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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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Minor M, Jaywant A, Toglia J, Campo M, O'Dell MW. Discharge Rehabilitation Measures Predict Activity Limitations in Patients With Stroke 6 Months After Inpatient Rehabilitation. Am J Phys Med Rehabil 2022; 101:761-767. [PMID: 34686630 DOI: 10.1097/phm.0000000000001908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this study was to identify rehabilitation measures at discharge from acute inpatient stroke rehabilitation that predict activity limitations at 6 mos postdischarge. DESIGN This is a retrospective analysis of a prospective, longitudinal, observational cohort study. It was conducted in an acute inpatient rehabilitation unit at an urban, academic medical center. Activity limitations in patients ( N = 141) with stroke of mild-moderate severity were assessed with the activity measure for post-acute care at inpatient stroke rehabilitation discharge and 6-mo follow-up. Rehabilitation measures at discharge were investigated as predictors for activity limitations at 6 mos. RESULTS Measures of balance (Berg Balance Scale), functional limitations in motor-based activities (functional independence measure-motor subscore), and motor impairment (motricity index), in addition to discharge activities measure for post-acute care scores, strongly predicted activity limitations in basic mobility and daily activities at 6 mos (51% and 41% variance explained, respectively). Functional limitations in cognition (functional independence measure-cognitive subscore) and executive function impairment (Trail Making Test-part B), in addition to the discharge activities measure for post-acute care score, modestly predicted limitations in cognitively based daily activities at 6 mos (12% of variance). CONCLUSIONS Standardized rehabilitation measures at inpatient stroke rehabilitation discharge can predict future activity limitations, which may improve prediction of outcome post-stroke and aid in postdischarge treatment planning.
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Affiliation(s)
- Maria Minor
- From the MD Program (MM), Department of Rehabilitation Medicine (AJ, JT, MWO), and Department of Psychiatry (AJ), Weill Cornell Medicine, New York, New York; School of Health and Natural Sciences, Mercy College, Dobbs Ferry, New York (JT, MC); and New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York (AJ, JT, MWO)
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O'Dell MW, Jaywant A, Frantz M, Patel R, Kwong E, Wen K, Taub M, Campo M, Toglia J. Changes in the Activity Measure for Post-Acute Care Domains in Persons With Stroke During the First Year After Discharge From Inpatient Rehabilitation. Arch Phys Med Rehabil 2021; 102:645-655. [PMID: 33440132 DOI: 10.1016/j.apmr.2020.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To describe functional changes after inpatient stroke rehabilitation using the Activity Measure for Post-Acute Care (AM-PAC), an assessment measure sensitive to change and with a low risk of ceiling effect. DESIGN Retrospective, longitudinal cohort study. SETTING Inpatient rehabilitation unit of an urban academic medical center. PARTICIPANTS Among 433 patients with stroke admitted from 2012-2016, a total of 269 (62%) were included in our database and 89 of 269 patients (33.1%) discharged from inpatient stroke rehabilitation had complete data. Patients with and without complete data were very similar. The group had a mean age of 68.0±14.2 years, National Institutes of Health Stroke Score of 8.0±8.0, and rehabilitation length of stay of 14.7±7.4 days, with 84% having an ischemic stroke and 22.5% having a recurrent stroke. INTERVENTION None. MAIN OUTCOME MEASURES Changes in function across the first year after discharge (DC) were measured in a variety of ways. Continuous mean scores for the basic mobility (BM), daily activity (DA), and applied cognitive domains of the AM-PAC were calculated at and compared between inpatient DC and 6 (6M) and 12 months (12M) post DC. Categorical changes among individuals were classified as "improved," "unchanged," or "declined" between the 3 time points based on the minimal detectable change, (estimated) minimal clinically important difference, and a change ≥1 AM-PAC functional stage (FS). RESULTS For the continuous analyses, the Friedman test was significant for all domains (P≤.002), with Wilcoxon signed-rank test significant for all domains from DC to 6M (all P<.001) but with no change in BM and DA between 6M and 12M (P>.60) and a decline in applied cognition (P=.002). Despite group improvements from DC to 6M, for categorical changes at an individual level 10%-20% declined and 50%-70% were unchanged. Despite insignificant group differences from 6M-12M, 15%-25% improved and 20%-30% declined in the BM and DA domains. CONCLUSIONS Despite group gains from DC to 6M and an apparent "plateau" after 6M post stroke, there was substantial heterogeneity at an individual level. Our results underscore the need to consider individual-level outcomes when evaluating progress or outcomes in stroke rehabilitation.
