Patient, family caregiver, and economic outcomes of an integrated screening and novel stepped collaborative care intervention in the oncology setting in the USA (CARES): a randomised, parallel, phase 3 trial.

BACKGROUND: The current standard of care of screening and referring patients for treatment for symptoms, such as depression, pain, and fatigue, is not effective. This trial aimed to test the efficacy of an integrated screening and novel stepped collaborative care intervention versus standard of care for patients with cancer and at least one of the following symptoms: depression, pain, or fatigue. METHODS: This randomised, parallel, phase 3 trial was conducted in 29 oncology outpatient clinics associated with the UPMC Hillman Cancer Center in the USA. Patients (aged ≥21 years) with any cancer type and clinical levels of depression, pain, or fatigue (or all of these) were eligible. Eligible family caregivers were aged 21 years or older and providing care to a patient diagnosed with cancer who consented for this study. Patients were randomly assigned (1:1) to stepped collaborative care or standard of care using a central, permuted block design (sizes of 2, 4, and 6) stratified by sex and prognostic status. The biostatistician, oncologists, and outcome assessors were masked to treatment assignment. Stepped collaborative care was once-weekly cognitive behavioural therapy for 50-60 min from a care coordinator via telemedicine (eg, telephone or videoconferencing). Pharmacotherapy for symptoms might be initiated or changed if recommended by the treatment team or preferred by the patient. Standard of care was screening and referral to a health-care provider for treatment of symptoms. The primary outcome was health-related quality of life in patients at 6 months. Maintenance of the treatment benefits was assessed at 12 months. Participants included in the primary analysis were per intention to treat, which included patients missing one or both follow-up assessments. This trial was registered with ClinicalTrials.gov (NCT02939755). FINDINGS: Between Dec 5, 2016, and April 8, 2021, 459 patients and 190 family caregivers were enrolled. 222 patients were assigned to standard of care and 237 to stepped collaborative care. Of 459 patients, 201 (44%) were male and 258 (56%) were female. Patients in the stepped collaborative care group had a greater 0-6-month improvement in health-related quality of life than patients in the standard-of-care group (p=0·013, effect size 0·09). Health-related quality of life was maintained for the stepped collaborative care group (p=0·74, effect size 0·01). Patients in the stepped collaborative care group had greater 0-6-month improvements than the standard-of-care group in emotional (p=0·012), functional (p=0·042), and physical (p=0·033) wellbeing. No adverse events were reported by patients in either group and deaths were considered unrelated to the study. INTERPRETATION: An integrated screening and novel stepped collaborative care intervention, compared with the current standard of care, is recommended to improve health-related quality of life. The findings of this study will advance the implementation of guideline concordant care (screening and treatment) and has the potential to shift the practice of screening and treatment paradigm nationwide, improving outcomes for patients diagnosed with cancer. FUNDING: US National Cancer Institute.

Convergent, discriminant, and known groups validity of the Behavioral Assessment Screening Tool (BAST) in chronic traumatic brain injury.

The Behavioral Assessment Screening Tool (BAST) measures self-reported neurobehavioral symptoms commonly experienced by adults with traumatic brain injury (TBI). To assess the convergent, discriminant, and known-groups validity of the BAST among community-dwelling adults with chronic traumatic brain injury (TBI), we conducted correlation analyses and tests of group differences with previously validated symptom measures in two samples (n = 111, n = 134). Measures used for comparison were: Patient Health Questionnaire (depression), Generalized Anxiety Disorder-7 (anxiety), Positive and Negative Affect Schedule, Frontal Systems Behavior Scale (Executive Dysfunction, Apathy, Disinhibition), Modified Fatigue Impact Scale, PROMIS Fatigue, Aggression Questionnaire (anger, hostility, physical and verbal aggression), and Alcohol Use Disorders Test (alcohol misuse). BAST subscales had stronger correlations with measures of similar (|r|=.602-.828, p < .001) and related (|r|>.30, p < .001) constructs and weaker correlations (|r|<.300) with measures of dissimilar/unrelated constructs, supporting hypotheses of convergent and discriminant validity, respectively. Statistically significant group differences (p's < .001) in BAST subscales were found, with large effect sizes (Cohen's d = 1.2-1.9), for known-groups with moderate-severe depression, moderate-severe anxiety, clinically significant fatigue, problematic disinhibited and frontal-executive behaviors, and alcohol use. Conclusions: Results support the convergent and discriminant validity of the BAST subscales. The BAST was specifically developed as a self-reported measure for remote symptom reporting, supporting its incorporation into mobile health platforms to improve chronic symptom monitoring in community-dwelling adults with TBI. With further validation research, the BAST could be used for early identification of persons with TBI who could benefit from intervention.

