Effectiveness of Bivalent mRNA COVID-19 Vaccines in Preventing SARS-CoV-2 Infection in Children and Adolescents Aged 5 to 17 Years.

Importance: Bivalent mRNA COVID-19 vaccines were recommended in the US for children and adolescents aged 12 years or older on September 1, 2022, and for children aged 5 to 11 years on October 12, 2022; however, data demonstrating the effectiveness of bivalent COVID-19 vaccines are limited. Objective: To assess the effectiveness of bivalent COVID-19 vaccines against SARS-CoV-2 infection and symptomatic COVID-19 among children and adolescents. Design, Setting, and Participants: Data for the period September 4, 2022, to January 31, 2023, were combined from 3 prospective US cohort studies (6 sites total) and used to estimate COVID-19 vaccine effectiveness among children and adolescents aged 5 to 17 years. A total of 2959 participants completed periodic surveys (demographics, household characteristics, chronic medical conditions, and COVID-19 symptoms) and submitted weekly self-collected nasal swabs (irrespective of symptoms); participants submitted additional nasal swabs at the onset of any symptoms. Exposure: Vaccination status was captured from the periodic surveys and supplemented with data from state immunization information systems and electronic medical records. Main Outcome and Measures: Respiratory swabs were tested for the presence of the SARS-CoV-2 virus using reverse transcriptase-polymerase chain reaction. SARS-CoV-2 infection was defined as a positive test regardless of symptoms. Symptomatic COVID-19 was defined as a positive test and 2 or more COVID-19 symptoms within 7 days of specimen collection. Cox proportional hazards models were used to estimate hazard ratios for SARS-CoV-2 infection and symptomatic COVID-19 among participants who received a bivalent COVID-19 vaccine dose vs participants who received no vaccine or monovalent vaccine doses only. Models were adjusted for age, sex, race, ethnicity, underlying health conditions, prior SARS-CoV-2 infection status, geographic site, proportion of circulating variants by site, and local virus prevalence. Results: Of the 2959 participants (47.8% were female; median age, 10.6 years [IQR, 8.0-13.2 years]; 64.6% were non-Hispanic White) included in this analysis, 25.4% received a bivalent COVID-19 vaccine dose. During the study period, 426 participants (14.4%) had laboratory-confirmed SARS-CoV-2 infection. Among these 426 participants, 184 (43.2%) had symptomatic COVID-19, 383 (89.9%) were not vaccinated or had received only monovalent COVID-19 vaccine doses (1.38 SARS-CoV-2 infections per 1000 person-days), and 43 (10.1%) had received a bivalent COVID-19 vaccine dose (0.84 SARS-CoV-2 infections per 1000 person-days). Bivalent vaccine effectiveness against SARS-CoV-2 infection was 54.0% (95% CI, 36.6%-69.1%) and vaccine effectiveness against symptomatic COVID-19 was 49.4% (95% CI, 22.2%-70.7%). The median observation time after vaccination was 276 days (IQR, 142-350 days) for participants who received only monovalent COVID-19 vaccine doses vs 50 days (IQR, 27-74 days) for those who received a bivalent COVID-19 vaccine dose. Conclusion and Relevance: The bivalent COVID-19 vaccines protected children and adolescents against SARS-CoV-2 infection and symptomatic COVID-19. These data demonstrate the benefit of COVID-19 vaccine in children and adolescents. All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations.

Inpatient Rehabilitation Facility Patients' Functional Abilities and Validity Testing of the Standardized Self-Care and Mobility Data Elements.

