Implementing Patient-Reported Outcome Measures in Inpatient Rehabilitation: Challenges and Solutions.

A project with the goal of implementing electronic health record (EHR)-based patient-reported outcome measures (PROMs) into a large inpatient spinal cord injury (SCI) rehabilitation program took twice as long as expected. This report details the lessons learned from the barriers, successes, and unexpected issues that arose during this prolonged, but now successful, project. The goals of this implementation project were to (1) identify barriers and supports to the use of PROMs; (2) develop an implementation strategy to incorporate the use of PROMs into inpatient rehabilitation; and (3) implement the strategy and evaluate its effects on team communication. In brief, we conducted an initial pilot phase outside of the EHR and used our findings to guide procedural and EHR incorporation during a demonstration phase. We encountered multiple barriers. Procedural issues were significant; although grant funding covered the cost of writing the code for integration of the PROMs into the EHR, our institution's competing priorities slowed progress. Institutional inertia was reflected in the reluctance of some clinical staff members to assume new duties that would take away from direct patient care responsibilities. Therefore, we needed to obtain additional staffing. Detailed planning upfront, guided by changes when necessary; cooperation and interaction with our institution's Information Systems department; and identification of key players and Implementation Champions proved essential to our success. We now have an up-and-running system and are sharing our experience, observations, and recommendations to assist other health care organizations incorporate PROMs into their EHRs.

Rasch Analysis of Social Attitude Barriers and Facilitators to Participation for Individuals with Disabilities.

OBJECTIVES: To develop item banks of social attitude barriers and facilitators to participation and validate them with established instruments. DESIGN: We used the Rasch model to identify misfitting items and rating scale problems, calibrate items, and develop KeyForms and short forms. Correlations between the Social Attitude Barriers and Facilitators item banks with the Patient-Reported Outcomes Measurement Information System (PROMIS) Social Health domain and National Institutes of Health Toolbox Emotional Battery Social Relationships domain were computed to evaluate convergent and divergent validity. SETTING: Community-dwelling individuals traveled to 3 academic medical centers for testing. PARTICIPANTS: Participants (N=558) who had a primary impairment of stroke, spinal cord injury, or traumatic brain injury (mean age, 47.0±16.0y) completed 31 social attitude facilitator and 51 barrier items using a 5-point rating scale. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Item banks to measure social attitude barriers and facilitators for individuals with disabilities. RESULTS: After combining the "never" and "rarely" rating scale categories, 30 Facilitator items fit the Rasch model and demonstrated person reliability of 0.93. After collapsing the "never" and "rarely" rating scale categories, 45 Barrier items fit the Rasch model and demonstrated person reliability of 0.95. Ceiling and floor effects were negligible for both item banks. Facilitators and Barriers item banks were negatively correlated, and these banks were moderately correlated with PROMIS and Toolbox measures, providing evidence of convergent and divergent validity. CONCLUSIONS: Findings support the reliability and validity of the Social Attitude Facilitators and Barriers item banks. These item banks allow investigators and clinicians to measure perceptions of social attitudes, providing information that can guide individual interventions to reduce barriers and promote facilitators. Moderate correlations between the Social Attitude banks and PROMIS and Toolbox variables provide support for the measurement and theory of environmental influences on social health and participation.

My Vocational Situation (MVS): Case Example and Psychometric Review.

This case report provides an overview of the psychometric properties and clinical utility of the My Vocational Situation (MVS) instrument. The accompanying hypothetical case description illustrates how clinicians could use the MVS to evaluate vocational preferences and outcomes and how the MVS can be used to inform treatment planning and rehabilitation decision making. The information contained in this report is intended to familiarize clinicians with the administration and scoring of the MVS, the psychometric information necessary to interpret results obtained from the MVS, and how the results could be used to provide comprehensive, patient-centered care. It is important to note that the information provided represents only a sample of the available research literature on the MVS.

Evaluating Individual Change With the Quality of Life in Neurological Disorders (Neuro-QoL) Short Forms.