Bidirectional temporal associations between sleep and affect and cognitive symptoms among community-dwelling stroke survivors: An ecological momentary assessment study.

INTRODUCTION: Sleep plays a critical role in daily functioning and stroke recovery but receives little attention in stroke rehabilitation. Sleep disturbances are linked to affective and cognitive impairments, but temporal associations between sleep and affect and cognitive symptoms are less clear. Understanding these temporal associations may inform new directions in intervention and prevention to support continued stroke recovery. OBJECTIVE: To examine the bidirectional temporal associations between sleep and affect and cognitive symptoms among community-dwelling stroke survivors. DESIGN: A secondary analysis of a longitudinal observational study involving 7 days of ecological momentary assessment (EMA), during which participants completed eight EMA surveys and a sleep diary per day. Multilevel modeling was used to analyze data. SETTING: Community. PARTICIPANTS: Community-dwelling stroke survivors (N = 40). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: EMA measures of depressed affect, cheerful affect, and cognitive symptoms. Sleep quality and duration as measured using a sleep diary. RESULTS: Between-person sleep quality was negatively associated with next-day depressed affect (B = -.16; p = .028) and positively associated with next-day cheerful affect (B = .63; p < .001). Inversely, between-person depressed affect was negatively associated with next night sleep quality (B = -.77; p = .015), and vice versa for cheerful affect (between-person: B = .45; p < .001; within-person: B = .09; p = .008). Long sleep (>9 hours) was positively associated with next-day cognitive symptoms (B = .13; p = .002), whereas cognitive symptoms were associated with a higher odds of long sleep the following night (odds ratio [OR] = 0.25; p = .047). CONCLUSIONS: This study identified the bidirectional associations of sleep with affect and cognitive symptoms in the context of the everyday life of stroke survivors. The findings suggest that interventions addressing sleep quality and duration may impact affect and cognitive symptoms, and vice versa.

Evaluation of providers' assistive technology service delivery practices in Pakistan.

PURPOSE: Globally, one in three individuals needs at least one assistive product. The primary objective of this study was to conduct a survey of Pakistani rehabilitation service providers to determine what proportion provide assistive technology and if their characteristics (including geographical region, education, and experience) are associated with adherence to the service delivery process. The secondary objective was to determine if individuals that provide assistive technology adhere to a standard assistive technology service delivery process. The tertiary objective was to determine if the providers that adhered to a standard delivery process had characteristics that differed from the rest of the service providers. MATERIALS AND METHODS: An online survey composed of multiple-choice questions was distributed to physiotherapists, community-based healthcare workers, and related rehabilitation professions through a convenience sampling method. SPSS Statistics was used to develop correlation matrices to determine Pearson's coefficient of number of steps, education level, experience level and continuing education received. RESULTS: There were 71 respondents from 4 Pakistani provinces. 53.5% of respondents stated they provide assistive technology. There was participation in most steps of the service delivery process. There is weak correlation between number of steps and education level, number of steps and experience level, and number of steps and continuing education received. CONCLUSIONS: While the majority of respondents provide assistive technology, a significant proportion (46.5%) don't. This may suggest there is a need for additional advocacy and awareness raising of the benefits of and how to access assistive technology in Pakistan.

Implications for RehabilitationPakistan implemented a Rapid Assistive Technology Assessment and determined that only 22% of the population that needs an assistive device has had their needs met.From a relatively small sample, this study investigated if there is a presence of assistive technology service delivery in Pakistan and whether traditional education, experience, or continuing education promotes participation in the assistive technology service delivery process.This study found a presence of assistive technology service delivery in Pakistan, but found weak correlations between participation in the service delivery process with traditional education, experience, and continuing education.These findings suggest that there is room for additional advocacy and awareness training on assistive technology in Pakistan.

Evaluation of Face Validity and Acceptability of the Care Partner Hospital Assessment Tool.

