Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD).

INTRODUCTION: We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer's disease and related dementias (ADRD). METHODS: Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge. RESULTS: Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA. DISCUSSION: Black patients are more likely to experience a delay in home health care initiation than White patients.

Home health services for minorities in urban and rural areas with Alzheimer's and related dementia.

Timely access and continuum of care in older adults with Alzheimer's Disease and Related Dementia (ADRD) is critical. This is a retrospective study on Medicare fee-for-service beneficiaries with ADRD diagnosis discharged to home with home health care following an episode of acute hospitalization. Our sample included 262,525 patients. White patients in rural areas have significantly higher odds of delay (odds ratio [OR], 1.03; 95% CI, 1.01-1.06). Black patients in urban areas (OR, 1.15; 95% CI, 1.12-1.19) and Hispanic patients in urban areas also were more likely to have a delay (OR, 1.07; 95% CI, 1.03-1.11). Black and Hispanic patients residing in urban areas had a higher likelihood of delay in home healthcare initiation following hospitalization compared to Whites residing in urban areas.

Medicare Claim-Based National Institutes of Health Stroke Scale to Predict 30-Day Mortality and Hospital Readmission.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) penalizes hospitals for higher than expected 30-day mortality rates using methods without accounting for condition severity risk adjustment. For patients with stroke, CMS claims did not quantify stroke severity until recently, when the National Institutes of Health Stroke Scale (NIHSS) reporting began. OBJECTIVE: Examine the predictive ability of claim-based NIHSS to predict 30-day mortality and 30-day hospital readmission in patients with ischemic stroke. DESIGN: Retrospective cohort study of Medicare claims data. PATIENTS: Medicare beneficiaries with ischemic stroke (N=43,241) acute hospitalization between October 2016 and November 2017. MEASUREMENTS: All-cause 30-day mortality and 30-day hospital readmission. NIHSS score was derived from ICD-10 codes and stratified into the following: minor to moderate, moderate, moderate to severe, and severe categories. RESULTS: Among 43,241 patients with ischemic stroke with NIHSS from 2,659 US hospitals, 64.6% had minor to moderate stroke, 14.3% had moderate, 12.7% had moderate to severe, and 8.5% had a severe stroke,10.1% died within 30 days, 12.1% were readmitted within 30 days. The NIHSS exhibited stronger discriminant property (C-statistic 0.83, 95% CI: 0.82-0.84) for 30-day mortality compared to Elixhauser (0.74, 95% CI: 0.73-0.75). A monotonic increase in the adjusted 30-day mortality risk occurred relative to minor to moderate stroke category: hazard ratio [HR]=2.92 (95% CI=2.59-3.29) for moderate stroke, HR=5.49 (95% CI=4.90-6.15) for moderate to severe stroke, and HR=7.82 (95% CI=6.95-8.80) for severe stroke. After accounting for competing risk of mortality, there was a significantly higher readmission risk in the moderate stroke (HR=1.11, 95% CI=1.03-1.20), but significantly lower readmission risk in the severe stroke (HR=0.84, 95% CI=0.74-0.95) categories. LIMITATION: Timing of NIHSS reporting during hospitalization is unknown. CONCLUSIONS: Medicare claim-based NIHSS is significantly associated with 30-day mortality in Medicare patients with ischemic stroke and significantly improves discriminant property relative to the Elixhauser comorbidity index.

Feasibility and thematic analysis of narrative visualization materials with physical activity monitoring among breast cancer survivors.