OBJECTIVE: To provide a clinically useful means of interpreting change for individual patients on the Quality of Life in Neurological Disorders (Neuro-QoL) adult short forms (SFs) by applying a classical test theory concept for interpreting individual change. DESIGN: Secondary analysis of existing data. SETTING: Community. PARTICIPANTS: Persons with neurologic conditions including stroke, epilepsy, amyotrophic lateral sclerosis, multiple sclerosis, and Parkinson disease residing in community settings. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Neuro-QoL SFs for Applied Cognition-General Concerns, Applied Cognition-Executive Function, Applied Cognition-Combined, Ability to Participate in Social Roles and Activities, Satisfaction With Social Roles and Activities, Positive Affect and Well-Being, Depression, Stigma, Upper Extremity Function (Fine Motor, Activities of Daily Living), Lower Extremity Function (Mobility), Anxiety, Sleep Disturbance, Fatigue, and Emotional and Behavioral Dyscontrol. We estimated conditional minimal detectable change (cMDC) indices from the pooled SEs adjusted for a 95% confidence interval using the average of the SEs for any given pair of scores multiplied by the z score, or ([SE(Score1) + SE(Score2)]/2) * (1.96) * (SQRT(2)). RESULTS: The cMDC indices are generally smallest in the midrange of all scales, ranging from 3.6 to 11.2 T-score points, and higher on the outer quartiles ranging from 3.7 to 21.6 T-score points. The lowest midrange cMDCs were for Satisfaction With Social Roles and Activities (3.6-4.7 T-score points), and the largest were for Sleep Disturbance (9.4-11.2 T-score points). CONCLUSIONS: Change indices can help clinicians and investigators identify differences for individual patients or subjects that are large enough to motivate treatment change. cMDCs can reduce misclassification of magnitudes of change that are near the margins of error across the range of the Neuro-QoL SFs.

Integrating Spinal Cord Injury - Quality of Life instruments into rehabilitation: Implementation science to guide adoption of patient-reported outcome measures.

Context/objective: This study describes a development strategy for integrating the Spinal Cord Injury - Quality of Life (SCI-QOL) item banks into inpatient spinal cord injury (SCI) rehabilitation and recommendations for protocol implementation.Design: We adopted an implementation science approach to develop a strategy for adapting and contextualizing SCI-QOL use during SCI rehabilitation. We conducted focus groups and stakeholder meetings with clinical assessment champions to (1) identify barriers and supports to SCI-QOL adoption; (2) reduce barriers and emphasize supports; (3) evaluate and select relevant SCI-QOL domains and item banks; (4) develop administration and reporting guidelines; and (5) identify hospital roles to alert with SCI-QOL results.Setting: A regional inpatient rehabilitation hospital. This study focuses on clinicians providing inpatient rehabilitation to patients with SCI.Participants: Fifty-nine clinicians, including physicians, speech language pathologists, occupational and physical therapists, nurses, and social workers providing care to SCI inpatients.Interventions: N/A.Outcome measures: N/A.Results: Clinicians identified the SCI-QOL domains that were most relevant to inpatient care; when SCI-QOL should be administered; what hospital roles were best suited for administering SCI-QOL; how results should be displayed in the electronic medical record; and which clinical roles needed notification of SCI-QOL results.Conclusions: Clinicians acknowledge the value of patient-reported outcome measures in inpatient SCI rehabilitation, but noted barriers to adoption. Engaging clinicians in the decision-making process for developing an implementation and administration protocol can inform strategies to overcome barriers and emphasize supports.

Effects of an Implementation Intervention to Promote Use of Patient-Reported Outcome Measures on Clinicians' Perceptions of Evidence-Based Practice, Implementation Leadership, and Team Functioning.

INTRODUCTION: Patient-reported outcome measures (PROMs) are administered rarely during rehabilitation hospitalizations because clinicians are unfamiliar with their use and the technology to integrate PROMs into electronic medical records is nascent. This study evaluated an implementation intervention that targeted teams' perceptions of evidence-based practice (EBP), implementation leadership, and team functioning that might facilitate PROM use. METHODS: We compared clinicians' perceptions on three inpatient rehabilitation units, with sequential implementation across units. Clinicians completed the EBP Attitudes Scale, Implementation Leadership Scale, and the Team Functioning Survey before, shortly after, and 1 month after training. RESULTS: Forty-seven clinicians participated, including nurses (27.7%), occupational (21.3%) and physical therapists (21.3%), and two physicians. They worked on spinal cord injury (46.8%), neurologic (40.4%), or pediatric (12.8%) units. EBP Attitude Scale scores improved from preintervention to postintervention and remained above baseline levels at follow-up. The interaction between time and unit was statistically significant for the Divergence subscale such that Pediatric Unit scores increased from preintervention to postintervention and follow-up, while on the spinal cord injury, unit scores increased from preintervention to postintervention, and on the Neurologic Unit scores declined from preintervention to postintervention and follow-up. The EBP Attitudes Requirements score increased at postintervention and follow-up. The Implementation Leadership Scale Proactive score and team functioning survey scores decreased slightly. DISCUSSION: Implementing PROMs had varied effects on EBP attitudes and perceptions of leadership and team functioning. Perceptions across units were distinctive on the Evidence-Based Practice Attitudes Scale Divergence subscale. Introduction of PROMs should consider clinician attitudes regarding EBP as well as implementation leadership and team functioning.

Uncorrected versus demographically-corrected scores on the NIH Toolbox Cognition Battery in persons with traumatic brain injury and stroke.