Background and Objectives: Care partners of hospitalized older adults report their caregiving needs are not being addressed. The Care Partner Hospital Assessment Tool (CHAT) is a feasible and appropriate tool for practitioners' use with care partners in the hospital setting. This article explores the face validity and acceptability of the CHAT among care partners of hospitalized older adults. Research Design and Methods: A qualitative descriptive study was used to identify common themes among care partners' responses from semistructured interviews. The CHAT was administered to care partners of older adults admitted to a medical-surgical unit in an academic medical center in Madison, WI, from October 2021 to January 2022. A semistructured, follow-up interview was completed by the same care partners after discharge. Interviews were transcribed and coded for themes to capture overall impressions of the CHAT. Care partners addressed the usefulness, comfort, content, and complexity of the CHAT. Results: Twelve care partners participated in the study. Care partners reported that the CHAT was easy to understand and complete, was judged to be useful to both the care partner and older adult, and helped identify care partner needs. Care partners suggested ways to improve the tool including administration, additional content areas to include, and modes of delivery. Discussion and Implications: The results establish the face validity of the CHAT and support the acceptability of the tool for use with care partners of hospitalized older adults.

Examining Real-World Therapy Practice of Cognitive Screening and Assessment in Post-Acute Care.

OBJECTIVES: Routine implementation of cognitive screening and assessment by therapy providers in post-acute settings may promote improved care coordination. This study examined the frequency of cognitive screening and assessment documentation across post-acute settings, as well as its relationship with contextual factors and outcomes. DESIGN: Cross-sectional observational study using Medicare claims and electronic health record data from 1 large health system. SETTING AND PARTICIPANTS: Older adults admitted to post-acute care after an acute hospitalization. METHODS: Descriptive analysis examined documentation of cognitive screening and assessment. Logistic and hierarchical linear regression evaluated the relationship among patient factors, cognitive screening and assessment, and patient outcomes. RESULTS: The most common admission diagnoses for the final sample (n=2535) were total hip or knee joint replacement (41.7%) and stroke (15.3%). Following acute hospitalization, patients were discharged to inpatient rehabilitation (22.6%), skilled nursing (9.3%), or home health (68.1%). During the post-acute care stay, 38% of patients had documentation of cognitive screening by any therapy discipline. Patterns of documentation varied across disciplines and post-acute settings. Documentation of standardized cognitive assessments was limited, occurring for less than 2% of patients. Admission for stroke was associated with significantly higher odds of cognitive screening or assessment [odds ratio (OR) 2.07, 95% CI 1.13, 3.82] compared to patients with other diagnoses. There was no significant relationship between documentation of cognitive screening or assessment and 30-day readmissions (OR 0.81, 95% CI 0.53, 1.28). CONCLUSION AND IMPLICATIONS: The key finding was inconsistent documentation of cognitive screening and assessment across disciplines and post-acute settings, which could be in part due to variation in electronic health record platforms. Future work can expand on these results to understand the degree to which contextual factors facilitate or inhibit routine delivery and documentation of cognitive screening and assessment. Findings can support implementation of standardized data elements to lead to improved care coordination and outcomes.

The Behavioral Assessment Screening Tool for Mobile Health (BASTmHealth): Development and Compliance in 2 Weeks of Daily Reporting in Chronic Traumatic Brain Injury.

OBJECTIVES: To develop and evaluate the feasibility of a short form of the Behavioral Assessment Screening Tool (BASTmHealth) for high frequency in situ self-reported assessment of neurobehavioral symptoms using mobile health technology for community-dwelling adults with traumatic brain injury (TBI). DESIGN: Prospective, repeated-measures study of mHealth assessment of self-reported neurobehavioral symptoms in adults with and without a lifetime history of TBI over a 2-week period. SETTING: Community. PARTICIPANTS: Community-dwelling adults with (n=52) and without (n=12) a lifetime TBI history consented to the study (N=64). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: BASTmHealth subscales (2-items each): negative affect, fatigue, executive function, substance abuse, impulsivity; feasibility measured via compliance (assessments assigned/assessments completed) and participant-reported usability. RESULTS: We developed the 10-item BASTmHealth as a screener for high frequency in situ self-reported assessment of neurobehavioral symptoms leveraging mHealth. Compliance for 2 weeks of BASTmHealth supports its feasibility. Fifty-six of 64 participants (87.5%) who completed baseline assessments completed the 2 weeks of daily assessments; all 8 participants who did not complete ecological momentary assessment had a history of TBI. Overall compliance was 81.4% (496 completed of 609 assigned assessments) among all 52 participants with TBI and 96.7% (494 completed of 511 assigned assessments) among the 44 who completed any daily measures, compared with 91.8% (135 completed of 147 assigned assessments) among those with no TBI history. Participants thought the daily surveys were easy to understand and complete and the number of prompts were reasonable. CONCLUSIONS: Conducting daily high-frequency in situ self-reported assessment of neurobehavioral symptoms using the BASTmHealth is feasible among individuals with and without a lifetime history of TBI. Developing and evaluating self-reported assessments for community-based assessment is a critical step toward expanding remote clinical monitoring systems to improve post-TBI outcomes.

