Basic Mobility scale was 1.9 minutes, using, on average, 6.6 items per CAT session, and the mean length of time to complete the Daily Activity scale was 1.01 minutes, using on average, 6.8 items. BACKGROUND AND CONCLUSION: Overall, the findings are encouraging, yet they do reveal several areas where the AM-PAC-CAT scales can be improved to best suit the needs of patients who are receiving outpatient orthopedic physical therapy of the type included in this study.
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Affiliation(s)
- Alan M Jette
- Health and Disability Research Institute, School of Public Health, Boston University, 580 Harrison Ave, 4th Floor, Boston, MA 02218, USA.
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Keysor JJ, Jette AM, Coster W, Bettger JP, Haley SM. Association of environmental factors with levels of home and community participation in an adult rehabilitation cohort. Arch Phys Med Rehabil 2007; 87:1566-75. [PMID: 17141635 DOI: 10.1016/j.apmr.2006.08.347] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Revised: 08/28/2006] [Accepted: 08/29/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine whether home and community environmental barriers and facilitators are predictors of social and home participation and community participation at 1 and 6 months after discharge from an acute care or inpatient rehabilitation hospital. DESIGN Cohort study. SETTING Postacute care. PARTICIPANTS Adults (N=342) age 18 years or older with a diagnosis of complex medical, orthopedic, or neurologic condition recruited from acute care and inpatient rehabilitation facilities. The mean age +/- standard deviation of participants was 68+/-14 years; 49% were women and 92% were white. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participation in social, home and community affairs as assessed with the Participation Measure for Post-Acute Care. RESULTS Adjusting for covariates, 1 month after discharge a greater presence of home mobility barriers (P<.01) was associated with less social and home participation; whereas greater community mobility barriers (P<.01) and more social support (P<.001) were associated with greater participation. At 6 months, social support was the only environmental factor associated with participation after adjusting for covariates. CONCLUSIONS This study provides new empirical evidence that environmental barriers and facilitators do influence participation in a general rehabilitation cohort, at least in the short term.
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Affiliation(s)
- Julie J Keysor
- Department of Physical Therapy and Athletic Training, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA 02215, USA.
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Haley SM, Siebens H, Coster WJ, Tao W, Black-Schaffer RM, Gandek B, Sinclair SJ, Ni P. Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: I. Activity outcomes. Arch Phys Med Rehabil 2006; 87:1033-42. [PMID: 16876547 DOI: 10.1016/j.apmr.2006.04.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2005] [Accepted: 04/11/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home. DESIGN Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit. SETTING Follow-up visits conducted in patients' home setting. PARTICIPANTS Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66). RESULTS AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77-.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval. CONCLUSIONS Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.
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Affiliation(s)
- Stephen M Haley
- Health and Disability Research Institute, Boston University, MA 02215, USA.
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Abstract
OBJECTIVE The objective of this study was to examine the agreement between respondents of summary scores from items representing three functional content areas (physical and mobility, personal care and instrumental, applied cognition) within the Activity Measure for Postacute Care (AM-PAC). We compare proxy vs. patient report in both hospital and community settings as represented by intraclass correlation coefficients and two graphic approaches. DESIGN The authors conducted a prospective, cohort study of a convenience sample of adults (n = 47) receiving rehabilitation services either in hospital (n = 31) or community (n = 16) settings. In addition to using intraclass correlation coefficients (ICC) as indices of agreement, we applied two graphic approaches to serve as complements to help interpret the direction and magnitude of respondent disagreements. We created a "mountain plot" based on a cumulative distribution curve and a "survival-agreement plot" with step functions used in the analysis of survival data. RESULTS ICCs on summary scores between patient and proxy report were physical and mobility ICC = 0.92, personal care and instrumental ICC = 0.93, and applied cognition ICC = 0.77. Although combined respondent agreement was acceptable, graphic approaches helped interpret differences in separate analyses of clinician and family agreement. CONCLUSIONS Graphic analyses allow for a simple interpretation of agreement data and may be useful in determining the meaningfulness of the amount and direction of interrespondent variation.
