Draw & Doodle Simulation: A colorful strategy to prepare medical teams for electronic dance music festival emergencies.

EDUCATIONAL CHALLENGE: Electronic dance music (EDM) festivals - crowded, loud, low-resource environments - pose unique challenges to event medical teams. Simulation can prepare teams to manage clinical presentations in this unconventional context. Without access to simulation infrastructure, a low-technological, low-fidelity simulation modality is warranted. SOLUTION: Draw & Doodle Simulation (D&D SIM) is a low-fidelity simulation where patients are hand-drawn (i.e. on paper, whiteboard, or digitally) instead of utilizing manikins or live actors. Facilitators draw all patient findings, while participants doodle any possible interventions. SOLUTION IMPLEMENTATION: Two D&D SIM cases (serotonin toxicity and refractory anaphylaxis) were piloted in classrooms. Participants included paramedics, medical students, lifeguards, and first aiders. Facilitators conducted simulations using chart paper, with each participant doodling contributions using differently colored markers. LESSONS LEARNED: Participants responded positively, rating the serotonin toxicity case 4.31/5 (n = 13) and refractory anaphylaxis case 4.53/5 (n = 15). Participants appreciated the 'low-stakes', useful 'visual' representation of progress, 'fun and [interactivity]', and appropriate '[realism]' of D&D SIM. However, D&D SIM was perceived as 'less life threatening', would not be appropriate for physical skills (e.g. CPR), required everyone to be 'oriented in the same direction to see the drawing', and the chart paper risked becoming cluttered. NEXT STEPS: Next steps include writing new cases, implementing D&D SIM in other teaching contexts, exploring its use in digital platforms, and studying its effectiveness against higher-fidelity simulation.

Test-Retest Reliability of the Electronic Instrumental activities of daily living Satisfaction Assessment (EISA): A Cohort Study.

IMPORTANCE: Currently, no self-report instruments exist for assessing satisfaction with performing instrumental activities of daily living and occupations for people with disabilities using internet-connected assistive devices like accessible smartphones, tablets, laptops, and apps. OBJECTIVE: To assess the test-retest reliability and internal consistency of the Electronic Instrumental activities of daily living Satisfaction Assessment (EISA) self-report outcome tool. DESIGN: Repeated-measures cohort study with a time frame of 7 to 21 days. SETTING: Multicity online recruitment at assistive technology clinics, nongovernmental organizations, advocacy and peer support groups for people with disabilities, and higher education institutions. PARTICIPANTS: Eighty-four participants with disabilities, age 18 yr or older, with a mean age of 43.3 yr (range = 19-75 yr), and 57% female. INTERVENTION: Not applicable. OUTCOMES AND MEASURES: The a priori study hypotheses were that the EISA test-retest reliability scores would be above the minimum acceptable level (Rs > .80) and that internal consistency would be good (Cronbach's α = .70-.90). RESULTS: On the basis of the study data, the EISA, Version 1.0, demonstrated good test-retest reliability (Rs = .81) and excellent internal consistency (Cronbach's α = .88). CONCLUSIONS AND RELEVANCE: The results of the test-retest reliability and internal consistency analyses provide good support for the EISA to be used in clinical settings. What This Article Adds: This article documents the reliability and internal consistency of, to our knowledge, the first-ever self-report instrument for assessing satisfaction with performance of everyday occupations for people with disabilities using internet-connected assistive devices such as smartphones, tablets, laptops, and apps.

A vocational rehabilitation partnership to provide transition services to young adults with neurodevelopmental disabilities: The cognitive skills enhancement program.

BACKGROUND: There is an urgent need for services that support a successful transition to postsecondary education and employment for young adults with neurodevelopmental and cognitive disabilities (e.g. autism spectrum disorder, attention-deficit/hyperactivity disorder, traumatic brain injury). OBJECTIVE: The purpose of this expository article is to describe the Cognitive Skills Enhancement Program (CSEP), a comprehensive clinical program designed for young adults with neurodevelopmental and cognitive disabilities transitioning to postsecondary education. METHODS: CSEP was developed through a community-academic partnership between a university and a state vocational rehabilitation program. Young adult participants complete programming that addresses four primary clinical targets: (1) emotion regulation, (2) social skills, (3) work readiness, and (4) community participation with the overall goal to increase awareness and promote successful employment outcomes while they transition to post-secondary education. RESULTS: To date, CSEP has supported 18 years of sustained programming and clinical services to 621 young adults with neurodevelopmental and cognitive disabilities. CONCLUSION: This partnership model allows for flexible responses to participant needs, implementation barriers, and advances in evidence-based practices. CSEP meets the needs of diverse stakeholders (e.g. state vocational rehabilitation, postsecondary training facilities, participants, universities) while providing high-quality and sustainable programming. Future directions include examining the clinical efficacy of current CSEP programming.