OBJECTIVE: The association between demographic characteristics and neurocognitive performance is well established; however, clinicians may have difficulty selecting when to use uncorrected versus demographically corrected scores. We compared these score types in individuals with traumatic brain injury (TBI) and stroke, on the National Institutes of Health Toolbox-Cognition Battery (NIHTB-CB). RESEARCH METHOD: Adults with TBI and stroke were demographically matched to controls, and completed the NIHTB-CB. Published "corrected scores" are adjusted for age, education, sex, and race/ethnicity; "uncorrected scores" were created using census data to represent the average adult in the U.S. RESULTS: Effect sizes for the TBI and stroke groups versus controls were larger using corrected scores compared with uncorrected scores for the fluid composite (uncorrected to corrected effect sizes: TBI: d = 0.66, p < .001 to 0.83, p < .001; stroke d = 0.97, p < .001 to 1.10, p < .001). For the crystallized composite, effect sizes for the TBI and stroke groups versus controls were smaller and nonsignificant using corrected scores (uncorrected to corrected effect sizes: TBI d = 0.23, p = .03 to 0.20, p = .06; stroke d = 0.40, p < .001 to 0.17, p = .09). In the injury groups, demographic characteristics accounted for up to 33% of variance in uncorrected scores (p < .001), but <5% of variance in corrected scores (p > .06). CONCLUSIONS: Corrected scores were more sensitive to neurocognitive impairments in the brain-injured groups. Corrected scores have the advantage of controlling for variance associated with premorbid factors rather than changes in neurological functioning; are more helpful in characterizing acquired neurocognitive changes; and can aid in the interpretation of test performance. (PsycINFO Database Record

Scoping review to develop common data elements for lumbar spinal stenosis.

BACKGROUND CONTEXT: Common data elements (CDE) represent an important tool for understanding and classifying health outcomes across settings. Although CDEs have been developed for a number of disorders, to date CDEs for lumbar spinal stenosis (LSS) have not been fully developed. To facilitate the identification of CDEs and measures to assess them, this technical study leverages the International Classification of Functioning, Disability and Health (ICF), peer-reviewed research, and a panel of experts to identify CDEs specific to LSS. PURPOSE: The study aimed to define CDEs for disease characteristics and outcomes of LSS using the World Health Organization's ICF taxonomy, and to facilitate the selection of assessment instruments for research and clinical care. DESIGN: This is a scoping review using a modified Delphi approach with a technical expert panel composed of clinicians and scientists representing the academia, policy and advocacy stakeholders, and professional associations with expertise in LSS. METHODS: This is a scoping review to identify measures that assess LSS symptoms. Thirty-one subject matter experts (SMEs) prioritized ICF codes and evaluated instruments measuring specific domains. We used a modified Delphi technique to evaluate item-level content and achieve consensus. RESULTS: SMEs prioritized 53 ICF codes; 3 received 100% endorsement, 27 received ≥90% endorsement, whereas the remaining 23 received ≥80% endorsement. Prioritized ICF codes represent diverse domains, including pain, activities and participation, and emotional well-being. The review yielded 58 instruments; we retained 24 for content analysis. CONCLUSIONS: The retained instruments adequately represent the ICFs activities and participation, and body function domains. Body structure and environmental factors were assessed infrequently. Adoption of these CDEs may guide clinical decision making and facilitate comparative effectiveness trials for interventions focused on LSS.

Measurement characteristics and clinical utility of the Brief Pain Inventory-Short Form for individuals with multiple sclerosis.

This Rehabilitation Measures Database summary provides a review of the psychometric properties of the BPI in individuals with MS. A full review of the BPI as well as reviews of over 330 other instruments can be found at www.rehabmeasures.org.

Slope-driven goal location behavior in pigeons.

A basic tenet of principles of associative learning applicable to models of spatial learning is that a cue should be assigned greater weight if it is a better predictor of the goal location. Pigeons were trained to locate a goal in an acute corner of an isosceles trapezoid arena, presented on a slanted floor with 3 (Experiment 1) or 2 (Experiment 2) orientations. The goal could be consistently determined by the geometric shape of the arena; however, its position with respect to the slope gradient varied, such that slope position was not a good predictor of the goal. Pigeons learned to solve the task, and testing on a flat surface revealed successful encoding of the goal relative to the geometric shape of the arena. However, when tested in the arena placed in a novel orientation on the slope, pigeons surprisingly made systematic errors to the other acute-but geometrically incorrect-mirror image corner. The results indicate that, for each arena orientation, pigeons encoded the goal location with respect to the slope. Then, in the novel orientation, they chose the corner that matched the goal's position on the slope plus local cue (corner angle). Although geometry was 2 times (Experiment 2) or even 3 times (Experiment 1) as predictive as slope, it failed to control behavior during novel test trials. Instead, searching was driven by the less predictive slope cues. The reliance on slope and the unresponsiveness to geometry are explained by the greater salience of slope despite its lower predictive value.