BACKGROUND: Breast cancer survivors have a unique risk for negative health outcomes. Engaging in routine physical activity (PA) can reduce these risks. However, PA levels are low among this population. Narrative visualization (NV) is a technique that uses drawings, photographs, and text to contextualize data, which may increase integrated regulation, or motivation related to personal values and identity. A PA intervention targeting breast cancer survivors using an NV strategy may improve PA behavior. The purpose of this study was to determine whether scrapbooking activities could successfully be used as an NV strategy for older (55+) breast cancer survivors. METHODS: Breast cancer survivors were given workbooks, wearable electronic activity monitors, instant cameras, and art supplies including a variety of stickers (e.g., emojis, affirmations). Participants were instructed to use these materials for 7 days. The workbook pages prompted participants to re-draw their daily activity graphs from the wearable's mobile app, then annotate them with text, photographs, stickers, etc. to reflect what the data meant to them. Hybrid thematic analysis was used to analyze the photographs, drawings, and written content to identify emergent themes. Content analysis was also used to investigate use of stickers and photographs. RESULTS: Of the 20 consented women (mean age 67 ± 5 years, 45% non-Hispanic white), 3 participants were lost to follow-up or unable to complete the procedures. The NV procedures were successfully utilized by the remaining 17 participants, who collectively used 945 stickers over 7 days, most of which were emojis. Emojis were both positively and negatively valanced. Participants took a mean of 9 photos over 7 days and completed workbook questions regarding current PA and PA goals. Themes within the photos included family, specific locations, everyday objects, religion, and friends. Themes within the written portions of the workbook included family, chores and obligations, health, personal reflection, hobbies, and shopping. CONCLUSIONS: The materials provided allowed breast cancer survivors to successfully use NV techniques to reflect on their PA data and behavior. These techniques show promise for promoting integrated regulation in activity monitoring interventions. TRIAL REGISTRATION: This study was funded by the National Cancer Institute ( R21CA218543 ) beginning July 1, 2018.

Making the Case for Patient-Reported Outcome Measures in Big-Data Rehabilitation Research: Implications for Optimizing Patient-Centered Care.

Advances in data science and timely access to health informatics provide a pathway to integrate patient-reported outcome measures (PROMs) into clinical workflows and optimize rehabilitation service delivery. With the shift toward value-based care in the United States health care system, as highlighted by the recent Centers for Medicare and Medicaid Services incentive and penalty programs, it is critical for rehabilitation providers to systematically collect and effectively use PROMs to facilitate evaluation of quality and outcomes within and across health systems. This editorial discusses the potential of PROMs to transform clinical practice, provides examples of health systems using PROMs to guide care, and identifies barriers to aggregating data from PROMs to conduct health services research. The article proposes 2 priority areas to help advance rehabilitation health services research: (1) standardization of collecting PROMs data in electronic health records to facilitate comparing health system performance and quality and (2) increased partnerships between rehabilitation providers, researchers, and payors to accelerate health system learning. As health care reform continues to emphasize value-based payment strategies, it is essential for the field of physical medicine and rehabilitation to be at the forefront of demonstrating its value in the care continuum.

Economic impact of comorbid TBI-dementia on VA facility and non-VA facility costs, 2000-2020.

OBJECTIVE: There is evidence Traumatic Brain Injury (TBI) is associated with increased risk of dementia (D). We compared VA and non-VA facility costs associated with TBI+D and each diagnosis alone, relative to neither diagnosis, annually and over time, 2000-2020. METHODS: We estimated adjusted panel models of annual VHA costs in VA and non-VA facilities, stratified by age, and by TBI-dementia status. We also estimated cost for the TBI+D cohort by time since TBI and dementia diagnoses. All costs were 2021 inflation adjusted. RESULTS: Veterans <65 ($30,736) and ≥65 ($15,650) with TBI+D, while veterans <65 ($3,379) and ≥65 ($4,252) with TBI-only had higher annual total VHA costs, relative to neither diagnosis. Veterans with TBI+D < 65 ($42,864) and ≥65 ($72,424) had higher costs in years≥15 after TBI diagnosis, while <65 ($36,431) and ≥65 ($37,589) had higher costs in years ≥10 after dementia diagnosis. CONCLUSIONS: The main cost driver was inpatient non-VA facility costs. Veterans had continuously increasing inpatient care costs in non-VA facilities over time since their TBI and dementia diagnoses. Given budget constraints on the VA system, quality of care in non-VA facilities warrants comparison with VA facilities to make informed decisions regarding referrals to non-VA facilities.

