Measurement Properties of the Stroke-Predischarge Occupational Therapy Assessment.

There is no comprehensive predischarge occupational therapy assessment tool in South Korea. The objective of this study was to determine Stroke-Predischarge Occupational Therapy Assessment (S-POTA) validity and reliability. Twenty-seven occupational therapists (OTs) assessed 97 patients with stroke. Concurrent validity was evaluated by comparing S-POTA scores with stroke-specific quality of life (SS-QOL). Discriminant validity was evaluated by comparing S-POTA scores between outpatient and readmitted groups, and a receiver operating characteristic analysis was conducted. The test-retest was conducted twice in 20 patients, and the inter-rater test was conducted with two OTs per patient. S-POTA positively correlated with SS-QOL. S-POTA rating differs significantly across outpatients and readmitted groups. All S-POTA areas under curve values ranged from .70 to .85, and cut-off points were derived. Cronbach's α for internal consistency was .953, the intraclass correlation coefficient for test-retest was .990, and .987 for inter-rater reliability. The results suggest S-POTA is a reliable tool for efficient implementation of discharge planning.

The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults.

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Item-Level Psychometrics of the Meaningful Activity Participation Assessment (MAPA) Scale.

This study investigates the psychometric properties of the Meaningful Activity Participation Assessment-Meaning (MAPA-M) scale using the Rasch measurement model. For the psychometric properties of MAPA-M, principal component analysis, Rasch analysis, and differential item functioning analysis were conducted. Participants in this study were 480 older adults from the USC Well Elderly 2 study, recruited from 21 locations in the Los Angeles metropolitan area. There were eight items with DIF, but they were accepted because they assumed unidimensionality and showed good person invariance. The 25 items assuming unidimensionality of MAPA-M had values between 0.6 and 1.4 in infit and Outfit MnSq, and all ZSTD values were less than 2.0. The 25 items demonstrated a conceptual item-difficulty hierarchy. The person strata value was 2.68, which is equivalent to a reliability index value of .76. The findings indicate that the revised scale can accurately and reliably measure meaningful activities by older adults.

Pressure Injury on Poststroke Admission Assessment to Skilled Nursing Facilities: Risk Factors, Management, and Impact on Rehabilitation.

OBJECTIVE: To describe pressure injury (PrI) prevalence, comorbidities, and rehabilitation utilization among older adults with stroke at skilled nursing facilities' (SNFs') admission assessment. DESIGN: Retrospective cohort. SETTING AND PARTICIPANTS: Older Medicare beneficiaries (>65 years old) with stroke admitted to SNFs. METHODS: We extracted data between 2013 and 2014 using the Master Beneficiary Summary, Medicare Provider Analysis and Review, and Minimum Data Set 3.0. PI data were assessed during admission assessment. RESULTS: Of the 65,330 older adults poststroke admitted to SNFs, 11% had at least 1 PrI present on admission assessment. Individuals who were non-Hispanic Black, with a longer hospital stay, from lower socioeconomic status, with higher proportions of comorbidities (eg, underweight, urinary and bowel incontinence, diabetes, congestive heart failure, arrhythmias, and infections), and higher functional impairments were likely to present with a PrI at SNF admission assessment. Compared with individuals with superficial PrI, individuals with deep PrI were more likely to be young-old (<75 years), non-Hispanic Black, from lower socioeconomic status, present with a shorter hospital stay, an intensive care unit stay, with higher functional impairments, skin integrity issues, system failure, and infections. Compared to those without PrI or superficial PrI, individuals with any-stage PrI or deep PrI were more likely to be cotreated by physical and occupational therapist and less likely to receive individual therapy. Those with PrI poststroke had low documented turning and repositioning rates than those without PrI. CONCLUSIONS AND IMPLICATIONS: Identifying modifiable risk factors to prevent PrIs poststroke in SNFs will facilitate targeted preventative interventions and improve wound care efficacy and rehabilitation utilization for optimized patient outcomes. Identifying residents with a higher risk of PrI during acute care discharge and providing early preventive care during post-acute care would possibly decrease costs and improve outcome quality.

Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement.

OBJECTIVE: To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016. DESIGN: Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design. SETTING: Skilled nursing facilities (n=12,829). PARTICIPANTS: Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments. RESULTS: The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016. CONCLUSIONS: Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.

Post-acute care use patterns among Hospital Service Areas by older adults in the United States: a cross-sectional study.