Construct validity of the enfranchisement scale of the community participation indicators.

OBJECTIVE: This study examined the construct validity of the Enfranchisement scale of the Community Participation Indicators. DESIGN: We conducted a secondary analysis of data collected in a cross-sectional study of rehabilitation outcomes. SUBJECTS: The parent study included 604 community-dwelling adults with chronic traumatic brain injury, stroke, or spinal cord injury. The sample had a mean age of 64.1 years, was two-thirds male, and included a high proportion of racial minorities (n = 250, 41.4%). MAIN MEASURES: The Enfranchisement scale contains two subscales: the Control subscale and the Importance subscale. We examined correlations between each Enfranchisement subscale and measures of participation, environment, and impairments. The current analyses included cases with at least 80% of items completed on each subscale (Control subscale: n = 391; Importance subscale: n = 219). Missing values were imputed using multiple imputation. RESULTS: The sample demonstrated high scores, indicating poor enfranchisement (Control subscale: M = 51.7; Importance subscale: M = 43.0). Both subscales were most strongly associated with measures of participation (Control subscale: r = 0.56; Importance subscale: r = 0.52), and least strongly associated with measures of cognition (Control subscale: r = 0.03; Importance subscale: r = 0.03). The Importance subscale was closely associated with depression (r = 0.54), and systems, services, and policies (r = 0.50). Both subscales were associated with social attitudes (Control subscale: r = 0.44; Importance subscale: r = 0.44) and social support (Control subscale: r = 0.49; Importance subscale: r = 0.41). CONCLUSIONS: We found evidence of convergent validity between the Enfranchisement scale and measures of participation, and discriminant validity between the Enfranchisement scale and measures of disability-related impairments. The analyses also revealed the importance of the environment to enfranchisement outcomes.

Detecting change in community participation with the Enfranchisement scale of the community participation indicators.

OBJECTIVE: This study determined the sensitivity to change of the Enfranchisement scale of the Community Participation Indicators in people with stroke. DATA SOURCES: We analyzed data from two studies of participants with stroke: an intervention study and an observational study. MAIN MEASURES: The Enfranchisement Scale contains two subscales: the Importance subscale (feeling valued by and contributing to the community; range: 14-70) and the Control subscale (choice and control: range: 13-64). DATA ANALYSIS: Assessments were administered 6 months apart. We calculated minimum detectable change and minimal clinically important difference. RESULTS: The Control subscale analysis included 121 participants with a mean age of 61.2 and mild-moderate disability (Functional Independence Measure, mean = 97.9, SD = 24.7). On the Control subscale, participants had a mean baseline score of 51.4 (SD = 10.4), and little mean change (1.3) but with large variation in change scores (SD = 11.5). We found a minimum detectable change of 9 and a minimum clinically important difference of 6. The Importance subscale analysis included 116 participants with a mean age of 60.7 and mild-moderate disability (Functional Independence Measure, mean = 98.9, SD = 24.5). On the Importance subscale, participants had a mean baseline score of 44.1 (SD = 12.7), and again demonstrated little mean change (1.08) but with large variation in change scores (SD = 12.6). We found a minimum detectable change of 11 and a minimum clinically important difference 7. CONCLUSIONS: The Control subscale required 9 points of change, and the Importance subscale required 11 points of change, to achieve statistically and clinically meaningful changes, suggesting adequate sensitivity to change.

Effect of interventions on activity and participation outcomes for adults with brain injury: a scoping review.