Predictors of Discharge Settings After Total Knee Arthroplasty in Medicare Patients.

OBJECTIVES: To determine the factors associated with acute hospital discharge to the 3 most common postacute settings following total knee arthroplasty (TKA): inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and directly back to the community. DESIGN: Retrospective cohort study. SETTING: Acute care hospitals submitting claims to Medicare. PARTICIPANTS: National cohort (N=1,189,286) of 100% Medicare Part A data files from 2009-2011. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Observed rates and adjusted odds of discharge to the 3 main postacute settings based on the clinical and facility level variables: amount of comorbidity, bilateral procedures, and facility TKA volume. RESULTS: Using IRF discharge as the reference, patients who received a bilateral procedure had lower odds of both SNF and community discharge, patients with more comorbidity had lower odds for community discharge and higher odds for SNF discharge, and patients who received their TKA from hospitals with lower TKA volumes had lower odds of SNF and community discharge. CONCLUSIONS: Clinical populations within Medicare beneficiaries may systematically vary across the 3 most common discharge settings following TKA. This information may be helpful for a better understanding on which patient or clinical factors influence postacute care settings following TKA. Additional research including functional status, living situation, and social support systems would be beneficial.

Impact of Multiple Chronic Conditions on Activity Limitations Among Older Mexican-American Care Recipients.

INTRODUCTION: Older Mexican Americans are living longer with multiple chronic conditions (MCCs). This has placed greater demands on caregivers to assist with basic activities of daily living (ADL) or instrumental activities of daily living (IADL). To understand the needs of older Mexican-American care recipients, we examined the impact of MCC on ADL and IADL limitations. METHODS: We analyzed data from 485 Mexican American care-receiving/caregiving dyads. Selected MCCs in the analysis were diabetes, hypertension, stroke, heart disease, arthritis, emphysema/chronic obstructive pulmonary disease, cognitive impairment, depression, and cancer. Care recipients were dichotomized as having 3 or more conditions or as having 2 or fewer conditions. Three comorbidity clusters were established on the basis of the most prevalent health conditions among participants with comorbid arthritis and hypertension. These clusters included arthritis and hypertension plus: diabetes (cluster 1), cognitive impairment (cluster 2), and heart disease (cluster 3). RESULTS: Care recipients with 3 or more chronic conditions (n = 314) had higher odds of having mobility limitations (OR = 1.98; 95% CI, 1.34-2.94), self-care limitations (OR = 2.53; 95% CI, 1.70-3.81), >3 ADL limitations (OR = 2.00; 95% CI, 1.28-3.17), and >3 IADL limitations (OR = 1.88; 95% CI, 1.26-2.81). All clusters had increased odds of ADL and severe ADL limitations. Of care recipients in cluster 2, those with arthritis, hypertension, and cognitive impairment had significantly higher odds of mobility limitations (OR = 2.33; 95% CI, 1.05-5.24) than those with just arthritis and hypertension. CONCLUSION: MCCs were associated with more ADL and IADL limitations among care recipients, especially for those with hypertension and arthritis plus diabetes, cognitive impairment, or heart disease. These findings can assist in developing programs to meet the needs of older Mexican-American care recipients.

Longitudinal Investigation of Rehospitalization Patterns in Spinal Cord Injury and Traumatic Brain Injury Among Medicare Beneficiaries.

