Development of an IRT-Based Short Form to Assess Applied Cognitive Function in Outpatient Rehabilitation

Outcome Measures and Patient-Reported Metrics in Cancer Rehabilitation

PURPOSE OF REVIEW

The current panorama of measurement tools for use in cancer rehabilitation is reviewed. For rehabilitation purposes, evaluating function is of the highest priority.

RECENT FINDINGS

From a patient-reported outcome (PRO) standpoint, SF-36 and EORTC-QLQ-C30 are in most common use in cancer rehabilitation research; these are quality of life measures that contain functional subdomains. Newer tools which are based on item response theory and have options for both computer assisted or short form (SF) administration, including the Patient-Reported Outcomes Measurement Information System (PROMIS) and Activity Measure for Post-acute Care (AMPAC) instruments, show increasing use, especially PROMIS Physical Function SF, and, recently, PROMIS Cancer Function Brief 3D, which has been validated in the cancer population, with domains of physical function, fatigue, and social participation, to track clinical rehabilitation outcomes. Evaluating objective measures of function in cancer patients is also crucial. Utilization of clinically feasible tools for cancer rehabilitation, to employ for both screening purposes and for monitoring of rehabilitation treatment efficacy, is an evolving area, much needed to promote further research and improved, consistent clinical care for cancer patients and survivors.

Development and Implementation of a Standard Assessment Battery Across the Continuum of Care for Patients After Stroke

ABSTRACT

Stroke rehabilitation occurs across the continuum of care starting in the acute hospital and through the inpatient and outpatient settings. Rehabilitation aims to minimize impairments and maximize function in individuals after stroke. Because patients often undergo rehabilitation for extended periods, longitudinal assessment of impairment, activity, and participation can facilitate the evaluation of patients' progress toward recovery, as well as communication and decision making to guide clinical practice regarding the intervention(s) to be used and may also be leveraged for clinical research. However, the clinical implementation of a standard assessment battery that spans the continuum of care for patients after stroke is challenging because of operational and time constraints. Here, we describe the development and implementation of a standard assessment battery across the continuum of care by physical therapists, occupational therapists, and speech-language pathologists at the Sheikh Khalifa Stroke Institute. We specifically describe our experience in (1) identifying the core team to lead the process, (2) selecting the measures for the standard assessment battery, and the timeframe for administration, and (3) implementing the standard assessment battery in routine clinical practice.

Linking AM-PAC Cognition to PROMIS Cognitive Function

OBJECTIVE

To link the Activity Measure for Post-Acute Care (AM-PAC) Applied Cognition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function, allowing for a common metric across scales.

DESIGN

Cross-sectional survey study.

SETTING

Outpatient rehabilitation clinics.

PARTICIPANTS

Consecutive sample of 500 participants (N=500) aged ≥18 years presenting for outpatient therapy (physical, occupation, speech).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

AM-PAC Medicare and Generic Cognition short forms and PROMIS Cognitive Function items representing the PROMIS Cognitive Function item bank.

RESULTS

The calibration of 25 AM-PAC cognition items with 11 fixed PROMIS cognitive function item parameters using item-response theory indicated that items were measuring the same underlying construct (cognition). Both scales measured a wide range of functioning. The AM-PAC Generic Cognitive assessment showed more reliability with lower levels of cognition, whereas the PROMIS Cognitive Function full-item bank was more reliable across a larger distribution of scores. Data were appropriate for a fixed-anchor item response theory-based crosswalk and AM-PAC Cognition raw scores were mapped onto the PROMIS metric.

CONCLUSIONS

The crosswalk developed in this study allows for converting scores from the AM-PAC Applied Cognition to the PROMIS Cognitive Function scale.

Development and Evaluation of the Boston University Osteoarthritis Functional Pain Short Form (BU-OA-FPS)

BACKGROUND

Pragmatic studies have gained popularity, thus emphasizing the need for patient-reported outcomes (PRO) to be integrated into electronic health records.

OBJECTIVE

This study describes the development of a customized short form from the Boston University Osteoarthritis Functional Assessment PRO (BU-OA-PRO) for a specific pragmatic clinical trial.

METHODS

A Functional Pain Short Form was created from an existing item bank of deidentified data in the BU-OA-PRO. Item response theory (IRT) methods were used to select items. Reliability was measured with the Cronbach alpha, then with IRT simulation methods. To examine validity, ceiling and floor effects, correlations between the short-form scores and scores from the BU-OA-PRO and the Western Ontario McMasters University Osteoarthritis Index (WOMAC) Pain and Difficulty subscales, and the area under the curve (AUC) were calculated. A minimum detectable change at 90% confidence (MDC90) was calculated based on a calibration sample.

RESULTS

The BU-OA-PRO was reduced from 126 items to 10 items to create the BU-OA Functional Pain Short Form (BU-OA-FPS). The Cronbach alpha indicated high internal consistency (0.91), and reliability distribution estimates were 0.96 (uniform) and 0.92 (normal). Low ceiling effects (4.57%) and floor effects (0%) were found. Moderate-to-high correlations between the BU-OA-PRO and BU-OA-FPS were found with WOMAC Pain (BU-OA-FPS = 0.67; BU-OA-PRO = 0.64) and Difficulty (BU-OA-FPS = 0.73; BU-OA-PRO = 0.69) subscales. The correlation between the BU-OA-PRO and BU-OA-FPS was 0.94. The AUC ranged from 0.80 to 0.88. The MDC90 was approximately 6 standardized points.

CONCLUSIONS

The BU-OA-FPS provides reliable and valid measurement of functional pain. Pragmatic studies may consider the BU-OA-FPS for use in electronic health records to capture outcomes.

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.

Developing Item Response Theory–Based Short Forms to Measure the Social Impact of Burn Injuries

OBJECTIVE

To develop self-reported short forms for the Life Impact Burn Recovery Evaluation (LIBRE) Profile.

DESIGN

Short forms based on the item parameters of discrimination and average difficulty.

SETTING

A support network for burn survivors, peer support networks, social media, and mailings.

PARTICIPANTS

Burn survivors (N=601) older than 18 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The LIBRE Profile.

RESULTS

Ten-item short forms were developed to cover the 6 LIBRE Profile scales: Relationships with Family & Friends, Social Interactions, Social Activities, Work & Employment, Romantic Relationships, and Sexual Relationships. Ceiling effects were ≤15% for all scales; floor effects were <1% for all scales. The marginal reliability of the short forms ranged from .85 to .89.

CONCLUSIONS

The LIBRE Profile-Short Forms demonstrated credible psychometric properties. The short form version provides a viable alternative to administering the LIBRE Profile when resources do not allow computer or Internet access. The full item bank, computerized adaptive test, and short forms are all scored along the same metric, and therefore scores are comparable regardless of the mode of administration.

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.