OBJECTIVE: To characterize the intervention elements associated with improvements in activity and participation outcomes for adults with brain injury. DATA SOURCES: PubMed and PsycINFO/Ovid. STUDY SELECTION: We included RCTs that examined interventions for adults with acquired brain injury with an activity or participation outcome measure. DATA EXTRACTION: We classified intervention elements and extracted effect sizes. We examined patterns of effect sizes associated with each intervention element based on time of follow-up and level of outcome (home versus community). DATA SYNTHESIS: Thirty-nine articles were included. Outcomes focused on the performance of home and community activities. There was wide variation in effect sizes across all intervention elements, as well as by time and by outcome level (home versus community). Metacognitive interventions and daily life skills interventions showed the greatest promise for improving performance of home and community activities. Additionally, cognitive training interventions may play a role in improving home activity performance and social skills training interventions may play a role in community activity performance. Physical activity interventions showed the least promise for improving home and community activity performance. CONCLUSION: This study highlights the importance of interventions that incorporate explicit strategies and task-specific training, rather than only addressing specific injury-related impairments.

Domains and dimensions of community participation following traumatic brain injury.

PRIMARY OBJECTIVE: To examine patterns of community participation, as well as the relationship among community participation outcomes and time since injury, impairments, environmental factors, and enfranchisement in adults with traumatic brain injury (TBI). RESEARCH DESIGN: Cross-sectional study of a sample of 61 adults with TBI. METHODS AND PROCEDURES: We administered the Participation Measure- 3 Domains 4 Dimensions to examine community participation in the three domains (productivity, community activities, and social participation) using four dimensions (diversity of activities, frequency, difficulty, and desire for change). MAIN RESULTS AND OUTCOMES: All dimensions of community participation seem to be impaired following TBI, as evidenced by scores in the lower half of the available range. Most impaired was social participation (frequency: M = 10.0, SD = 3.4, possible range 0-24; difficulty: M=  11.3, SD = 3.2, possible range 4-16). Correlational analyses revealed that depression (r = 0.51), environmental factors (r = 0.51), and enfranchisement (r = 0.42), seem to play an important role in community participation outcomes, and may be potential targets for intervention. Results did not vary based on time since injury. CONCLUSION: Our results suggest that depression, environmental factors, and enfranchisement may be important considerations for future interventions aiming to promote management of identified barriers.

Activating Behavior to Reduce Sedentary Behavior After Stroke: A Nonrandomized Pilot Feasibility Study.

IMPORTANCE: Reducing poststroke sedentary behavior is important for reducing recurrent stroke risk, yet interventions to achieve this are scant. OBJECTIVE: To assess the feasibility of, and estimate change in sedentary behavior over time associated with, a behavioral intervention. DESIGN: Single-arm delayed baseline with postintervention and 8-wk follow-up assessment. SETTING: Community based. PARTICIPANTS: Ambulatory, community-dwelling people with chronic stroke and reported ≥6 hr daily sitting time (N = 21). INTERVENTION: Activating Behavior for Lasting Engagement (ABLE) was delivered by an occupational therapist 3×/wk for 4 wk. ABLE involves activity monitoring, activity scheduling, self-assessment, and collaborative problem solving. OUTCOMES AND MEASURES: Feasibility (participant safety, adherence, satisfaction, and reliable intervention delivery) was assessed against preestablished benchmarks. Changes over time in sedentary behavior (assessed with an ActivPAL micro3 device) and participation (Stroke Impact Scale-Participation subscale) were described. RESULTS: ABLE was safe (0 serious adverse events), adhered to (11.95 sessions/participant), and reliably delivered (90.00%-97.50% adherence). Participant satisfaction was unmet (Client Satisfaction Questionnaire-8, M = 28.75, SD = 3.84). ABLE was associated with a mean group reduction in prolonged sitting of 54.95 min (SD = 81.10) at postintervention and 14.08 (SD = 58.95) at follow-up. ABLE was associated with a negligible mean group increase over time in participation at postintervention (M = 1.48%, SD = 8.52) and follow-up (M = 1.33%, SD = 15.38). CONCLUSIONS AND RELEVANCE: The ABLE intervention is feasible and may be associated with within-group reduction in sedentary behavior over time. Further refinement is indicated. WHAT THIS ARTICLE ADDS: The ABLE intervention uses engagement in meaningful daily activities to reduce sedentary behavior after stroke. These findings suggest that ABLE can be delivered safely and consistently. Further research is required to enhance participant satisfaction and determine the effects of ABLE on stroke survivors' sedentary behavior.

The Health of the Small-Group Insurance Market.