Using the lens of assistive technology to develop a technology translation readiness assessment tool (TTRAT)™ to evaluate market readiness.

PURPOSE: Assistive Technologies encompass a wide array of products, services, healthcare standards, and the systems that support them. Product/market fit is necessary for a technology to be transferred successfully. Current tools lack variables that are key to technology transfer, and current trainings do not have a validated tool to assess the effectiveness of a training, increasing innovators' readiness for technology transfer. The goal was to develop a tool to evaluate the readiness of a technology by incorporating other models and focusing beyond just commercialization. MATERIALS AND METHODS: The development involved five stages: 1. Review of current tools used in technology transfer in academic, government, and industry settings; 2. Development of the draft version of the tool with internal review; 3. Alpha version review and refinement, 4. Content validation of the tool's beta version; 5. Assessment of the readiness tool for reliability and preparedness for wide-use dissemination. RESULTS: The tool was revised and validated to 6 subscales and 25 items. The assistive technology subscale was removed from the final version to eliminate repetitive questions and taking into consideration that the tool could be used across technologies. CONCLUSIONS: We developed a flexible assessment tool that looked beyond just commercial success and considered the problem being solved, implications on or input from stakeholders, and sustainability of a technology. The resulting product, the Technology Translation Readiness Assessment Tool (TTRAT)TM, has the potential to be used to evaluate a broad range of technologies and assess the success of training programs.IMPLICATIONS FOR REHABILIATIONQuality of life can be substantially impacted when an assistive technology does not meet the needs of an end-user. Thus, effective Assistive Technology Tech Transfer (ATTT) is needed.The use of the TTRAT may help to inform NIDILRR and other funding agencies that invest in rehabilitation technology development on the overall readiness of a technology, but also the impact of the funding on technology readiness.The TTRAT may help to educate novice rehabilitation technology innovators on appropriate considerations for not only technology readiness, but also general translation best practices like assembling a diverse team with appropriate skillsets, understanding of the market and its size, and sustainability strategies.

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.

Rasch analysis of the Behavioral Assessment Screening Tool (BAST) in chronic traumatic brain injury.

The Behavioral Assessment Screening Tool (BAST) measures neurobehavioral symptoms in adults with traumatic brain injury (TBI). Exploratory Factor Analyses established five subscales: Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse. In the current study, we assessed all the subscales except Substance Abuse using Rasch analysis following the Rasch Reporting Guidelines in Rehabilitation Research (RULER) framework. RULER identifies unidimensionality and fit statistics, item hierarchies, targeting, and symptom severity strata as areas of interest for Rasch analysis. The BAST displayed good unidimensionality with only one item from the Impulsivity scale exhibiting potential item misfit (MnSQ 1.40). However, removing this item resulted in a lower average domain measure (1.42 to -1.49) and higher standard error (0.34 to 0.43) so the item was retained. Items for each of the four subscales also ranged in difficulty (i.e. endorsement of symptom frequency) with more severe symptoms being endorsed in the Fatigue subscale and more mild symptoms being endorsed in the Impulsivity subscale. Though Negative Affect and Executive Function displayed appropriate targeting, the Fatigue and Impulsivity Subscales had larger average domain values (1.35 and -1.42) meaning that more items may need to be added to these subscales to capture differences across a wider range of symptom severity. The BAST displayed excellent reliability via item and person separation indices and distinct strata for each of the four subscales. Future work should use Rasch analysis in a larger, more representative sample, include more items for the Fatigue and Impulsivity subscale, and include the Substance Abuse subscale.

The Development and Content Validation of the Care Partner Hospital Assessment Tool.