OBJECTIVES: To model 12-month rehospitalization risk among Medicare beneficiaries receiving inpatient rehabilitation for spinal cord injury (SCI) or traumatic brain injury (TBI) and to create 2 (SCI- and TBI-specific) interactive tools enabling users to generate monthly projected probabilities of rehospitalization on the basis of an individual patient's clinical profile at discharge from inpatient rehabilitation. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Medicare beneficiaries receiving inpatient rehabilitation for SCI (n=2587) or TBI (n=10,864). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Monthly rehospitalization (yes/no) based on Medicare claims. RESULTS: Results are summarized through computer-generated interactive tools, which plot individual level trajectories of rehospitalization probabilities over time. Factors associated with the probability of rehospitalization over time are also provided, with different combinations of these factors generating different individual level trajectories. Four case studies are presented to demonstrate the variability in individual risk trajectories. Monthly rehospitalization probabilities for the individual high-risk TBI and SCI cases declined from 33% to 15% and from 41% to 18%, respectively, over time, whereas the probabilities for the individual low-risk cases were much lower and stable over time: 5% to 2% and 6% to 2%, respectively. CONCLUSIONS: Rehospitalization is an undesirable and multifaceted health outcome. Classifying patients into meaningful risk strata at different stages of their recovery is a positive step forward in anticipating and managing their unique health care needs over time.

Social Support and Actual Versus Expected Length of Stay in Inpatient Rehabilitation Facilities.

OBJECTIVES: To describe impairment-specific patterns in shorter- and longer-than-expected lengths of stay in inpatient rehabilitation, and examine the independent effects of social support on deviations from expected lengths of stay. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Medicare fee-for-service beneficiaries (N=119,437) who were discharged from inpatient rehabilitation facilities in 2012 after stroke, lower extremity fracture, or lower extremity joint replacement. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Relative length of stay (actual minus expected). The Centers for Medicare & Medicaid Services posts annual expected lengths of stay based on patients' clinical profiles at admission. We created a 3-category outcome variable: short, expected, long. Our primary independent variable (social support) also included 3 categories: family/friends, paid/other, none. RESULTS: Mean ± SD actual lengths of stay for joint replacement, fracture, and stroke were 9.8±3.6, 13.8±4.5, and 15.8±7.3 days, respectively; relative lengths of stay were -1.2±3.1, -1.6±3.7, and -1.7±5.2 days. Nearly half of patients (47%-48%) were discharged more than 1 day earlier than expected in all 3 groups, whereas 14% of joint replacement, 15% of fracture, and 20% of stroke patients were discharged more than 1 day later than expected. In multinomial regression analysis, using family/friends as the reference group, paid/other support was associated (P<.05) with higher odds of long stays in joint replacement. No social support was associated with lower odds of short stays in all 3 impairment groups and higher odds of long stays in fracture and joint replacement. CONCLUSIONS: Inpatient rehabilitation experiences and outcomes can be substantially affected by a patient's level of social support. More research is needed to better understand these relationships and possible unintended consequences in terms of patient access issues and provider-level quality measures.

Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status.

OBJECTIVE: To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke. DESIGN: Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions. SETTING: Inpatient rehabilitation units and facilities. PARTICIPANTS: Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument. RESULTS: Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level. CONCLUSIONS: Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.

The effect of obesity on incidence of disability and mortality in Mexicans aged 50 years and older.

OBJECTIVE: To examine the effect of obesity on incidence of disability and mortality among non-disabled older Mexicans at baseline. MATERIALS AND METHODS: The sample included 8 415 Mexicans aged ≥ 50 years from the Mexican Health and Aging Study (2001 -2012), who reported no limitations in activities of daily living (ADLs) at baseline and have complete data on all covariates. Sociodemographics, smoking status, comorbidities, ADL activities, and body mass index (BMI) were collected. RESULTS: The lowest hazard ratio (HR) for disability was at BMI of 25 to < 30 (HR = 0.97;95% confidence interval [CI], 0.85-1.12).The lowest HR for mortality were seen among participants with BMIs 25 to < 30 (HR = 0.85; 95%CI, 075-0.97), 30 to < 35 (HR = 0.86; 95 %CI, 0.72-1.02), and > 35 (HR = 0.92; 95 %CI, 0.70-1.22). CONCLUSION: Mexican older adults with a BMI of 25 to < 30 were at less risk for both disability and mortality.

Regional variation in stroke rehabilitation outcomes.

OBJECTIVE: To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation. DESIGN: Retrospective cohort design. SETTING: Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States. PARTICIPANTS: Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS). RESULTS: Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days. CONCLUSIONS: Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.