BACKGROUND: Despite the success of stroke rehabilitation services, differences in service utilization exist. Some patients with stroke may travel across regions to receive necessary care prescribed by their physician. It is unknown how availability and combinations of post-acute care facilities in local healthcare markets influence use patterns. We present the distribution of skilled nursing, inpatient rehabilitation, and long-term care hospital services across Hospital Service Areas among a national stroke cohort, and we describe drivers of post-acute care service use. METHODS: We extracted data from 2013 to 2014 of a national stroke cohort using Medicare beneficiaries (174,498 total records across 3232 Hospital Service Areas). Patients' ZIP code of residence was linked to the facility ZIP code where care was received. If the patient did not live in the Hospital Service Area where they received care, they were considered a "traveler". We performed multivariable logistic regression to regress traveling status on the care combinations available where the patient lived. RESULTS: Although 73.4% of all Hospital Service Areas were skilled nursing-only, only 23.5% of all patients received care in skilled nursing-only Hospital Service Areas; 40.8% of all patients received care in Hospital Service Areas with only inpatient rehabilitation and skilled nursing, which represented only 18.2% of all Hospital Service Areas. Thirty-five percent of patients traveled to a different Hospital Service Area from where they lived. Regarding "travelers," for those living in a skilled nursing-only Hospital Service Area, 49.9% traveled for care to Hospital Service Areas with only inpatient rehabilitation and skilled nursing. Patients living in skilled nursing-only Hospital Service Areas had more than five times higher odds of traveling compared to those living in Hospital Service Areas with all three facilities. CONCLUSIONS: Geographically, the vast majority of Hospital Service Areas in the United States that provided rehabilitation services for stroke survivors were skilled nursing-only. However, only about one-third lived in skilled nursing-only Hospital Service Areas; over 35% traveled to receive care. Geographic variation exists in post-acute care; this study provides a foundation to better quantify its drivers. This study presents previously undescribed drivers of variation in post-acute care service utilization among Medicare beneficiaries-the "traveler effect".

Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement.

OBJECTIVES: Understand the association between social determinants of health and community discharge after elective total joint arthroplasty. DESIGN: Retrospective cohort design using Optum de-identified electronic health record dataset. SETTING AND PARTICIPANTS: A total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018. METHODS: Logistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics. RESULTS: Mean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.85; knee: OR 0.73, 95% CI 0.69-0.77], current smoking (hip: OR 0.82, 95% CI 0.77-0.88; knee: OR 0.90, 95% CI 0.85-0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50-0.60; knee: OR 0.57, 95% CI 0.53-0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively. CONCLUSIONS AND IMPLICATIONS: Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.

Is Referral to Home Health Rehabilitation After Inpatient Rehabilitation Facility Associated With 90-Day Hospital Readmission for Adult Patients With Stroke?

OBJECTIVE: We examined the association between home health rehabilitation referral and 90-day risk-adjusted hospital readmission after discharge from inpatient rehabilitation facilities among adult patients recovering from stroke (N = 1219). DESIGN: A secondary data analysis of the 2005-2006 Stroke Recovery in Underserved Population database. A logistic regression model, multilevel model, and the propensity score inverse probability weighting model were used to evaluate the risk of 90-day rehospitalization between patients with stroke who received a referral for home health rehabilitation and those who did not receive a home health rehabilitation referral at inpatient rehabilitation facility discharge. RESULTS: The regression, multilevel, and propensity score inverse probability weighting models indicated that inpatient rehabilitation facility patients with stroke who received home health rehabilitation referral had substantially lower odds of 90-day rehospitalization after inpatient rehabilitation facility discharge compared with those who were not referred to home health (odds ratio = 0.325, 95% confidence interval = 0.138-0.764; odds ratio = 0.340, 95% confidence interval = 0.139-0.832; odds ratio = 0.407, 95% confidence interval = 0.183-0.906, respectively). CONCLUSIONS: Our findings suggest the importance of continuation of care (home health) after hospitalization and intense inpatient rehabilitation for stroke. Additional research is needed to establish appropriate use criteria and explore potential underuse of home health services as well as the benefits for follow-up outpatient services for those who do not qualify for home health at inpatient rehabilitation facility discharge.

The Impact of One's Sex and Social Living Situation on Rehabilitation Outcomes After a Stroke.