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Affiliation(s)
- Michael W O'Dell
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York; Department of Rehabilitation Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York.
| | - Abhishek Jaywant
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York; Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Megan Frantz
- Kaiser Foundation Rehabilitation Center, Vallejo, California
| | - Ruchi Patel
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York; Department of Rehabilitation Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Erica Kwong
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York
| | - Karen Wen
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York
| | - Michael Taub
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York
| | - Marc Campo
- Department of Allied Health and Natural Sciences, Mercy College, Dobbs Ferry, New York
| | - Joan Toglia
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York; Department of Allied Health and Natural Sciences, Mercy College, Dobbs Ferry, New York
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Kuceyeski A, Navi BB, Kamel H, Raj A, Relkin N, Toglia J, Iadecola C, O'Dell M. Structural connectome disruption at baseline predicts 6-months post-stroke outcome. Hum Brain Mapp 2016; 37:2587-601. [PMID: 27016287 DOI: 10.1002/hbm.23198] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/17/2016] [Accepted: 03/14/2016] [Indexed: 12/21/2022] Open
Abstract
In this study, models based on quantitative imaging biomarkers of post-stroke structural connectome disruption were used to predict six-month outcomes in various domains. Demographic information and clinical MRIs were collected from 40 ischemic stroke subjects (age: 68.1 ± 13.2 years, 17 female, NIHSS: 6.8 ± 5.6). Diffusion-weighted images were used to create lesion masks, which were uploaded to the Network Modification (NeMo) Tool. The NeMo Tool, using only clinical MRIs, allows estimation of connectome disruption at three levels: whole brain, individual gray matter regions and between pairs of gray matter regions. Partial Least Squares Regression models were constructed for each level of connectome disruption and for each of the three six-month outcomes: applied cognitive, basic mobility and daily activity. Models based on lesion volume were created for comparison. Cross-validation, bootstrapping and multiple comparisons corrections were implemented to minimize over-fitting and Type I errors. The regional disconnection model best predicted applied cognitive (R(2) = 0.56) and basic mobility outcomes (R(2) = 0.70), while the pairwise disconnection model best predicted the daily activity measure (R(2) = 0.72). These results demonstrate that models based on connectome disruption metrics were more accurate than ones based on lesion volume and that increasing anatomical specificity of disconnection metrics does not always increase model accuracy, likely due to statistical adjustments for concomitant increases in data dimensionality. This work establishes that the NeMo Tool's measures of baseline connectome disruption, acquired using only routinely collected MRI scans, can predict 6-month post-stroke outcomes in various functional domains including cognition, motor function and daily activities. Hum Brain Mapp, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Amy Kuceyeski
- Department of Radiology, Weill Cornell Medical College, New York, New York.,Feil Family Brain and Mind Research Institute, New York, New York
| | - Babak B Navi
- Feil Family Brain and Mind Research Institute, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Hooman Kamel
- Feil Family Brain and Mind Research Institute, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Ashish Raj
- Department of Radiology, Weill Cornell Medical College, New York, New York.,Feil Family Brain and Mind Research Institute, New York, New York
| | - Norman Relkin
- Feil Family Brain and Mind Research Institute, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Joan Toglia
- Rehabilitation Medicine, New York, New York.,School of Health and Natural Sciences, Mercy College, New York, New York
| | - Costantino Iadecola