Inpatient rehabilitation volume and functional outcomes in stroke, lower extremity fracture, and lower extremity joint replacement.

BACKGROUND: It is unclear if volume-outcome relationships exist in inpatient rehabilitation. OBJECTIVES: Assess associations between facility volumes and 2 patient-centered outcomes in the 3 most common diagnostic groups in inpatient rehabilitation. RESEARCH DESIGN: We used hierarchical linear and generalized linear models to analyze administrative assessment data from patients receiving inpatient rehabilitation services for stroke (n=202,423), lower extremity fracture (n=132,194), or lower extremity joint replacement (n=148,068) between 2006 and 2008 in 717 rehabilitation facilities across the United States. Facilities were assigned to quintiles based on average annual diagnosis-specific patient volumes. MEASURES: Discharge functional status (FIM instrument) and probability of home discharge. RESULTS: Facility-level factors accounted for 6%-15% of the variance in discharge FIM total scores and 3%-5% of the variance in home discharge probability across the 3 diagnostic groups. We used the middle volume quintile (Q3) as the reference group for all analyses and detected small, but statistically significant (P<0.01) associations with discharge functional status in all 3 diagnosis groups. Only the highest volume quintile (Q5) reached statistical significance, displaying higher functional status ratings than Q3 each time. The largest effect was observed in FIM total scores among fracture patients, with only a 3.6-point difference in Q5 and Q3 group means. Volume was not independently related to home discharge. CONCLUSIONS: Outcome-specific volume effects ranged from small (functional status) to none (home discharge) in all 3 diagnostic groups. Patients with these conditions can be treated locally rather than at higher volume regional centers. Further regionalization of inpatient rehabilitation services is not needed for these conditions.

Assessing functional recovery for individuals with spinal cord injury post-discharge from inpatient rehabilitation.

OBJECTIVE: To determine the associations between trauma variables, acute phase-related variables, and patient-level characteristics with functional recovery during the first-year post-discharge from inpatient rehabilitation facilities (IRF) for individuals with spinal cord injury (SCI). DESIGN: Retrospective cohort analysis. SETTING: Two SCI Model Centers in Pennsylvania, United States. METHODS: We were able to link 378 individuals with traumatic SCI between the Pennsylvania Trauma Systems Outcomes Study and the National SCI Model Systems databases. Nineteen individuals with SCI were excluded due to missing data. We estimated functional recovery based on changes in functional independence measure (FIM) total motor score during the first-year post-discharge from IRF in 359 individuals with SCI, who did not have any missing data, using ordinary least squares regression (OLS). RESULTS: After discharge from IRF the majority of individuals with SCI improved over the first-year post-injury. Individuals with cervical A-C (injury severity group) who were older had a slight decrease in motor FIM at 1-year post-injury. Regression analysis indicated that lower functional recovery was associated with being of Black and Hispanic race and ethnicity, higher injury severity group, occurrence of non-pulmonary infection during acute care, and longer length of stay at IRF (R2 = 0.36). CONCLUSIONS: Patient-level characteristics, trauma variables, and acute phase-related variables were associated with functional recovery post-discharge from IRF. Further research is necessary to collect and assess post-rehabilitation and socio-economic factors that play a critical role in continued functional recovery in the community.

Association Between Hospital Participation in Value-Based Programs and Timely Initiation of Post-Acute Home Health Care, Functional Recovery, and Hospital Readmission After Joint Replacement.

OBJECTIVES: This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission. METHOD: This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016 to 2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A 2-staged generalized boosted model was used to examine the association between delay in home health initiation and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission. RESULTS: Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20-1.26), mobility (OR = 1.15; 95% CI = 1.13-1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15-1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13-1.20) and mobility (OR = 1.26; 95% CI = 1.22-1.30) for hip replacement. CONCLUSION: Hospital participation in BPCI or comprehensive CJR was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission. IMPACT: Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models.

Relation of Aerobic Activity to Cognition and Well-being in Chronic Mild Traumatic Brain Injury: A LIMBIC-CENC Study.