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Affiliation(s)
- Stephen M Haley
- Health and Disability Research Institute, Boston University, Boston, Massachusetts 02215, USA
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Haley SM, Ni P, Hambleton RK, Slavin MD, Jette AM. Computer adaptive testing improved accuracy and precision of scores over random item selection in a physical functioning item bank. J Clin Epidemiol 2006; 59:1174-82. [PMID: 17027428 DOI: 10.1016/j.jclinepi.2006.02.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Revised: 02/21/2006] [Accepted: 02/27/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Measuring physical functioning (PF) within and across postacute settings is critical for monitoring outcomes of rehabilitation; however, most current instruments lack sufficient breadth and feasibility for widespread use. Computer adaptive testing (CAT), in which item selection is tailored to the individual patient, holds promise for reducing response burden, yet maintaining measurement precision. We calibrated a PF item bank via item response theory (IRT), administered items with a post hoc CAT design, and determined whether CAT would improve accuracy and precision of score estimates over random item selection. METHODS 1,041 adults were interviewed during postacute care rehabilitation episodes in either hospital or community settings. Responses for 124 PF items were calibrated using IRT methods to create a PF item bank. We examined the accuracy and precision of CAT-based scores compared to a random selection of items. RESULTS CAT-based scores had higher correlations with the IRT-criterion scores, especially with short tests, and resulted in narrower confidence intervals than scores based on a random selection of items; gains, as expected, were especially large for low and high performing adults. CONCLUSION The CAT design may have important precision and efficiency advantages for point-of-care functional assessment in rehabilitation practice settings.
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Affiliation(s)
- Stephen M Haley
- Department of Rehabilitation Sciences, Sargent College of Health and Rehabilitation Sciences, Boston University, 635 Commanwealth Ave, Boston, MA 02215, USA.
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Jette AM, Keysor J, Coster W, Ni P, Haley S. Beyond function: predicting participation in a rehabilitation cohort. Arch Phys Med Rehabil 2005; 86:2087-94. [PMID: 16271553 DOI: 10.1016/j.apmr.2005.08.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To monitor participation in a rehabilitation cohort and to identify determinants of change during a 12-month period posthospitalization following the onset of one of several major disabling conditions. DESIGN Cohort study. SETTING Postacute care rehabilitation settings. PARTICIPANTS Adults (N=435) aged 18 years and older with complex medical, lower-extremity orthopedic, and major neurologic impairments. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES At 1-, 6-, and 12-month follow-ups, community participation and social and home participation were assessed by personal interviews using the Participation Measure for Post-Acute Care. Information on potential determinants was abstracted from the medical chart and by personal interview using standardized instruments. RESULTS On average, rehabilitation patients achieved modest improvements in their levels of community participation during the first 6 months after acute hospitalization. In contrast, these same patients displayed a modest loss in social and home participation levels during the follow-up period. Activity limitations were the dominant factors that explained much of the variance in the extent of community participation achieved by patients. Personal and social environmental factors played a major role in predicting levels of social and home participation. CONCLUSIONS The focus of rehabilitation interventions aimed at achieving posthospital participation requires careful consideration of the specific domain of participation that is being targeted.
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Affiliation(s)
- Alan M Jette
- Health and Disability Research Institute, Boston University, Boston, MA 02215, USA.
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Coster WJ, Haley SM, Ludlow LH, Andres PL, Ni PS. Development of an applied cognition scale to measure rehabilitation outcomes. Arch Phys Med Rehabil 2004; 85:2030-5. [PMID: 15605343 DOI: 10.1016/j.apmr.2004.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the structure and content coverage of an item pool of new items based on the Activity categories from the International Classification of Functioning, Disability and Health and items from existing instruments to measure the applied cognition dimension of function. DESIGN Prospective study. SETTING Four postacute care rehabilitation settings (inpatient, transitional care, home care, outpatient) in an urban-suburban area of northeast United States. PARTICIPANTS Convenience sample of 477 patients (mean age, 62.7 y) receiving rehabilitation services for neurologic, orthopedic, or complex medical conditions. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participants were administered applied cognition items from the new Activity Measure for Post-Acute Care, the Medical Outcomes Study 8-Item Short-Form Health Survey, and an additional setting-specific measure: the FIM instrument (inpatient rehabilitation); the Minimum Data Set (skilled nursing facility); the Minimum Data Set-Post Acute Care (postacute settings); or the Outcome Assessment and Information Set (home care). Rasch (partial-credit model) analyses were conducted to examine item fit, item coverage, scale unidimensionality, and category difficulty estimates. RESULTS The majority of items (46/59) could be located along a single continuum. Relatively few people were performing at the lower end of the difficulty scale, and about 25% were at ceiling. CONCLUSIONS The proposed definition of applied cognition dimension provides a useful guide for item development to measure this dimension. Further work is needed to determine how best to measure function in this domain for people at the upper and lower ends of the continuum.
