Validation of the Standardized Function Data Elements among Medicare Skilled Nursing Facility Residents.

OBJECTIVE: To examine the distribution of admission and discharge functional abilities among Medicare fee-for-service beneficiaries with a skilled nursing facility (SNF) stay. Further, to assess the validity of the standardized discharge self-care and mobility data by examining their association to community discharge. DESIGN: Observational study of SNF Medicare fee-for-service residents' self-care and mobility scores at admission and discharge. SETTING AND PARTICIPANTS: Medicare beneficiaries with Medicare Part A SNF stays in 2017 from 15,127 Medicare-certified SNFs. METHODS: We calculated self-care and mobility score frequencies and percentages at admission and discharge to describe the functional abilities of SNF residents; we examined discharge scores by percentage discharge to the community to evaluate item construct validity. RESULTS: Between admission and discharge, SNF resident scores showed overall improvements in function for all self-care and most mobility activities. For example, between admission and discharge the percentage of residents independent with toileting hygiene and sit to lying increased from 3.7% and 8.2%, to 25.3% and 32.7%, respectively. For all but 2 data elements, residents with lower functional abilities had a lower percentage of being discharged into the community, and the percentage of residents discharged into the community increased as residents performed functional activities of self-care and mobility at higher score ratings. There was a consistent monotonic relationship between residents' discharge self-care and mobility scores and community discharge rates for all but 2 data elements. CONCLUSIONS AND IMPLICATIONS: Our study found measurable improvements for each self-care and mobility function item for SNF Medicare Part A resident stays in 2017. The results also demonstrated a positive association between higher discharge self-care and mobility scores and higher discharge to community rates. These findings support the validity of the data elements in measuring functional abilities among SNF Medicare Part A residents.

A Postacute Care Function Process Quality Measure for the Collection of Standardized Self-Care and Mobility Data: Development, Implementation, and Quality Measure Scores.

OBJECTIVE: To describe the development of and quality measure scores for the cross-setting postacute care function process quality measure that requires the collection of standardized self-care and mobility data at admission and discharge and at least 1 function goal. DESIGN: Description of the development and implementation of the quality measure and the associated standardized self-care and mobility data elements. Descriptive analyses of quality measure scores for the first calendar year using data from the Minimum Data Set, the Inpatient Rehabilitation Facility Patient Assessment Instrument, the Long-Term Care Hospitals (LTCH) Continuity Assessment Record and Evaluation Data Set, and Outcome and Assessment Information Set. SETTING: 15,127 skilled nursing facilities (SNFs), 1129 inpatient rehabilitation facilities (IRFs), 414 LTCHs, and 10,352 home health agencies (HHAs) in the United States. PARTICIPANTS: In total there were 9,216,943 stays/quality episodes (N = 9,216,943), including 2,084,774 SNF Medicare fee-for-service patient stays, 493,209 IRF Medicare patient stays, 161,714 patient stays, and 6,477,246 Medicare and Medicaid quality episodes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Scores for the cross-setting postacute care function process quality measure. RESULTS: The mean process quality measure scores for SNFs, IRFs, LTCHs, and HHAs were 95.5%, 99.7%, 99.1%, and 95.8, respectively. The 10th percentile scores for SNFs, IRFs, LTCHs, and HHAs were 88.5%, 99.3%, 98.4%, and 89.4, respectively, indicating that at least 90% of postacute care providers submitted the standardized data for a large proportion of their patients. Mean quality measure scores did not vary by provider characteristics. CONCLUSIONS: Most SNFs, IRFs, LTCHs, and HHAs submitted the self-care and mobility data, resulting in high quality measure scores during the first year of implementation. The availability of the standardized self-care and mobility data across postacute care settings offers the opportunity to compare the characteristics and functional outcomes of patients treated in postacute care.

Demographic and functional differences among social security disability claimants.

PURPOSE: Sociodemographic characteristics may influence responses on self-reported measures. Differential item functioning (DIF) is when individuals expected to have the same ability level on a construct of interest have a different probability of endorsing an item on an item response theory (IRT) scale due to population characteristics. The goal of this study was to identify DIF for items in an outcome instrument by sociodemographic factors and, one controlling for DIF, assess true differences in function by those same factors. METHODS: The Work Disability Functional Assessment Battery 2.0 (WD-FAB 2.0) is an IRT-based self-reported measure of activity limitations relevant to work. Two samples from WD-FAB developed were used: 3793 SSA disability claimants randomly drawn from a pool of 16,500 claimants and a general sample if 2100 working age adults. We used a two-step IRT-based DIF method for three pairs of respondent characteristics: age, gender, and race/ethnicity, and calculated the weighted absolute difference between item characteristic curves. Independent two-group T-tests assessed differences in scores across groups. RESULTS: Seventeen items displayed DIF. Men had higher scores than women on two physical and two mental function scales. Older respondents had lower physical and higher mental function scores. The lower education group had lower mental function scores. CONCLUSION: DIF impacts function measurement and is important when assessing psychometric characteristics of instruments. Self-report measures should include diverse samples to conduct similar analyses. WD-FAB 2.0 scores are now reflections of function with reduced bias related to gender, race/ethnicity, or age.