INTRODUCTION: Because chronic difficulties with cognition and well-being are common after mild traumatic brain injury (mTBI) and aerobic physical activity and exercise (PAE) is a potential treatment and mitigation strategy, we sought to determine their relationship in a large sample with remote mTBI. MATERIALS AND METHODS: The Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study is a national multicenter observational study of combat-exposed service members and veterans. Study participants with positive mTBI histories (n = 1,087) were classified as "inactive" (23%), "insufficiently active" (46%), "active" (19%), or "highly active" (13%) based on the aerobic PAE level. The design was a cross-sectional analysis with multivariable regression. PAE was reported on the Behavioral Risk Factor Surveillance System. Preselected primary outcomes were seven well-validated cognitive performance tests of executive function, learning, and memory: The California Verbal Learning Test-Second Edition Long-Delay Free Recall and Total Recall, Brief Visuospatial Memory Test-Revised Total Recall, Trail-Making Test-Part B, and NIH Toolbox for the Assessment of Neurological Behavior and Function Cognition Battery Picture Sequence Memory, Flanker, and Dimensional Change Card Sort tests. Preselected secondary outcomes were standardized self-report questionnaires of cognitive functioning, life satisfaction, and well-being. RESULTS: Across the aerobic activity groups, cognitive performance tests were not significantly different. Life satisfaction and overall health status scores were higher for those engaging in regular aerobic activity. Exploratory analyses also showed better working memory and verbal fluency with higher aerobic activity levels. CONCLUSIONS: An association between the aerobic activity level and the preselected primary cognitive performance outcome was not demonstrated using this study sample and methods. However, higher aerobic activity levels were associated with better subjective well-being. This supports a clinical recommendation for regular aerobic exercise among persons with chronic or remote mTBI. Future longitudinal analyses of the exercise-cognition relationship in chronic mTBI populations are recommended.

Small sample research designs for evidence-based rehabilitation: issues and methods.

Conventional research methods, including randomized controlled trials, are powerful techniques for determining the efficacy of interventions. These designs, however, have practical limitations when applied to many rehabilitation settings and research questions. Alternative methods are available that can supplement findings from traditional research designs and improve our ability to evaluate the effectiveness of treatments for individual patients. The focus on individual patients is an important element of evidenced-based rehabilitation. This article examines one such alternate approach: small-N research designs. Small-N designs usually focus on 10 or fewer participants whose behavior (outcomes) are measured repeatedly and compared over time. The advantages and limitations of various small-N designs are described and illustrated using 3 examples from the rehabilitation literature. The challenges and opportunities of applying small-N designs to enhance evidence-based rehabilitation are discussed.

Factors associated with provision of wheelchairs in older adults.

The objectives of this study were: to identify the factors that are associated with prescription of wheeled mobility devices for older adults, and to determine the effect that living setting has on the types of devices that older adults receive. Retrospective medical chart review at the Center for Assistive Technology on 337 older individuals. These individuals were aged >60 years, and each of them received a new wheeled mobility device from the center during 2007 or 2008. Data were analyzed in three tiers: tier 1 (manual versus powered mobility devices); tier 2 (motorized scooters versus power wheelchairs); and tier 3 (customized versus standard power wheelchairs). For tier 1, the factor associated with higher odds for receipt of manual wheelchairs versus powered were: cognitive limitations (OR = .03). For tier 2, diagnosis of cardio-vascular and pulmonary conditions were associated with prescription of motorized scooters (OR = 3.9). For tier 3, neurological conditions (OR = 3.1), male gender (OR = .37), institutional living (OR = .23), and lower age (OR = .96) were associated with receipt of customized power wheelchairs. This study objectively describes factors associated with prescription of wheeled mobility for older adults. This information can aid in development of guidelines and improving standards of practice for prescription of wheelchairs for older adults.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity.

Importance: Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. Objective: To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. Design, Setting, and Participants: This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. Exposures: Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. Main Outcomes and Measures: Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. Results: Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. Conclusions and Relevance: In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.