- Feil Family Brain and Mind Research Institute, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Michael O'Dell
- Department of Neurology, Weill Cornell Medical College, New York, New York.,Rehabilitation Medicine, New York, New York
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Abberger B, Haschke A, Wirtz M, Kroehne U, Bengel J, Baumeister H. Development and evaluation of a computer adaptive test to assess anxiety in cardiovascular rehabilitation patients. Arch Phys Med Rehabil 2013; 94:2433-2439. [PMID: 23880319 DOI: 10.1016/j.apmr.2013.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/27/2013] [Accepted: 07/07/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To develop and evaluate a computer adaptive test for the assessment of anxiety in cardiovascular rehabilitation patients (ACAT-cardio) that tailors an optimal test for each patient and enables precise and time-effective measurement. DESIGN Simulation study, validation study (against the anxiety subscale of the Hospital Anxiety and Depression Scale and the physical component summary scale of the 12-Item Short-Form Health Survey), and longitudinal study (beginning and end of rehabilitation). SETTING Cardiac rehabilitation centers. PARTICIPANTS Cardiovascular rehabilitation patients: simulation study sample (n=106; mean age, 57.8y; 25.5% women) and validation and longitudinal study sample (n=138; mean age, 58.6 and 57.9y, respectively; 16.7% and 12.1% women, respectively). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Hospital Anxiety and Depression Scale, 12-Item Short-Form Health Survey, and ACAT-cardio. RESULTS The mean number of items was 9.2 with an average processing time of 1:13 minutes when an SE ≤.50 was used as a stopping rule; with an SE ≤.32, there were 28 items and a processing time of 3:47 minutes. Validity could be confirmed via correlations between .68 and .81 concerning convergent validity (ACAT-cardio vs Hospital Anxiety and Depression Scale anxiety subscale) and correlations between -.47 and -.30 concerning discriminant validity (ACAT-cardio vs 12-Item Short-Form Health Survey physical component summary scale). Sensitivity to change was moderate to high with standardized response means between .45 and .82. CONCLUSIONS The ACAT-cardio shows good psychometric properties and provides the opportunity for an innovative and time-effective assessment of anxiety in cardiovascular rehabilitation. A more flexible stopping rule might further improve the ACAT-cardio. Additionally, testing in other cardiovascular populations would increase generalizability.
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Affiliation(s)
- Birgit Abberger
- Department of Rehabilitation and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany.
| | - Anne Haschke
- Department of Rehabilitation and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany
| | - Markus Wirtz
- Department of Research Methods, Institute of Psychology, University of Education Freiburg, Freiburg, Germany
| | - Ulf Kroehne
- German Institute for International Educational Research, Frankfurt/Main, Germany
| | - Juergen Bengel
- Department of Rehabilitation and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany
| | - Harald Baumeister
- Department of Rehabilitation and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany; Department of Medical Psychology and Medical Sociology, Medical Faculty, University of Freiburg, Freiburg, Germany
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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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Sandel ME, Jette AM, Appelman J, Terdiman J, TeSelle M, Delmonico RL, Wang H, Camicia M, Rasch EK, Brandt DE, Chan L. Designing and implementing a system for tracking functional status after stroke: a feasibility study. PM R 2012; 5:481-90; quiz 490. [PMID: 23159241 DOI: 10.1016/j.pmrj.2012.09.579] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 09/12/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the feasibility of tracking stroke patients' functional outcomes in an integrated health system across a care continuum using the computer version of the Activity Measure of