The Development of a Crosswalk for Functional Measures in Postacute Medicare Claims.

OBJECTIVE: Although Medicare assessment files will include Standardized Patient Assessment Data Elements from 2016 forward, lack of uniformity of functional data prior to 2016 impedes longitudinal research. The purpose of this study was to create crosswalks for postacute care assessment measures and the basic mobility and daily activities scales of the Activity Measure for Post-Acute Care (AM-PAC) and to test their accuracy and validity in development and validation datasets. METHODS: This cross-sectional study is a secondary analysis of AM-PAC, the Inpatient Rehabilitation Facility Patient Assessment Instrument, the Minimum Data Set, and the Outcome and Assessment Information Set data from 300 adults receiving rehabilitation recruited from 6 health care networks in 1 metropolitan area. Rasch analysis was used to co-calibrate items from the 3 measures onto the AM-PAC metric and to create look-up tables to create estimated AM-PAC (eAM-PAC) scores. Mean scores and correlation and agreement between actual and estimated scores were examined in the development dataset. Scores were estimated in a cohort of Medicare beneficiaries with hip, humerus and radius fractures. Correlations between eAM-PAC and Functional Independence Measure motor scores were examined. Differences in mean eAM-PAC scores were evaluated across groups of known differences (age, fracture type, dementia). RESULTS: Strong correlations were found between actual and eAM-PAC scores in the development dataset. Moderate to strong correlations were found between the eAM-PAC basic mobility and Functional Independence Measure motor scores in the validation dataset. Differences in basic mobility scores across known groups were statistically significant and appeared to be clinically important. Differences between mean daily activities scores were statistically significant but appeared not to be clinically important. CONCLUSION: Although further testing is warranted, the basic mobility crosswalk appears to provide valid scores for aggregate analysis of Medicare postacute care data. IMPACT: This study reports on a method to take data from different Medicare administrative data sources and estimate scores on 1 scale. This approach was applied separately for data related to basic mobility and to daily activities. This may allow researchers to overcome challenges with using Medicare administrative data from different sources.

Burn survivors injured as children exhibit resilience in long-term community integration outcomes: A life impact burn recovery evaluation (LIBRE) study.

INTRODUCTION: There is limited understanding of how burn injuries at different ages are associated with normal growth and development as well as the burn recovery process. This study provides new useful insights by comparing social participation outcomes among burn survivors injured in childhood compared with injuries sustained in middle age, and older adulthood. METHODS: Items from the development of the LIBRE profile were administered to 601 adult burn survivors with ≥5% TBSA burned or burns to critical areas (hands, feet, face, or genitals). Each item was answered on a 5-point Likert scale with higher scores denoting better outcomes. Mean scores for the 6 LIBRE profile scales (sexual relationships, family and friends, social interactions, social activities, work and employment, and romantic relationships) were compared between those burned as children (<18years) and those burned as adults (≥18years). Regression analyses were used to assess differences between groups with adjustment for demographic and clinical characteristics. RESULTS: Of the 597 burn survivors having complete data on age at injury, 165 (27.6%) sustained burn injuries as a child. Those burned as children were more frequently female than those burned as adults (57% vs 47%) and were also more frequently white non-Hispanic (89% vs 77%). Marital status and education level were similar in the two groups. Those who were burned as children had slightly higher scores on the social activities, work and employment and romantic relationships scales. However, these differences did not persist in adjusted regression analyses. CONCLUSIONS: Burn survivors who sustained injuries as a child fared at least as well as those burned as adults in a broad range of long-term social participation outcomes. The impact on long-term social participation outcomes of burn survivors was not significantly different between individuals with burns sustained during important developmental stages at young ages and those injured later in life.

Psychometric Evaluation of the Improved Work-Disability Functional Assessment Battery.