OBJECTIVE: The aim of the study was to investigate sex differences and the impact of social living situation on individual functional independence measure outcomes after stroke rehabilitation. DESIGN: A retrospective observational study using Medicare fee-for-service beneficiaries (N = 125,548) who were discharged from inpatient rehabilitation facilities in 2013 and 2014 after a stroke. Discharge individual functional independence measure score, dichotomized as ≥5 and <5, was the primary outcome measure. A two-step generalized linear mixed model was used to measure the effect of sex on each functional independence measure item while controlling for many clinical and sociodemographic covariates. RESULTS: After adjusting for sociodemographic and clinical factors, females had higher odds of reaching a supervision level for 14 of 18 functional independence measure items. Males had higher odds of reaching a supervision level on 2 of 18 functional independence measure items. Individuals who lived alone before their stroke had higher odds of reaching a supervision level than individuals who lived with a caregiver or with family for all functional independence measure items. CONCLUSIONS: When sociodemographic and clinical factors are controlled, females are more likely to discharge from inpatient rehabilitation at a supervision level or better for most functional independence measure items. Individuals who live alone before their stroke have higher odds of discharging at a supervision level or better.

Comparisons of the Association of Family and Social Factors With Functional Limitations Across the United States, Mexico, and South Korea: Findings From the HRS Family of Surveys.

Objective: The association of family and social factors with the level of functional limitations was examined across the United States, Mexico, and Korea. Method: Participants included adults from the 2012 Health and Retirement Study (n = 10,017), Mexican Health and Aging Study (n = 6,367), and Korean Longitudinal Study of Aging (n = 4,134). A common functional limitation scale was created based on Rasch analysis with a higher score indicating better physical function. Results: The American older adults (3.65 logits) had better physical function compared with Mexican (2.81 logits) and Korean older adults (1.92 logits). There were different associations of family and social factors with functional limitations across the three countries. Discussion: The American older adults demonstrated less functional limitation compared with Mexican and Korean older adults at the population level. The findings indicate the need to interpret carefully the individual family and social factors associated with functional limitations within the unique context of each country.

Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities.

Importance: Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Design, Setting, and Participants: This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. Exposures: Inpatient rehabilitation received in IRFs vs SNFs. Main Outcomes and Measures: Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Results: Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. Conclusions and Relevance: In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Piloting an empirical approach to link the international classification of functioning, disability, and health to job demand classification.

BACKGROUND: The Social Security Administration has a thorough disability claims process, though one goal is to process claims more efficiently. This pilot described the creation and trial of a web-based tool to assist this process. OBJECTIVE: To empirically link the International Classification of Functioning, Disability and Health (ICF) model to the Occupational Information Network (O*NET) with a self-reported activity measure (physical domain). METHODS: ICF Activity domains and item difficulty calibrations were obtained from a self-reported ICF-Activity Measure. Three work/disability experts matched measurement constructs, job names, and item difficulties with job demands. Item difficulties were linked for "Positioning and Transfer" with O*NET data values of "Stamina"; "Trunk Strength", and "Walking and Moving" with O*NET data values of "Stamina." The system was then pilot tested with 14 adults with more than one activity challenges. RESULTS: An average total of 613 jobs were generated per participant and each job was categorized into one of 16 job clusters. Person ability measures and constructs were significant predictors for numbers of job (R2 = 0.92, p < 0.05). Participants demonstrated moderate satisfaction with program usability, and reported capability in performing jobs. CONCLUSIONS: The system provides a feasible means to assist disability examiners and claimants in identifying relevant job abilities and options.

Construct validity of the Eating Assessment Tool (EAT-10).

PURPOSE: We aimed to evaluate the construct validity of the Eating Assessment Tool (EAT-10) by determining its dimensionality, rating scale integrity, item-person match, precision and relationship with the degree of airway invasion and functional oral intake. METHODS: We conducted a retrospective analysis of patients' EAT-10 scores. We used the Rasch rating scale model. We investigated correlations between the EAT-10 and scores on the Penetration-Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS). RESULTS: The median score of the EAT-10 from 127 patients was 16 of 40 (range 0-40). Confirmatory factor analysis supported unidimensionality. The 5-point rating scale categories met published criteria. Two items misfit the Rasch model and two other items displayed differential item functioning. Rasch person reliability was 0.79. Our patient cohort was divided into three person-strata. Correlations between the EAT-10 and the PAS and FOIS were weak to moderate in strength (respectively: r = 0.26, p = 0.0036; r = -0.27, p = 0.0027). CONCLUSIONS: Our analyses identified deficits in the construct validity of the EAT-10 suggestive of a need to improve the EAT-10 to support its frequent use in clinical practice and research. Implications for Rehabilitation Swallowing disorders are associated with severe complications, such as pneumonia and malnutrition, and impose both social and psychological burdens on patients. The Eating Assessment Tool is a self-report instrument developed to estimate initial dysphagia severity and monitor change in patient-reported dysphagia symptoms as a response to treatment. This study shows that the Eating Assessment Tool has deficits in its construct validity and a need to improve the instrument to support its frequent use in clinical practice and research.