BACKGROUND/OBJECTIVES: When aging adults are hospitalized due to a major health event, they often turn to care partners ('family members or friends') for support. Assessment of care partners' needs during hospital care may be important to inform and target information and skills training that will equip them to fulfill caregiving tasks for the aging adults. The objectives of this study were to develop and complete content validation of the Care Partner Hospital Assessment Tool (CHAT). METHODS: Based on standard instrumentation methodology and an assessment framework recommended by the National Center on Caregiving at the Family Caregiving Alliance, three steps were followed to develop and validate CHAT: (1) generation of a 24-item tool grouped into three content domains (background, plans and preferences, skills and supports), and a survey by a multidisciplinary team, (2) administration of an online survey of care partners and experts, and (3) assessment of item and scale-content validity indices (I-CVI and S-CVI). RESULTS: A total of four care partners that provide unpaid care to a family member or friend age 65 years or older with a chronic illness or disability either before or after a hospitalization, and 19 leading experts in gerontology, caregiving, and health services completed an online survey in English. Twenty-two items were accepted by having an I-CVI at or above the acceptable 78% cut point; the S-CVI for the tool was 85%. Most revisions to the tool were associated with modifying or clarifying language within each item. For example, participants shared the following open-ended suggestions for revising CHAT: (1) change the "do you prefer" sentence stem to "do you want" (n = 12), define "training" (n = 6), and (2) allow care partners to provide an unsure response (n = 5). CONCLUSION: CHAT may be a promising way to increase health care practitioner's understanding of care partners' backgrounds, preferences and plans, and potential information or training needs during a patient's hospital stay. Initial evaluation of CHAT reveals strong conceptual development and content validity.

Evaluating the Appropriateness and Feasibility of the Care Partner Hospital Assessment Tool (CHAT).

Hospital practitioners rely on care partners of older adults to provide complex care without identifying and addressing their needs. The Care Partner Hospital Assessment Tool (CHAT) was developed to identify the education skill training needs of care partners of hospitalized older adults. This two-phased mixed-method study evaluated the appropriateness and feasibility of the CHAT. The phase 1 quantitative survey with caregiving experts indicated 70-100% agreement for the length and helpfulness of the CHAT (n = 23). These results were supported by phase 2 qualitative interviews with hospital administrators and practitioners, which revealed the following themes: (1) intuitive and clear design worth sustaining and (2) concerns and proposed solutions for implementation. Findings suggest the CHAT is an appropriate and feasible tool for hospital practitioners to tailor their education and skills training to address care partners' needs. Identifying care partners' needs is an important step in ensuring they are prepared to complete their caregiving responsibilities.

Factor analysis of the adolescent version of the behavioural assessment screening tool (BAST-A) in adolescents with concussion.

Objective: Develop and validate the Behavioral Assessment Screening Tool for Adolescents with brain injury.Setting: Concussion clinicsParticipants: Adolescents with mild traumatic brain injury 3 months after initial concussion clinic visit (n = 138).Design: Assessment development and validation (cross-sectional cohort) studyMain Measures: Behavioral Assessment Screening Tool - AdolescentResults: Expert panel members added or modified items specific to adolescents to the original Behavioral Assessment Screening Tool for adults. The Content Validity Index was 97.2%. Exploratory factor analysis of the Behavioral Assessment Screening Tool - Adolescent reduced the initial 70 items to 46 primary items with a 3-factor solution: Negative Affect & Fatigue, Executive & Social Function, and Risk Behaviors. Internal consistency reliabilities ranged from good to excellent for all factors (Cronbach's α =.80-.95). We retained four secondary maladaptive coping items (from an initial six), though these require further modification and testing (Cronbach's α =.67).Conclusion: The Behavioral Assessment Screening Tool for Adolescents, a measure of neurobehavioral symptoms after mild traumatic brain injury in adolescents, has a multidimensional factor structure with evidence of good internal consistency reliabilities. Future work will further evaluate its convergent and discriminant validity and employ item response theory analyses for validation in a new sample of adolescents with concussion.

Factor structure of the Behavioral Assessment Screening Tool (BAST) in traumatic brain injury.