OBJECTIVE: To assess psychometric properties of the improved Work Disability Functional Assessment Battery (WD-FAB 2.0). DESIGN: Longitudinal study. SETTING: Community. PARTICIPANTS: Three samples of working-age (21-66) adults (N=1006): (1) unable to work because of a physical condition (n=375); (2) unable to work because of a mental health condition (n=296); (3) general United States working age sample (n=335). INTERVENTION: NA. MAIN OUTCOME MEASURES: All samples completed the WD-FAB 2.0; the second administration came 5 days after the first. Construct validity was examined by convergent and divergent correlational analysis using legacy measures. Test-retest reliability was assessed by intraclass correlation coefficients (ICC3,1). Standard error of the mean (SEM) and minimal detectable change (MDC90) were calculated to measure scale precision and sensitivity. RESULTS: Physical function ICCs ranged from 0.69 to 0.77 in the general sample, and 0.66 to 0.86 in the disability sample. Mental health function scales ICCs ranged from 0.62 to 0.73 in the general sample, and 0.74 to 0.76 in the disability sample. SEMs for all scales indicated good discrimination; those for the physical function scales were generally lower than those for the mental health scales. MDC90 values ranged from 3.41 to 10.55. Correlations between all WD-FAB 2.0 scales and legacy measures were in the expected direction. CONCLUSIONS: The study provides substantial support for the reliability and construct validity of the WD-FAB 2.0 among 3 diverse samples. Although initially developed for use within the Social Security Administration (SSA), these results suggest that the WD-FAB 2.0 could be used for assessment and measurement of work-related physical and mental health function in other contexts as well.

Improving Assessment of Work Related Mental Health Function Using the Work Disability Functional Assessment Battery (WD-FAB).

Purpose To improve the mental health component of the Work Disability Functional Assessment Battery (WD-FAB), developed for the US Social Security Administration's (SSA) disability determination process. Specifically our goal was to expand the WD-FAB scales of mood & emotions, resilience, social interactions, and behavioral control to improve the depth and breadth of the current scales and expand the content coverage to include aspects of cognition & communication function. Methods Data were collected from a random, stratified sample of 1695 claimants applying for the SSA work disability benefits, and a general population sample of 2025 working age adults. 169 new items were developed to replenish the WD-FAB scales and analyzed using factor analysis and item response theory (IRT) analysis to construct unidimensional scales. We conducted computer adaptive test (CAT) simulations to examine the psychometric properties of the WD-FAB. Results Analyses supported the inclusion of four mental health subdomains: Cognition & Communication (68 items), Self-Regulation (34 items), Resilience & Sociability (29 items) and Mood & Emotions (34 items). All scales yielded acceptable psychometric properties. Conclusions IRT methods were effective in expanding the WD-FAB to assess mental health function. The WD-FAB has the potential to enhance work disability assessment both within the context of the SSA disability programs as well as other clinical and vocational rehabilitation settings.

Improving measures of work-related physical functioning.

PURPOSE: To expand content of the physical function domain of the Work Disability Functional Assessment Battery (WD-FAB), developed for the US Social Security Administration's (SSA) disability determination process. METHODS: Newly developed questions were administered to 3532 recent SSA applicants for work disability benefits and 2025 US adults. Factor analyses and item response theory (IRT) methods were used to calibrate and link the new items to the existing WD-FAB, and computer-adaptive test simulations were conducted. RESULTS: Factor and IRT analyses supported integration of 44 new items into three existing WD-FAB scales and the addition of a new 11-item scale (Community Mobility). The final physical function domain consisting of: Basic Mobility (56 items), Upper Body Function (34 items), Fine Motor Function (45 items), and Community Mobility (11 items) demonstrated acceptable psychometric properties. CONCLUSIONS: The WD-FAB offers an important tool for enhancement of work disability determination. The FAB could provide relevant information about work-related functioning for initial assessment of claimants; identifying denied applicants who may benefit from interventions to improve work and health outcomes; enhancing periodic review of work disability beneficiaries; and assessing outcomes for policies, programs and services targeting people with work disability.

Work-related measures of physical and behavioral health function: Test-retest reliability.

BACKGROUND: The Work Disability Functional Assessment Battery (WD-FAB), developed for potential use by the US Social Security Administration to assess work-related function, currently consists of five multi-item scales assessing physical function and four multi-item scales assessing behavioral health function; the WD-FAB scales are administered as Computerized Adaptive Tests (CATs). OBJECTIVE: The goal of this study was to evaluate the test-retest reliability of the WD-FAB Physical Function and Behavioral Health CATs. METHODS: We administered the WD-FAB scales twice, 7-10 days apart, to a sample of 376 working age adults and 316 adults with work-disability. Intraclass correlation coefficients were calculated to measure the consistency of the scores between the two administrations. Standard error of measurement (SEM) and minimal detectable change (MDC90) were also calculated to measure the scales precision and sensitivity. RESULTS: For the Physical Function CAT scales, the ICCs ranged from 0.76 to 0.89 in the working age adult sample, and 0.77-0.86 in the sample of adults with work-disability. ICCs for the Behavioral Health CAT scales ranged from 0.66 to 0.70 in the working age adult sample, and 0.77-0.80 in the adults with work-disability. The SEM ranged from 3.25 to 4.55 for the Physical Function scales and 5.27-6.97 for the Behavioral Health function scales. For all scales in both samples, the MDC90 ranged from 7.58 to 16.27. CONCLUSION: Both the Physical Function and Behavioral Health CATs of the WD-FAB demonstrated good test-retest reliability in adults with work-disability and general adult samples, a critical requirement for assessing work related functioning in disability applicants and in other contexts.