Evaluating Korean Personal Assistance Services Classification System.

OBJECTIVE: To evaluate the utility of using the Personal Assistance Services classification system (PAS-CS) that examines individuals with disabilities for services and government funding. To this end, this study also tests for significant differences in PAS-CS scores across disability grades and disability types. METHODS: A retrospective analysis was conducted using the 2014 National Survey on People with Disabilities (NSPD) data set. We selected patients with three types of disabilities (physical disabilities, brain lesions, and visual impairments). We compared the average PAS-CS scores of patients with different disability types and grades using general linear models with multiple comparisons. RESULTS: A total of 4,810 patients were included in the analysis. Patients with brain lesions had the highest average PAS-CS scores in activities of daily living (ADL) and instrumental activities of daily living (IADL) domains. Patients with visual impairments had the highest average scores in 'Disease-specific disability' and 'Social-environment' domains. For patients with physical disabilities and visual impairments, no PAS-CS domains were significantly different between patients with disability grade III and those with disability grade IV (p>0.05). CONCLUSION: The PAS-CS scores of disability grades were not equivalent among individuals with different disability types. The Korean Ministry of Health and Welfare currently only considers certain disability grades for PAS preeligibility, as a result disregarding the characteristics of different disability types. Thus, the current PAS-CS requires modifications.

Cross-national health comparisons using the Rasch model: findings from the 2012 US Health and Retirement Study and the 2012 Mexican Health and Aging Study.

PURPOSE: Cross-national comparisons of patterns of population aging have emerged as comparable national micro-data have become available. This study creates a metric using Rasch analysis and determines the health of American and Mexican older adult populations. METHODS: Secondary data analysis using representative samples aged 50 and older from 2012 U.S. Health and Retirement Study (n = 20,554); 2012 Mexican Health and Aging Study (n = 14,448). We developed a function measurement scale using Rasch analysis of 22 daily tasks and physical function questions. We tested psychometrics of the scale including factor analysis, fit statistics, internal consistency, and item difficulty. We investigated differences in function using multiple linear regression controlling for demographics. Lastly, we conducted subgroup analyses for chronic conditions. RESULTS: The created common metric demonstrated a unidimensional structure with good item fit, an acceptable precision (person reliability = 0.78), and an item difficulty hierarchy. The American adults appeared less functional than adults in Mexico (ß = - 0.26, p < 0.0001) and across two chronic conditions (arthritis, ß = - 0.36; lung problems, ß = - 0.62; all p < 0.05). However, American adults with stroke were more functional than Mexican adults (ß = 0.46, p = 0.047). CONCLUSIONS: The Rasch model indicates that Mexican adults were more functional than Americans at the population level and across two chronic conditions (arthritis and lung problems). Future studies would need to elucidate other factors affecting the function differences between the two countries.

Discharge Patterns for Ischemic and Hemorrhagic Stroke Patients Going From Acute Care Hospitals to Inpatient and Skilled Nursing Rehabilitation.

OBJECTIVE: The aim of the study was to explore variation in acute care use of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation after ischemic and hemorrhagic stroke. DESIGN: A secondary analysis of Medicare claims data linked to inpatient rehabilitation facilities and skilled nursing facilities assessment files (2013-2014) was performed. RESULTS: The sample included 122,084 stroke patients discharged to inpatient or skilled nursing facilities from 3677 acute hospitals. Of the acute hospitals, 3649 discharged patients with an ischemic stroke (range = 1-402 patients/hospital, median = 15) compared with 1832 acute hospitals that discharged patients with hemorrhagic events (range = 1-73 patients/hospital, median = 4). The intraclass correlation coefficient examined variation in discharge settings attributed to acute hospitals (ischemic intraclass correlation coefficient = 0.318, hemorrhagic intraclass correlation coefficient = 0.176). Patients older than 85 yrs and those with greater numbers of co-morbid conditions were more likely to discharge to skilled nursing facilities. Comparison of self-care and mobility across stroke type suggests that patients with ischemic stroke have higher functional abilities at admission. CONCLUSIONS: This study suggests demographic and clinical differences among stroke patients admitted for postacute rehabilitation at inpatient rehabilitation facilities and skilled nursing facilities settings. Furthermore, examination of variation in ischemic and hemorrhagic stroke discharges suggests acute facility-level differences and indicates a need for careful consideration of patient and facility factors when comparing the effectiveness of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation.

Stroke Administrative Severity Index: using administrative data for 30-day poststroke outcomes prediction.