Issue: There has been relatively little discussion about the small-group employer insurance market since the implementation of reforms under the Affordable Care Act. It is important to understand the condition of this market before the impact of recent regulatory changes from the Trump administration. Goal: To understand how the ACA's market reforms have affected prices, enrollment, and competition in the small-group market. Methods: Analysis of financial data filed by small-group insurers with the federal government, along with relevant published literature. Findings and Conclusions: Enrollment has declined in the small-group market, although this is largely a continuation of a trend in place prior to the ACA. Substantially more small-business owners and workers now have coverage than prior to the ACA because many have been able to take advantage of subsidized individual plans through the marketplaces. For those who remain in the small-group market, price increases have been similar to those in the large-group market. The ACA has not reduced the cost of small-group insurance, but has made it more accessible and comprehensive without harming the market. It will be important to continue monitoring the small-group market to ensure that recent regulatory changes do not worsen market conditions.

A novel tool for naturalistic assessment of behavioural dysregulation after traumatic brain injury: A pilot study.

OBJECTIVE: This study aimed to develop a novel tool for measuring behavioural dysregulation in adults with traumatic brain injury (TBI) using objective data sources and real-world application and provide preliminary evidence for its psychometric properties. RESEARCH DESIGN: Fourteen adults with TBI receiving services at a local brain injury rehabilitation programme completed multiple assessments of behaviour and followed by a series of challenging problem-solving tasks while being video recorded. Trained clinicians completed post-hoc behavioural assessments using the behavioural dysregulation ratings scale, and behavioural event data were then extracted for comparison with self-report measures. RESULTS: Subject matter experts in neurorehabilitation were in 100% agreement that preliminarily, the new tool measured the construct of behavioural dysregulation. Construct validity was established through strong convergence with 'like' measures and weak correlation with 'unlike' measures. Substantial inter-rater reliability was established between two trained clinician raters. CONCLUSIONS: This study provides preliminary evidence supporting the use of a new precision measurement tool of behaviour in post-acute TBI that has the capability to be deployed naturalistically where deficits truly manifest. Future large-scaled confirmatory psychometric trials are warranted to further establish the utility of this new tool in rehabilitation research.

How a diverse research ecosystem has generated new rehabilitation technologies: Review of NIDILRR's Rehabilitation Engineering Research Centers.

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.

How Have Health Insurers Performed Financially Under the ACA' Market Rules?

Issue: The Affordable Care Act (ACA) transformed the market for individual health insurance, so it is not surprising that insurers' transition was not entirely smooth. Insurers, with no previous experience under these market conditions, were uncertain how to price their products. As a result, they incurred significant losses. Based on this experience, some insurers have decided to leave the ACA's subsidized market, although others appear to be thriving. Goals: Examine the financial performance of health insurers selling through the ACA's marketplace exchanges in 2015--the market's most difficult year to date. Method: Analysis of financial data for 2015 reported by insurers from 48 states and D.C. to the Centers for Medicare and Medicaid Services. Findings and Conclusions: Although health insurers were profitable across all lines of business, they suffered a 10 percent loss in 2015 on their health plans sold through the ACA's exchanges. The top quarter of the ACA exchange market was comfortably profitable, while the bottom quarter did much worse than the ACA market average. This indicates that some insurers were able to adapt to the ACA's new market rules much better than others, suggesting the ACA's new market structure is sustainable, if supported properly by administrative policy.

The association between pre-treatment occupational skill level and mood and symptom burden in early-stage, postmenopausal breast cancer survivors during the first year of anastrozole therapy.

PURPOSE: Previous research has explored occupational activity of breast cancer survivors but has not examined the influence of occupational level on symptoms prospectively. The purpose of this study was to examine the relationship between occupational classification and changes in mood and symptom burden for postmenopausal breast cancer survivors during the first year of anastrozole therapy. METHODS: This was an exploratory secondary analysis in 49 postmenopausal women receiving anastrozole therapy for early-stage breast cancer. Participants reported their occupation at baseline and completed self-report questionnaires measuring mood and symptom burden at baseline, 6 months, and 12 months. Occupation was classified according to four major skill levels delineated by the International Standard Classification of Occupations (ISCO). RESULTS: Breast cancer survivors employed at occupational skill levels 1 through 3 reported significantly higher depressive symptoms, fatigue, and total symptoms on average than those employed at ISCO skill level 4. After adjusting for multiple comparisons, this pattern remained for the musculoskeletal, vasomotor, and gastrointestinal symptom subscales. CONCLUSIONS: Breast cancer survivors employed at lower skill levels (i.e., ISCO 1-3) reported poorer mood and greater symptom burden than breast cancer survivors employed at a higher skill level (i.e., ISCO 4). Assessing baseline occupation of occupationally active breast cancer survivors may improve understanding of the association between types of occupations and mood and symptom trajectories and may inform development of interventions to mitigate symptom severity in order to help breast cancer survivors maintain optimal occupational function and adherence to therapy.