Post-Acute Care (AM-PAC). SETTING A large integrated health care system in northern California. PARTICIPANTS A total of 222 stroke patients (aged ≥18 years) who were hospitalized after an acute cerebrovascular accident. METHODS An AM-PAC assessment was made at discharge from sites of care, including acute hospital, inpatient rehabilitation hospital, skilled nursing facility, home during home care, and outpatient settings. Assessments also were completed in the patient's home at 6 months. Data from the AM-PAC program were integrated with the health care system's databases. MAIN OUTCOME MEASUREMENTS (1) AM-PAC administration time at the various sites of care; (2) assessment of a floor or a ceiling effect; and (3) administrative burden of tracking participants. RESULTS AM-PAC assessment sessions averaged 7.9 minutes for data acquisition in 3 domains: Basic Mobility, Activities of Daily Living, and Applied Cognition. Participants answered, on average, 27 AM-PAC questions per session. A small ceiling effect was observed at 6 months, and there was a larger ceiling effect when the instrument was administered in an institution, ie, when the AM-PAC institutional item bank was used rather than the community item bank. It was feasible to track patients and to assess their function using the AM-PAC instrument from institutional to community settings. Implementation of the AM-PAC in clinical environments, and the success of the project, were influenced by instrumental, technological, operational, resource, and cultural factors. CONCLUSIONS This study demonstrates the feasibility of implementing a single functional outcome instrument in clinical and community settings to measure rehabilitation functional outcomes of stroke patients. Integrating the AM-PAC measurement system into clinical workflows and the electronic medical record could provide assistance to clinicians for medical decision making, functional prognostication, and discharge planning.
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Affiliation(s)
- M Elizabeth Sandel
- Physical Medicine and Rehabilitation, Napa/Solano Service Area, Kaiser Permanente Northern California, Kaiser Foundation Rehabilitation Center, 975 Sereno Drive, Vallejo, CA 94589, USA.
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Hula WD, Fergadiotis G, Martin N. Model choice and sample size in item response theory analysis of aphasia tests. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2012; 21:S38-S50. [PMID: 22230175 DOI: 10.1044/1058-0360(2011/11-0090)] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE The purpose of this study was to identify the most appropriate item response theory (IRT) measurement model for aphasia tests requiring 2-choice responses and to determine whether small samples are adequate for estimating such models. METHOD Pyramids and Palm Trees (Howard & Patterson, 1992) test data that had been collected from individuals with aphasia were analyzed, and the resulting item and person estimates were used to develop simulated test data for 3 sample size conditions. The simulated data were analyzed using a standard 1-parameter logistic (1-PL) model and 3 models that accounted for the influence of guessing: augmented 1-PL and 2-PL models and a 3-PL model. The model estimates obtained from the simulated data were compared to their known true values. RESULTS With small and medium sample sizes, an augmented 1-PL model was the most accurate at recovering the known item and person parameters; however, no model performed well at any sample size. Follow-up simulations confirmed that the large influence of guessing and the extreme easiness of the items contributed substantially to the poor estimation of item difficulty and person ability. CONCLUSION Incorporating the assumption of guessing into IRT models improves parameter estimation accuracy, even for small samples. However, caution should be exercised in interpreting scores obtained from easy 2-choice tests, regardless of whether IRT modeling or percentage correct scoring is used.
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Affiliation(s)
- William D Hula
- VA Pittsburgh Healthcare System and University of Pittsburgh, PA, USA.