Objective: Establish the factor structure of the Behavioral Assessment Screening Tool (BAST), a self-reported emotional/behavioral symptom measure for adults with traumatic brain injury (TBI).Setting: Community.Participants: Community-dwelling adults with moderate-severe TBI (n = 162; n = 110).Design: Assessment development (cohort study).Main measures: Behavioral Assessment Screening Tool.Results: The original BAST included 61 items (55 primary, six secondary), an Environmental Context checklist including recent major life events, and three open-ended questions about other relevant factors. Two rounds of pilot testing and exploratory factor analysis of the BAST (n = 162; n = 110) reduced the total items to 37 primary items and six secondary coping items. The final BAST had a five-factor solution with communalities ranging from 0.323 to 0.771. Internal consistency reliabilities ranged from acceptable to excellent for all factors (Cronbach's α = 0.76-0.90). The items related to coping, given only to those endorsing stress, had a two-factor solution with communalities ranging from 0.224 to 0.605, but demonstrated acceptable to poor internal consistency (Cronbach's α = 0.46-0.68). Participants rated ease of use and overall satisfaction with completing the scale as high, with mean scores of 6.42 and 6.22 out of 7, respectively.Conclusions: The BAST, a measure of behavioral and emotional symptoms after TBI, has a multidimensional factor structure with evidence of good internal consistency reliability. Future work will evaluate the convergent, discriminant, and discriminative validity of the BAST and employ item response theory analyses to further develop a short version for mobile health assessment.Implications for RehabilitationLong-term monitoring of behavioral and emotional symptoms after traumatic brain injury could improve clinical management and reduce negative participation and quality of life outcomes.The Behavioral Assessment Screening Tool demonstrates reliability for use among adults with chronic traumatic brain injury, through its factor structure and internal consistency reliabilities, to measure chronic behavioral and emotional symptoms.The Behavioral Assessment Screening Tool is a screening tool to identify potential behavioral and emotional problems that individuals with chronic traumatic brain injury may be experiencing; it could be implemented in a proactive, rather than reactive, system for long-term monitoring of these symptoms to improve early identification of clinical disorders.

Psychometric Evaluation of the Caregiver Needs Screen in Neuro-Oncology Family Caregivers.

BACKGROUND AND PURPOSE: The informal care demands of primary malignant brain tumor (PMBT) patients include unique issues associated with neurological and cognitive symptoms. Existing caregiver needs questionnaires do not include these disease-specific symptoms, which are particularly distressing. Therefore, we have developed the neuro-oncology Caregiver Needs Screen (CNS) and evaluated its psychometric properties. METHODS: The 32-item instrument was developed based on PMBT caregiver interviews (N = 109) and expert review. The CNS was tested along measures of depression, anxiety, burden, and mastery in 122 PMBT caregivers. Principal components analysis was used to examine item properties and internal structure. Internal consistency reliability and construct validity were assessed. RESULTS: Six subscales were identified with internal consistency ranging between alpha = .653 and .857. Convergent validity was verified by moderate/high correlations between measures of caregiver well-being and CNS scale scores. CONCLUSIONS: Findings provide preliminary evidence of reliability and validity for the CNS. This instrument can be useful when assessing caregivers' needs for supportive care.

Cohort Differences in Neurobehavioral Symptoms in Chronic Mild to Severe Traumatic Brain Injury.

Our understanding of neurobehavioral symptoms after traumatic brain injury (TBI) largely relies on data gathered in studies conducted at academic medical centers or large clinical centers with research infrastructure. Though this often provides a well-characterized clinical sample, it may also introduce bias based on geographic locations served by these institutions and personal factors associated with patient access to these institutions. We collected neurobehavioral symptoms via the self-reported Behavioral Assessment Screening Tool (BAST) in a National TBI Cohort (n = 263) and a Medical Center TBI Cohort (n = 218) of English-speaking community-dwelling adults with chronic TBI. The primary focus of the present study was to compare demographics and neurobehavioral symptom reporting across the two cohorts and to discuss the implications of any such differences on interpretation of symptom scores. Across all BAST subscales (Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse), participants in the National TBI Cohort reported significantly more frequent symptoms than those in the Medical Center TBI Cohort (p's < 0.001). Participants in the National TBI Cohort were more likely to be non-White and Hispanic compared to the Medical Center TBI Cohort, and those with mild TBI in the National TBI Cohort were more likely to have less than a high school education than those with mild TBI in the Medical Center TBI Cohort. Individuals with TBI recruited through academic and clinical institutions may not be representative of individuals with TBI living across the United States.

Development and content validity of the behavioral assessment screening tool (BASTß).