A Flexible and Integrated System for the Remote Acquisition of Neuropsychological Data in Stroke Research.

BACKGROUND: Neuropsychological testing is a central aspect of stroke research because it provides critical information about the cognitive-behavioral status of stroke survivors, as well as the diagnosis and treatment of stroke-related disorders. Standard neuropsychological methods rely upon face-to-face interactions between a patient and researcher, which creates geographic and logistical barriers that impede research progress and treatment advances. INTRODUCTION: To overcome these barriers, we created a flexible and integrated system for the remote acquisition of neuropsychological data (RAND). The system we developed has a secure architecture that permits collaborative videoconferencing. The system supports shared audiovisual feeds that can provide continuous virtual interaction between a participant and researcher throughout a testing session. Shared presentation and computing controls can be used to deliver auditory and visual test items adapted from standard face-to-face materials or execute computer-based assessments. Spoken and manual responses can be acquired, and the components of the session can be recorded for offline data analysis. MATERIALS AND METHODS: To evaluate its feasibility, our RAND system was used to administer a speech-language test battery to 16 stroke survivors with a variety of communication, sensory, and motor impairments. The sessions were initiated virtually without prior face-to-face instruction in the RAND technology or test battery. RESULTS: Neuropsychological data were successfully acquired from all participants, including those with limited technology experience, and those with a communication, sensory, or motor impairment. Furthermore, participants indicated a high level of satisfaction with the RAND system and the remote assessment that it permits. CONCLUSIONS: The results indicate the feasibility of using the RAND system for virtual home-based neuropsychological assessment without prior face-to-face contact between a participant and researcher. Because our RAND system architecture uses off-the-shelf technology and software, it can be duplicated without specialized expertise or equipment. In sum, our RAND system offers a readily available and promising alternative to face-to-face neuropsychological assessment in stroke research.

A Performance Analysis of Long-term Acute-Care Hospitals Owned by Large, Multistate Investor-Owned Companies.

This study provides a descriptive assessment of the operating performance of for-profit long-term acute-care hospitals owned by multistate, investor-owned companies (large FP LTCHs) compared with FP LTCHs owned by smaller FP companies (small FP LTCHs) and nonprofit LTCHs (NP LTCHs). The study used the Centers for Medicare & Medicaid Services cost report data for 290 LTCHs from 2010 through 2012 to compare the financial performance of large and small FP LTCHs and NP LTCHs. The study found that the median operating profit margin for large FP LTCHs was 8.06%, which was twice as high as that of the small FP LTCHs and NP LTCHs (4.78% and 2.80%, respectively). Larger size, serving a greater proportion of private pay and more complex patients and incurring lower operating expenses, including salary expenses, may account for the higher operating margin of the large FP LTCHs.

How Has the Affordable Care Act Affected Health Insurers' Financial Performance?

Starting in 2014, the Affordable Care Act transformed the market for individual health insurance by changing how insurance is sold and by subsidizing coverage for millions of new purchasers. Insurers, who had no previous experience under these market conditions, competed actively but faced uncertainty in how to price their products. This issue brief uses newly available data to understand how health insurers fared financially during the ACA's first year of full reforms. Overall, health insurers' financial performance began to show some strain in 2014, but the ACA's reinsurance program substantially buffered the negative effects for most insurers. Although a quarter of insurers did substantially worse than others, experience under the new market rules could improve the accuracy of pricing decisions in subsequent years.

Promoting Value for Consumers: Comparing Individual Health Insurance Markets Inside and Outside the ACA's Exchanges.

The new health insurance exchanges are the core of the Affordable Care Act's (ACA) insurance reforms, but insurance markets beyond the exchanges also are affected by the reforms. This issue brief compares the markets for individual coverage on and off of the exchanges, using insurers' most recent projections for ACA-compliant policies. In 2016, insurers expect that less than one-fifth of ACA-compliant coverage will be sold outside of the exchanges. Insurers that sell mostly through exchanges devote a greater portion of their premium dollars to medical care than do insurers selling only off of the exchanges, because exchange insurers project lower administrative costs and lower profit margins. Premium increases on exchange plans are less than those for off-exchange plans, in large part because exchange enrollment is projected to shift to closed-network plans. Finally, initial concerns that insurers might seek to segregate higher-risk subscribers on the exchanges have not been realized.