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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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Haley SM, Ni P, Lai JS, Tian F, Coster WJ, Jette AM, Straub D, Cella D. Linking the activity measure for post acute care and the quality of life outcomes in neurological disorders. Arch Phys Med Rehabil 2011; 92:S37-43. [PMID: 21958921 PMCID: PMC3372982 DOI: 10.1016/j.apmr.2011.01.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 01/06/2011] [Accepted: 01/06/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To use item response theory (IRT) methods to link physical functioning items in the Activity Measure for Post Acute Care (AM-PAC) and the Quality of Life Outcomes in Neurological Disorders (Neuro-QOL). DESIGN Secondary data analysis of the physical functioning items of AM-PAC and Neuro-QOL. We used a nonequivalent group design with 36 core items common to both instruments and a test characteristic curve transformation method for linking AM-PAC and Neuro-QOL scores. Linking was conducted so that both raw and scaled AM-PAC and Neuro-QOL scores (mean ± SD converted-logit scores, 50 ± 10) could be compared. SETTING AM-PAC items were administered to rehabilitation patients in post-acute care (PAC) settings. Neuro-QOL items were administered to a community sample of adults through the Internet. PARTICIPANTS PAC patients (N=1041) for the AM-PAC sample and community-dwelling adults (N=549) for the Neuro-QOL sample. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Mobility (N=25) and activity of daily living (ADL) items (N=11) common to both instruments were included in analysis. RESULTS Neuro-QOL items were linked to the AM-PAC scale by using the generalized partial credit model. Mobility and ADL subscale scores from the 2 instruments were calibrated to the AM-PAC metric. CONCLUSIONS An IRT-based linking method placed AM-PAC and Neuro-QOL mobility and ADL scores on a common metric. This linking allowed estimation of AM-PAC mobility and ADL subscale scores based on Neuro-QOL mobility and ADL subscale scores and vice versa. The accuracy of these results should be validated in a future sample in which participants respond to both instruments.
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Affiliation(s)
- Stephen M Haley
- Health and Disability Research Institute, Boston University School of Public Health, Boston, MA 02118, USA
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Walker J, Böhnke JR, Cerny T, Strasser F. Development of symptom assessments utilising item response theory and computer-adaptive testing--a practical method based on a systematic review. Crit Rev Oncol Hematol 2010; 73:47-67. [PMID: 19375939 DOI: 10.1016/j.critrevonc.2009.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2008] [Revised: 03/05/2009] [Accepted: 03/06/2009] [Indexed: 01/06/2023] Open
Abstract
Assessment of individual patients' distress is a cornerstone of clinical care for advanced cancer. Patients' ability to fill out lengthy questionnaires is compromised by many factors. Computer-adaptive tests (CAT) offer a promising approach to developing tailored instruments, that administer only items relevant to the individual patient. A systematic review of the literature about CATs in medical databases was conducted. Based on the results, a method for developing a CAT was designed that requires nine steps: (1) build an item pool; (2) administer the items to a predefined sample in a calibration study; (3) eliminate inappropriate items; (4) examine whether all items are influenced by a single dominant trait; (5) calibrate the items to the best-fitting item response theory (IRT) model; (6) evaluate items' parameter equivalence across subgroups; (7) build an item bank with the calibrated items; (8) develop the CAT; and (9) pilot test the developed CAT. CAT offers the chance to extend the usefulness of patient-reported outcome (PRO) measurements from clinical studies to daily clinical practice.
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Affiliation(s)
- Jochen Walker
- Oncological Palliative Medicine, Section Oncology/Haematology, Department of Internal Medicine and Palliative Care Center, Cantonal Hospital, Rorschacherstrasse 95, 9007 St. Gallen, Switzerland
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Letting the CAT out of the bag: comparing computer adaptive tests and an 11-item short form of the Roland-Morris Disability Questionnaire. Spine (Phila Pa 1976) 2008; 33:1378-83. [PMID: 18496352 PMCID: PMC2671199 DOI: 10.1097/brs.0b013e3181732acb] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A post hoc simulation of a computer adaptive administration of the items of a modified version of the Roland-Morris Disability Questionnaire. OBJECTIVE To evaluate the effectiveness of adaptive administration of back pain-related disability items compared with a fixed 11-item short form. SUMMARY OF BACKGROUND DATA Short form versions of the Roland-Morris Disability Questionnaire have been developed. An alternative to paper-and-pencil short forms is to administer items adaptively so that items are presented based on a person's responses to previous items. Theoretically, this allows precise estimation of back pain disability with administration of only a few items. MATERIALS AND METHODS Data were gathered from 2 previously conducted studies of persons with back pain. An item response theory model was used to calibrate scores based on all items, items of a paper-and-pencil short form, and several computer adaptive tests (CATs). RESULTS Correlations between each CAT condition and scores based on a 23-item version of the Roland-Morris Disability Questionnaire ranged from 0.93 to 0.98. Compared with an 11-item short form, an 11-item CAT produced scores that were significantly more highly correlated with scores based on the 23-item scale. CATs with even fewer items also produced scores that were highly correlated with scores based on all items. For example, scores from a 5-item CAT had a correlation of 0.93 with full scale scores. Seven- and 9-item CATs correlated at 0.95 and 0.97, respectively. A CAT with a standard-error-based stopping rule produced scores that correlated at 0.95 with full scale scores. CONCLUSION A CAT-based back pain-related disability measure may be a valuable tool for use in clinical and research contexts. Use of CAT for other common measures in back pain research, such as other functional scales or measures of psychological distress, may offer similar advantages.
