Agreement in Functional Assessment

Prediction of Changes in Functional Outcomes During the First Year After Inpatient Stroke Rehabilitation: A Longitudinal Study

OBJECTIVE

To identify meaningful changes in patients in 3 functional domains (basic mobility [BM], daily activity [DA], and applied cognition [AC]) after discharge from inpatient stroke rehabilitation and to identify the predictors of 1-year functional improvement.

DESIGN

A longitudinal, multicenter, prospective cohort study.

SETTING

The acute care wards of 3 hospitals in the Greater Taipei area of Taiwan.

PARTICIPANTS

Five hundred patients with stroke in acute care wards (mean age=60±12.2 years, 62% men, N=500).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

The Mandarin version of the Activity Measure for Post-Acute Care (AM-PAC) short forms were assessed at discharge and 3-, 6-, and 12-month follow-up. The minimal detectable change (MDC) was used to categorize changes in the scores as improved and unimproved at the 4 time points.

RESULTS

The mean scores of the AM-PAC BM and DA subscales substantially increased over the first 3 months after discharge (86% of participants exhibited improvement) and slightly increased during the subsequent 9 months (5∼26% of participants exhibited improvement). However, the mean score of the AC subscale decreased within the first 3 months and increased over the subsequent 9 months (22-23% of participants exhibited improvement). The BM, AC scores at discharge were the dominant predictors of subsequent functional improvement (P<.05). Patients with a higher functional stage at discharge were more likely to experience significant improvement.

CONCLUSION

This study established the capacity of the AM-PAC to predict functional improvement in 3 domains during the early, middle, and late stages of recovery. The findings can assist clinicians in identifying patients at risk of unfavorable long-term functional recovery and providing such patients with tailored interventions during the early stage of rehabilitation.

Patient Versus Clinician Proxy Reliability of the AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms

OBJECTIVE

The purpose of this study was to test the reliability of the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" mobility and activity short forms between patients and therapist proxies. As a secondary aim, reliability was examined when patients completed their self-report before versus after the therapist evaluation.

METHODS

Patients being seen for an initial physical therapist (N = 70) or occupational therapist (N = 71) evaluation in the acute care hospital completed the "6-Clicks" mobility short form (if a physical therapist evaluation) or activity short form (if an occupational therapist evaluation). Whether patients completed their self-assessment before or after the evaluation was randomized. Patient- and therapist-rated "6-Clicks" raw scores were converted to AM-PAC T-scores for comparison. Reliability was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots, and agreement was assessed with weighted kappa values.

RESULTS

The ICCs for the "6-Clicks" mobility and daily activity short forms were 0.57 (95% CI = 0.42-0.69) and 0.45 (95% CI = 0.28-0.59), respectively. For both short forms, reliability was higher when the patient completed the self-assessment after versus before the therapist evaluation (ICC = 0.67, 95% CI = 0.47-0.80 vs ICC = 0.50, 95% CI = 0.26-0.67 for the mobility short form; and ICC = 0.52, 95% CI = 0.29-0.70 vs ICC = 0.34, 95% CI = 0.06-0.56 for the activity short form).

CONCLUSION

Reliability of the "6-Clicks" total scores was moderate for both the mobility and activity short forms, though higher for the mobility short form and when patients' self-report occurred after the therapist evaluation.

IMPACT

Reliability of the AM-PAC "6-Clicks" short forms is moderate when comparing scores from patients with those of therapists responding as proxies. The short forms are useful for measuring participants' function in the acute care hospital; however, it is critical to recognize limitations in reliability between clinician- and patient-reported AM-PAC scores when evaluating longitudinal change and recovery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Functional Recovery Rate: A Feasible Method for Evaluating and Comparing Rehabilitation Outcomes Between Skilled Nursing Facilities

OBJECTIVES

The recovery of patients' physical function and the rate at which this occurs are important parameters for evaluating value in post-acute care (PAC). However, no metrics are presently used to compare skilled nursing facilities (SNFs) based on the functional recovery rates (FRRs) for patients in their care. The objectives of this study were to examine whether the average FRR differed significantly among SNFs and to compare the FRR to other measures currently used to assess care quality in SNFs.

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

3913 patients discharged from hospitals in one health system to one of 10 partner SNFs between January 2017 and September 2019.

METHODS

The FRR-the difference in Activity Measure for Post-Acute Care 6-Clicks basic mobility score from SNF admission to discharge relative to the SNF length of stay (in days)-was the primary outcome. Secondary outcomes included metrics from the SNF Quality Reporting Program (functional recovery alone, discharge to the community, and 30-day hospital readmission). Differences in patients' outcomes between SNFs were tested using multiple regression in order to adjust for patient characteristics.