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Affiliation(s)
- Wendy J Coster
- Center for Rehabilitation Effectiveness, Sargent College of Health and Rehabilitation Sciences, Boston University, MA 02215, USA.
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Haley SM, Coster WJ, Andres PL, Kosinski M, Ni P. Score comparability of short forms and computerized adaptive testing: Simulation study with the activity measure for post-acute care. Arch Phys Med Rehabil 2004; 85:661-6. [PMID: 15083444 DOI: 10.1016/j.apmr.2003.08.097] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare simulated short-form and computerized adaptive testing (CAT) scores to scores obtained from complete item sets for each of the 3 domains of the Activity Measure for Post-Acute Care (AM-PAC). DESIGN Prospective study. SETTING Six postacute health care networks in the greater Boston metropolitan area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services. PARTICIPANTS A convenience sample of 485 adult volunteers who were receiving skilled rehabilitation services. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Inpatient and community-based short forms and CAT applications were developed for each of 3 activity domains (physical & mobility, personal care & instrumental, applied cognition) using item pools constructed from new items and items from existing postacute care instruments. RESULTS Simulated CAT scores correlated highly with score estimates from the total item pool in each domain (4- and 6-item CAT r range,.90-.95; 10-item CAT r range,.96-.98). Scores on the 10-item short forms constructed for inpatient and community settings also provided good estimates of the AM-PAC item pool scores for the physical & movement and personal care & instrumental domains, but were less consistent in the applied cognition domain. Confidence intervals around individual scores were greater in the short forms than for the CATs. CONCLUSIONS Accurate scoring estimates for AM-PAC domains can be obtained with either the setting-specific short forms or the CATs. The strong relationship between CAT and item pool scores can be attributed to the CAT's ability to select specific items to match individual responses. The CAT may have additional advantages over short forms in practicality, efficiency, and the potential for providing more precise scoring estimates for individuals.
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Affiliation(s)
- Stephen M Haley
- Research and Training Center on Measuring Rehabilitation Outcomes, Center for Rehabilitation Effectiveness, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA, USA.
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Haley SM, Andres PL, Coster WJ, Kosinski M, Ni P, Jette AM. Short-form activity measure for post-acute care. Arch Phys Med Rehabil 2004; 85:649-60. [PMID: 15083443 DOI: 10.1016/j.apmr.2003.08.098] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To develop a comprehensive set of short forms using item response theory (IRT) and item pooling procedures for the purpose of monitoring postacute care functional recovery. DESIGN Prospective study. SETTING Six postacute health care networks in the greater Boston area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services. PARTICIPANTS A convenience sample of 485 adult volunteers who were currently receiving skilled rehabilitation services. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We developed a set of 6 short forms across 3 activity domains from new items and items from existing postacute care instruments. RESULTS Inpatient- and community-based short forms were developed for each of 3 activity domains: physical & movement, applied cognition, and personal care & instrumental. Items were selected for inclusion on the short forms to maximize content coverage and information value of items across the range of content and to minimize ceiling and floor effects. We were able to match the distribution of sample scores with very good item precision for 1 of the constructs (physical & movement); the other 2 domains (personal care & instrumental, applied cognition) were more challenging because of the variability in patient recovery and ceiling effects. CONCLUSIONS ITR methods and item pooling procedures were valuable in developing paired sets of short-form instruments for inpatient and community rehabilitation that provided estimates of functioning along a common metric for use across postacute care settings.
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Affiliation(s)
- Stephen M Haley
- Research and Training Center on Measuring Rehabilitation Outcomes, Center for Rehabilitation Effectiveness, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA, USA.
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