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Abstract
Outcomes are, simply put, why a surgeon comes to work each day. For decades, surgeons have insisted on a regular self-examination of outcomes to ensure the optimal treatment of our patients. Clinical research in pediatric surgery has largely subsisted on outcome analysis as it relates to the rudimentary end-result of an operation, utilizing variables such as mortality, operative time, specific complication rates, and hospital length of stay to name a few. Recently, outcomes research has become a more complex endeavor. This issue of Seminars in Pediatric Surgery addresses a wide array of these newfound complexities in contemporary outcomes research. The purpose of this review is to assist the pediatric surgeon in understanding the tools that are used in contemporary outcomes research and to be able to use this information to ask new questions of our patients and ourselves as we continue to strive for excellence in caring for sick infants and children.
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Affiliation(s)
- Casey M Calkins
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Haley SM, Gandek B, Siebens H, Black-Schaffer RM, Sinclair SJ, Tao W, Coster WJ, Ni P, Jette AM. Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: II. Participation outcomes. Arch Phys Med Rehabil 2008; 89:275-83. [PMID: 18226651 DOI: 10.1016/j.apmr.2007.08.150] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 08/20/2007] [Accepted: 08/20/2007] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To measure participation outcomes with a computerized adaptive test (CAT) and compare CAT and traditional fixed-length surveys in terms of score agreement, respondent burden, discriminant validity, and responsiveness. DESIGN Longitudinal, prospective cohort study of patients interviewed approximately 2 weeks after discharge from inpatient rehabilitation and 3 months later. SETTING Follow-up interviews conducted in patient's home setting. PARTICIPANTS Adults (N=94) with diagnoses of neurologic, orthopedic, or medically complex conditions. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participation domains of mobility, domestic life, and community, social, & civic life, measured using a CAT version of the Participation Measure for Postacute Care (PM-PAC-CAT) and a 53-item fixed-length survey (PM-PAC-53). RESULTS The PM-PAC-CAT showed substantial agreement with PM-PAC-53 scores (intraclass correlation coefficient, model 3,1, .71-.81). On average, the PM-PAC-CAT was completed in 42% of the time and with only 48% of the items as compared with the PM-PAC-53. Both formats discriminated across functional severity groups. The PM-PAC-CAT had modest reductions in sensitivity and responsiveness to patient-reported change over a 3-month interval as compared with the PM-PAC-53. CONCLUSIONS Although continued evaluation is warranted, accurate estimates of participation status and responsiveness to change for group-level analyses can be obtained from CAT administrations, with a sizeable reduction in respondent burden.
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Affiliation(s)
- Stephen M Haley
- Health and Disability Research Institute, School of Public Health, Boston University Medical Center, Boston, MA 02118-2639, USA.