AIM: Current stroke severity scales cannot be used for archival data. We develop and validate a measure of stroke severity at hospital discharge (Stroke Administrative Severity Index [SASI]) for use in billing data. METHODS: We used the NIH Stroke Scale (NIHSS) as the theoretical framework and identified 285 relevant International Classification of Diseases, 9th Revision diagnosis and procedure codes, grouping them into 23 indicator variables using cluster analysis. A 60% sample of stroke patients in Medicare data were used for modeling risk of 30-day postdischarge mortality or discharge to hospice, with validation performed on the remaining 40% and on data with NIHSS scores. RESULTS: Model fit was good (p > 0.05) and concordance was strong (C-statistic = 0.76-0.83). The SASI predicted NIHSS at discharge (C = 0.83). CONCLUSION: The SASI model and score provide important tools to control for stroke severity at time of hospital discharge. It can be used as a risk-adjustment variable in administrative data analyses to measure postdischarge outcomes.

Linking Existing Instruments to Develop an Activity of Daily Living Item Bank.

This study examined dimensionality and item-level psychometric properties of an item bank measuring activities of daily living (ADL) across inpatient rehabilitation facilities and community living centers. Common person equating method was used in the retrospective veterans data set. This study examined dimensionality, model fit, local independence, and monotonicity using factor analyses and fit statistics, principal component analysis (PCA), and differential item functioning (DIF) using Rasch analysis. Following the elimination of invalid data, 371 veterans who completed both the Functional Independence Measure (FIM) and minimum data set (MDS) within 6 days were retained. The FIM-MDS item bank demonstrated good internal consistency (Cronbach's α = .98) and met three rating scale diagnostic criteria and three of the four model fit statistics (comparative fit index/Tucker-Lewis index = 0.98, root mean square error of approximation = 0.14, and standardized root mean residual = 0.07). PCA of Rasch residuals showed the item bank explained 94.2% variance. The item bank covered the range of θ from -1.50 to 1.26 (item), -3.57 to 4.21 (person) with person strata of 6.3. The findings indicated the ADL physical function item bank constructed from FIM and MDS measured a single latent trait with overall acceptable item-level psychometric properties, suggesting that it is an appropriate source for developing efficient test forms such as short forms and computerized adaptive tests.

Development and Validation of the Activities of Daily Living Short Form for Community-Dwelling Korean Stroke Survivors.

This study developed and validated a short form (SF) using activities of daily living (ADL) outcome measures from the Korea National Health and Nutrition Examination Survey (KNHANES) that can minimize survey administration burden for clinicians. This study utilized secondary data from the 2005 KNHANES with 422 community-dwelling stroke survivors. The KNHANES data were collected from April to June 2005 in South Korea. We created a 7-item SF from the 17 ADL questions in the survey using item response theory (IRT) methodologies. The precision and validity of the SF were compared to the full questionnaire of ADL items and the EuroQol-5D total score. Among the 17 ADL questions, 14 questions demonstrated unidimensional construct validity. Using IRT methodologies, a set of 7 items were selected from the full bank. The 7-item SF demonstrated good psychometric properties: high correlation with the full bank ( r = .975, p < .001), good internal consistency (Cronbach's α = .93), and a high correlation with the EuroQol-5D total score ( r = .678, p < .001). These findings indicate that a well-developed SF can precisely measure ADL performance capacity for stroke survivors compared to the full item bank, which is expected to reduce the administration burden of the KNHANES.

Assessment of the psychometrics of a PROMIS item bank: self-efficacy for managing daily activities.

PURPOSE: The aim of this study is to investigate the psychometrics of the Patient-Reported Outcomes Measurement Information System self-efficacy for managing daily activities item bank. METHODS: The item pool was field tested on a sample of 1087 participants via internet (n = 250) and in-clinic (n = 837) surveys. All participants reported having at least one chronic health condition. The 35 item pool was investigated for dimensionality (confirmatory factor analyses, CFA and exploratory factor analysis, EFA), item-total correlations, local independence, precision, and differential item functioning (DIF) across gender, race, ethnicity, age groups, data collection modes, and neurological chronic conditions (McFadden Pseudo R (2) less than 10 %). RESULTS: The item pool met two of the four CFA fit criteria (CFI = 0.952 and SRMR = 0.07). EFA analysis found a dominant first factor (eigenvalue = 24.34) and the ratio of first to second eigenvalue was 12.4. The item pool demonstrated good item-total correlations (0.59-0.85) and acceptable internal consistency (Cronbach's alpha = 0.97). The item pool maintained its precision (reliability over 0.90) across a wide range of theta (3.70), and there was no significant DIF. CONCLUSION: The findings indicated the item pool has sound psychometric properties and the test items are eligible for development of computerized adaptive testing and short forms.