RESULTS

Across the 10 SNFs, the highest adjusted mean FRR was 0.70 [95% confidence interval (CI): 0.55, 0.90] and the lowest was 0.39 (95% CI: 0.33, 0.46) points per day. Two SNFs had an adjusted mean FRR statistically higher, and 2 had an FRR statistically lower, than the sample mean (0.50, 95% CI: 0.48-0.52). SNF rankings varied by metric.

CONCLUSIONS AND IMPLICATIONS

Individual SNFs vary in their mean FRR for patients making it a potentially useful measure of value for comparing SNFs. Standardized measurement and reporting of FRR could be beneficial to patients and their families as they consider specific SNFs for necessary post-acute rehabilitation and to hospital systems seeking to identify high-value PAC providers with whom to partner in collaborative care models.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The clinical utility of a 30-minute neuropsychological assessment battery in inpatient stroke rehabilitation

Cognitive assessment is an important component of inpatient stroke rehabilitation. Few studies have empirically evaluated the clinical utility of specific neuropsychological measures in this setting. We investigated the psychometric properties and clinical utility of a 30-minute neuropsychological battery developed by the National Institute of Neurologic Disorders and Stroke (NINDS) and the Canadian Stroke Network (CSN). Clinical data were analyzed from 100 individuals with mild-moderate stroke severity on an acute inpatient rehabilitation unit who completed the NINDS-CSN battery at admission. The battery comprised the Symbol-Digit Modalities Test (SDMT), Trail Making Test, Controlled Oral Word Association Test, Animal Naming, and the Hopkins Verbal Learning Test-Revised. We evaluated the battery's distribution of scores, frequency of impaired performance, internal consistency, and ability to predict rehabilitation gain and independence in cognitively-based instrumental activities of daily living (IADL) at discharge. Results indicated that the NINDS-CSN battery was sensitive to cognitive impairment, demonstrated moderately strong internal consistency, and predicted discharge IADL. The SDMT demonstrated the strongest sensitivity to impairment and predictive validity. The NINDS-CSN battery is a clinically useful assessment battery in acute inpatient stroke rehabilitation. Complex attention and processing speed performance may be most informative in predicting amount of rehabilitation gain and IADL functioning at discharge.

Postload Glycated Albumin as an Alternate Measure for Diabetes Screening in a Chinese Population

In previous epidemiological screening in China, glycated albumin (GA) was mostly detected during the fasting state. This strict restriction causes some problems with diabetes screening. It is unclear if GA could help improve the efficiency of screening for diabetes for subjects who are not in the fasting state. The present study analyzed the differences between fasting and postload (30, 60, 120, and 180 min) GA levels. A total of 691 participants were enrolled in the present study. The Bland-Altman difference plots revealed that 95.4, 94.8, 93.6, and 93.9% of data points were within the limits of agreement for each time point. The receiver operating characteristic curve showed that the areas under the curve (AUC) for baseline GA and postload GA for every time point were 0.822 (95% CI 0.791-0.849), 0.821 (95% CI 0.790-0.848), 0.833 (95% CI 0.803-0.860), 0.840 (95% CI 0.811-0.867), and 0.840 (95% CI 0.810-0.867), with sensitivities of 67.5, 68.1, 69.3, 71.6, and 69.3%, respectively. There was no difference between the baseline and postload GA levels in either AUC or sensitivity (all p > 0.05). In conclusion, postload serum GA levels were in good agreement with those at baseline, and thus, it may be reasonable to employ nonfasting measurements of GA levels for diabetes screening.

Association Between 2 Measures of Cognitive Instrumental Activities of Daily Living and Their Relation to the Montreal Cognitive Assessment in Persons With Stroke

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.

Do claimants over-report behavioral health dysfunction when filing for work disability benefits?

BACKGROND

Questions exist related to the best way to use medical evidence relative to self-report as part of the SSA disability determination process.

OBJECTIVE

To examine concordance between provider and claimant responses along the four dimensions of work related behavioral health functioning: Social Interactions, Mood and Emotions, Behavioral Control, and Self-Efficacy.

METHODS

Using secondary data from a larger study, which collected data on individuals reporting difficulties with work (claimants) due to mental conditions, 39 items were completed by claimants and their healthcare provider. Inter-rater agreement was assessed using three techniques: Cohen's kappa, percent absolute agreement, and folded mountain plots.