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15
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Abstract
Most patients who survive a stroke experience some degree of physical recovery. Selecting the appropriate outcome measure to assess physical recovery is a difficult task, given the heterogeneity of stroke etiology, symptoms, severity, and even recovery itself. Despite these complexities, a number of strategies can facilitate the selection of functional outcome measures in stroke clinical trial research and practice. Clinical relevance in stroke outcome measures can be optimized by incorporating a framework of health and disability, such as the International Classification of Functioning, Disability, and Health (ICF). The ICF provides the conceptual basis for measurement and policy formulations for disability and health assessment. All outcome measures selected should also have sound psychometric properties. The essential psychometric properties are reliability, validity, responsiveness, sensibility, and established minimal clinically important difference. It is also important to establish the purpose of the measurement (discriminative, predictive, or evaluative) and to determine whether the purpose of the study is to evaluate the efficacy or effectiveness of an intervention. In addition, when selecting outcome measures and time of assessment, the natural history of stroke and stroke severity must be regarded. Finally, methods for acquiring data must also be considered. We present a comprehensive overview of the issues in selecting stroke outcome measures and characterize existing measures relative to these issues.
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Affiliation(s)
- Sharon Barak
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, 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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Siebens H, Andres PL, Pengsheng N, Coster WJ, Haley SM. Measuring physical function in patients with complex medical and postsurgical conditions: a computer adaptive approach. Am J Phys Med Rehabil 2005; 84:741-8. [PMID: 16205429 DOI: 10.1097/01.phm.0000186274.08468.35] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine whether the range of disability in the medically complex and postsurgical populations receiving rehabilitation is adequately sampled by the new Activity Measure--Post-Acute Care (AM-PAC), and to assess whether computer adaptive testing (CAT) can derive valid patient scores using fewer questions. DESIGN Observational study of 158 subjects (mean age 67.2 yrs) receiving skilled rehabilitation services in inpatient (acute rehabilitation hospitals, skilled nursing facility units) and community (home health services, outpatient departments) settings for recent-onset or worsening disability from medical (excluding neurological) and surgical (excluding orthopedic) conditions. Measures were interviewer-administered activity questions (all patients) and physical functioning portion of the SF-36 (outpatients) and standardized chart items (11 Functional Independence Measure (FIM), 19 Standardized Outcome and Assessment Information Set (OASIS) items, and 22 Minimum Data Set (MDS) items). Rasch modeling analyzed all data and the relationship between person ability estimates and average item difficulty. CAT assessed the ability to derive accurate patient scores using a sample of questions. RESULTS The 163-item activity item pool covered the range of physical movement and personal and instrumental activities. CAT analysis showed comparable scores between estimates using 10 items or the total item pool. CONCLUSION The AM-PAC can assess a broad range of function in patients with complex medical illness. CAT achieves valid patient scores using fewer questions.
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Affiliation(s)
- Hilary Siebens
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia, USA
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Jette AM, Haley SM. Contemporary measurement techniques for rehabilitation outcomes assessment*. J Rehabil Med 2005; 37:339-45. [PMID: 16287664 DOI: 10.1080/16501970500302793] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
In this article, we review the limitations of traditional rehabilitation functional outcome instruments currently in use within the rehabilitation field to assess Activity and Participation domains as defined by the International Classification of Function, Disability, and Health. These include a narrow scope of functional outcomes, data incompatibility across instruments, and the precision vs feasibility dilemma. Following this, we illustrate how contemporary measurement techniques, such as item response theory methods combined with computer adaptive testing methodology, can be applied in rehabilitation to design functional outcome instruments that are comprehensive in scope, accurate, allow for compatibility across instruments, and are sensitive to clinically important change without sacrificing their feasibility. Finally, we present some of the pressing challenges that need to be overcome to provide effective dissemination and training assistance to ensure that current and future generations of rehabilitation professionals are familiar with and skilled in the application of contemporary outcomes measurement.
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Affiliation(s)
- Alan M Jette
- Health and Disability Research Institute, Boston University, 53 Bay State Road, Boston, MA 02215, USA.
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