PURPOSE: Develop and establish the content validity of the Behavioral Assessment Screening Tool (BASTß), a self-reported measure of behavioral and emotional symptoms after traumatic brain injury. METHODS: This was an assessment development study, including two focus groups of individuals with traumatic brain injury (n = 11) and their family members (n = 10) and an expert panel evaluation of content validity by experts in traumatic brain injury rehabilitation (n = 7). We developed and assessed the Content Validity Index of the BASTß. RESULTS: The BASTß initial items (n = 77) corresponded with an established conceptual model of behavioral dysregulation after traumatic brain injury. After expert panel evaluation and focus group feedback, the final BASTß included 66 items (60 primary, 6 branching logic) rated on a three-level ordinal scale (Never, Sometimes, Always) with reference to the past two weeks, and an Environmental Context checklist including recent major life events (n = 23) and four open-ended questions about environmental factors. The BASTß had a high Content Validity Index of 89.3%. CONCLUSION: The BASTß is a theoretically grounded, multidimensional self-reported assessment of behavioral dysregulation after traumatic brain injury, with good content validity. Future translation into mobile health modalities could improve effectiveness and efficiency of long-term symptom monitoring post-traumatic brain injury. Future work will establish and validate the factor structure, internal consistency reliabilities and other validities of the BAST. Implications for Rehabilitation Behavioral problems after traumatic brain injury is one of the strongest contributing factors to poor mood and community integration outcomes after injury. Behavior is complex and multidimensional, making it a challenge to measure and to monitor long term. The Behavioral Assessment Screening Tool (BAST) is a patient-oriented outcome assessment developed in collaboration with individuals with traumatic brain injury, their care partners, and experts in the field of traumatic brain injury rehabilitation to be relevant and accessible for adults with traumatic brain injuries. The BAST is a long-term monitoring and screening tool for community-dwelling adults with traumatic brain injuries, to improve identification and management of behavioral and emotional sequelae.

What Types of Treatment Are Provided for Patients With Carpal Tunnel Syndrome? A Retrospective Analysis of Commercial Insurance.

BACKGROUND: Treatment of carpal tunnel syndrome (CTS) in commercially insured patients across the spectrum of provider types rarely has been described. OBJECTIVE: To describe patterns of types of treatment for patients with CTS using a large commercial insurance database. DESIGN: Retrospective cohort descriptive study. SETTING: Administrative health data from the Clinformatics Data Mart (OptumInsight, Eden Prairie, MN). PATIENTS: Adults with a primary diagnosis of CTS seen from between January 2010 to December 2012 who had a total of 48 months of continuous data (12 months before diagnosis and 36 months after diagnosis) (n = 24,931). OUTCOMES: Frequency of types of treatment (heat, manual therapy, positioning, steroids, stretching, surgery) by number of treatments, number of visits, provider type, and characteristics. RESULTS: Fifty-four percent of patients received no reported treatment, and 50.4% had no additional visits. Surgery (42.5%) and positioning (39.8%) were the most frequent single treatments. Patients who were seen by orthopedist for their first visit more frequently received some treatment (75.1%) and at least 1 additional visit (74.1%) compared with those seen by general practitioners (59.5%, 57.5%, respectively) or other providers (65.4%, 68.4, respectively). Orthopedists more frequently prescribed positioning devices (26.8%) and surgery (36.8%) than general practitioners (18.8%, 14.1%, respectively) or other providers (15.7%, 19.7%, respectively). Older adults more frequently had CTS surgery, as did people who lived in the Midwest. Overall, only 24% of patients with CTS had surgery. CONCLUSIONS: For more than one-half of patients with CTS no treatment was provided after an initial visit. Surgery rates were much lower than what has previously been reported in the literature. Generally, patients with CTS receive treatments that are supported by current treatment guidelines. LEVEL OF EVIDENCE: NA.

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.

Hierarchical Linear Modeling for Analysis of Ecological Momentary Assessment Data in Physical Medicine and Rehabilitation Research.

Ecological momentary assessment (EMA) methods collect real-time data in real-world environments, which allow physical medicine and rehabilitation researchers to examine objective outcome data and reduces bias from retrospective recall. The statistical analysis of EMA data is directly related to the research question and the temporal design of the study. Hierarchical linear modeling, which accounts for multiple observations from the same participant, is a particularly useful approach to analyzing EMA data. The objective of this paper was to introduce the process of conducting hierarchical linear modeling analyses with EMA data. This is accomplished using exemplars from recent physical medicine and rehabilitation literature.