RESULTS

A sample of 65 dyads was obtained. Inter-rater agreement was low for most items (k=0.0-0.20) with a minority of items having fair agreement (k=0.21-0.40) Percent agreement was fair: Mood and Emotions (46%), Self-Efficacy (44%), Behavioral Control (39%) and Social Interactions (38%). Overall, providers reported lower functioning compared to claimants for the Behavioral Control and Self-Efficacy scales; the reverse trend held for the Mood and Emotions scale.

CONCLUSIONS

Results indicate discordance between provider and claimant report of behavioral health functioning. Understanding reasons for and approaches to reconciling the inconsistencies between claimant and provider perspectives is a complex task. These findings have implications for how best to assess mental and behavioral-health related work disability in the absence of an established gold standard measure.

Discrepancies between mothers and clinicians in assessing functional capabilities and performance of children with cerebral palsy

The current study is a cross-sectional study that aimed to investigate the concordance between health care professionals (HCPs) and mothers in rating capabilities and performance of children with cerebral palsy (CP), and the impact of CP gross motor severity on concordance. Seventy-three children with mild-to-severe CP (mean age 8.8 ± 2.10 years) and their mothers participated in this study. Two modes of Pediatric Evaluation Disability Inventory (PEDI) administration were used: mothers' interview by a social worker and HCPs' actual evaluation. Differences between raters were assessed by paired t-tests and intra-class correlation coefficients (ICCs). Agreement was defined as mean absolute difference of less than or equal to six points. The results indicated that in spite of excellent overall ICCs in PEDI (ICC>0.8), disagreement between raters was observed in all PEDI sub-domains: 38%, 56%, 72% and 59% disagreement in Functional Skills-Mobility, Functional Skills-Self Care, Caregiver Assistance-Mobility (CA-MO) and Caregiver Assistance-Self Care (CA-SC), respectively. In CA-SC and CA-MO disagreement mainly consisted of mothers rating their children lower in performance than HCPs. CP severity effected the agreement mostly in children with moderate CP severity. The implications of these results are that raters perceive child's activity differently, hence revealing hidden disability perceptions, with significant consequences for intended interventions.

Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke

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.

Evaluation of patient and proxy responses on the activity measure for postacute care

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.

Comparison between Tonopachy and other tonometric and pachymetric devices

PURPOSE

This study aimed to compare central corneal thickness (CCT) measurement by Tonopachy to that by Pentacam and ultrasound pachymetry, and intraocular pressure (IOP) measurement to that by Goldmann applanation tonometry (GAT). The reproducibility of CCT and IOP measurements by Tonopachy was also evaluated.

METHODS

In 104 eyes of 104 patients, CCT was measured by Tonopachy, Pentacam, and ultrasound pachymetry, and IOP was measured by Tonopachy and GAT. Each CCT and IOP measurement was compared using Pearson correlation, repeated measures analysis of variance, and Bland-Altman plots. In 30 subjects, CCT and IOP measurements by Tonopachy were repeated to evaluate intrasession and intraobserver variability.

RESULTS

Both CCT and IOP measurements were highly correlated among all instruments used in this study. CCT measurements by three pachymeters were statistically different (p<0.0001). CCT measured by ultrasound pachymetry was lowest (541.7 ± 30.6 μm) whereas those by Tonopachy and Pentacam showed no difference (557.3 ± 34.3 and 558.0 ± 33.7 μm, respectively). Tonopachy overestimated CCT by 13.9 μm when compared with ultrasound pachymetry. There was a statistically significant difference between IOP measurements by two tonometers (p<0.0001); IOP measurement was higher by Tonopachy than by GAT (13.9 ± 4.2 and 12.5 ± 3.2 mm Hg, respectively). Tonopachy overestimated IOP measurements by 1.2 mm Hg compared with GAT. Intersession agreements for IOP and CCT measurements by Tonopachy were excellent (intraclass correlation, 0.902 and 0.962, respectively) with 95% limits of agreement ranging from -1.4 to 2.2 mm Hg and from -12.9 to 12.1 μm, respectively.

CONCLUSIONS

Although CCT and IOP measurements obtained by Tonopachy were reproducible and showed close agreement with ultrasound pachymetry and Pentacam, and GAT, careful attention should be paid when comparing Tonopachy CCT measurement to ultrasound pachymetry or its IOP measurement to GAT as the values may not be interchangeable. Tonopachy is a reliable instrument for evaluating CCT and IOP.

Predictors of basic and instrumental activities of daily living performance in persons receiving rehabilitation services

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.