Pilot feasibility of an mHealth system for conducting ecological momentary assessment of mood-related symptoms following traumatic brain injury.

OBJECTIVE: This study assessed pilot feasibility and validity of a mobile health (mHealth) system for tracking mood-related symptoms after traumatic brain injury (TBI). DESIGN: A prospective, repeated measures design was used to assess compliance with daily ecological momentary assessments (EMA) conducted via a smartphone application over an 8-week period. METHODS: An mHealth system was developed specifically for individuals with TBI and utilized previously validated tools for depressive and anxiety symptoms (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7). Feasibility was assessed in 20 community-dwelling adults with TBI via an assessment of compliance, satisfaction and usability of the smartphone applications. The authors also developed and implemented a clinical patient safety management mechanism for those endorsing suicidality. RESULTS: Participants correctly completed 73.4% of all scheduled assessments, demonstrating good compliance. Daily assessments took <2 minutes to complete. Participants reported high satisfaction with smartphone applications (6.3 of 7) and found them easy to use (6.2 of 7). Comparison of assessments obtained via telephone-based interview and EMA demonstrated high correlations (r = 0.81-0.97), supporting the validity of conducting these assessments via smartphone application in this population. CONCLUSIONS: EMA conducted via smartphone demonstrates initial feasibility among adults with TBI and presents numerous opportunities for long-term monitoring of mood-related symptoms in real-world settings.

Usability and reliability of a remotely administered adult autism assessment, the autism diagnostic observation schedule (ADOS) module 4.

INTRODUCTION: The Autism Diagnostic Observation Schedule (ADOS) Module 4 is an autism assessment designed for verbally fluent adolescents and adults. Because of a shortage of available clinical expertise, it can be difficult for adults to receive a proper autism spectrum disorder (ASD) diagnostic assessment. A potential option to address this shortage is remote assessment. The objective of this study was to examine the feasibility, usability, and reliability of administering the ADOS Module 4 remotely using the Versatile and Integrated System for Telerehabilitation (VISYTER). MATERIALS AND METHODS: VISYTER consists of computer stations at the client site and clinician site for video communication and a Web portal for managing and coordinating the assessment process. Twenty-three adults with an ASD diagnosis participated in a within-subject crossover design study in which both a remote ADOS and a face-to-face ADOS were administered. After completing the remote ADOS, participants completed a satisfaction survey. RESULTS: Participant satisfaction with the remote ADOS delivery system was high. The kappa value was greater than 0.61 on 21 of 31 ADOS items. There was substantial agreement on ADOS classification (i.e., diagnosis) between assessments delivered face-to-face versus assessments delivered remotely (interclass coefficient=0.92). Non-agreement may have been due to outside factors or practice effect despite a washout period. CONCLUSIONS: The results of this study demonstrate that an autism assessment designed to be delivered face to face can be administered remotely using an integrated Web-based system with high levels of usability and reliability.

Hospital Acquisitions Before Healthcare Reform.

The hospital industry has experienced increased consolidation in the past 20 years. Since 2010, in particular, there has been a large rise in the number of hospital acquisitions, and observers have suggested this is due in part to the expected impact of federal healthcare reform legislation. This article reports on a study undertaken to identify the market, management, and financial factors affecting acute care, community hospitals acquired between 2010 and 2012. We identified 77 such hospitals and compared them to other acute care facilities. To assess how different factors were associated with acquisitions, the study used multiple logistic regressions whereby market factors were included first, followed by management and financial factors. Study findings show that acquired hospitals were located in markets with lower rates of preferred provider organization (PPO) penetration compared with nonacquired hospitals. Occupancy rate was found to be inversely related to acquisition rate; however, case-mix index was significantly and positively related to a hospital's being acquired. Financial factors negatively associated with a hospital's being acquired included age of plant and cash flow margin. In contrast to the findings from earlier studies of hospital acquisitions, our results showed that acquired hospitals possessed newer assets. However, similar to the findings of other studies, the cash flow margin of acquired hospitals was lower than that of nonacquired facilities.