OBJECTIVE: To describe the abilities of Medicare patients in inpatient rehabilitation facilities (IRFs) at admission and discharge using the standardized self-care and mobility data elements and examine the validity of the data elements. These data are used in the Center for Medicare & Medicaid's IRF payment and quality reporting programs. DESIGN: Descriptive study reporting IRF patients' self-care and mobility scores. We also examined content validity and the associations between admission scores and length of stay (LOS), discharge scores and discharge destination, and change scores and the number of comorbidities. SETTING: Patients discharged from 1129 IRFs in 2017. PARTICIPANTS: IRF Medicare fee-for-service and Medicare Advantage patient stays (N = 493,209). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Self-care and mobility item scores, IRF LOS, discharge destination, and categories of the number of comorbidities. RESULTS: For each self-care and mobility activity, patients in IRFs overall made substantial improvements in function between admission and discharge. For example, the percentage of patients independent with eating and toilet transfers increased from 29.04% to 66.68% and 0.80% to 39.87%, respectively, between admission and discharge. Activities represented in the standardized data elements are included in other functional assessment instruments addressing content validity. Analyses showed a monotonic relationship between admission scores and LOS and between discharge scores and discharge to community percentages with only a few exceptions. Self-care and mobility scale change scores decreased as the number of comorbidities increased across categories. CONCLUSIONS: Patients in IRFs overall show functional improvement across each of the activities as defined by the standardized self-care and mobility data elements. The results showing the associations between patient functioning and 3 metrics (LOS, discharge to community rates, and number of comorbidities) support the validity of the data elements measuring functional abilities in the IRF Medicare population.

Change in Mobility Quality Measure for Inpatient Rehabilitation Facilities: Exclusion Criteria and the Risk Adjustment Model.

OBJECTIVE: To describe the exclusion criteria and updated risk adjustment model developed for the Change in Mobility quality measure in the inpatient rehabilitation facility (IRF) quality reporting program. Facility-level quality measures focused on patient outcomes usually require risk adjustment to account for varied admission characteristics of patients across facilities. DESIGN: This cohort study analyzed admission demographic and clinical factors associated with mobility change scores using the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data for Medicare patients discharged from IRFs in calendar year 2017. SETTING: A total of 1129 IRFs in the United States. PARTICIPANTS: A total of 493,209 (N=493, 209) Medicare fee-for-service and Medicare Advantage IRF patient stays discharged in calendar year 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mobility change scores using admission and discharge standardized assessment data from the IRF-PAI. RESULTS: Approximately 53% of patients in the study were female, 67% were aged 65-84 years, and nearly 80% were White. In the final risk adjustment model, 105 covariates were included, explaining 20% of variance in mobility change scores. Key risk adjusters included IRF primary diagnosis group, prior indoor ambulation functioning, age older than 90 years, and 14 of the comorbidities. The model showed good calibration across the range of deciles of predicted IRF mobility change scores; the ratio of the average expected to observed change scores ranged from 0.93-1.03, with all but 1 within ±0.03. CONCLUSIONS: The updated risk adjustment model uses IRF patients' demographic and clinical characteristics to predict their mobility change scores. The exclusion criteria and resulting risk model are used to calculate the risk adjusted Change in Mobility quality measure scores, enabling comparisons of Change in Mobility scores across IRFs.

Change in Self-Care Quality Measure for Inpatient Rehabilitation Facilities: Exclusion Criteria and Risk-Adjustment Model.

OBJECTIVE: To describe the exclusion criteria and risk-adjustment model developed for the quality measure Change in Self-Care. The exclusion criteria and risk adjustment model are used to calculate Change in Self-Care scores, allowing scores to be compared across inpatient rehabilitation facilities (IRFs). DESIGN: This national cohort study examined admission demographic and clinical factors associated with IRF patients' self-care change scores using standardized self-care data for Medicare patients discharged in calendar year 2017. SETTING: A total of 1129 IRFs in the United States. PARTICIPANTS: A total of 493,209 (N=493,209) Medicare Fee-for-Service and Medicare Advantage IRF patient stays INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-care change scores using admission and discharge standardized assessment data elements from the Inpatient Rehabilitation Facility-Patient Assessment Instrument. RESULTS: Approximately 53% of patients were female, and 67% were between 65 and 84 years old. The final risk-adjustment model contained 93 clinically relevant risk adjusters and explained 23.1% of variance in self-care change scores. Risk adjusters that had the greatest effect on change scores and included IRF primary diagnosis group (ie, binary risk adjusters representing 13 diagnoses), prior self-care functioning, and age older than 90 years. When split by deciles of expected scores, the ratio of the average expected and observed change scores was within 2% of 1.0 across 8 groups and within 8% at the extremes, showing good predictive accuracy. CONCLUSIONS: The risk adjustment model quantifies the relationship between IRF patients' demographic and clinical characteristics and their self-care score changes. The exclusion criteria and model are used to risk-adjust the IRF Change in Self-Care quality measure.

Inpatient Rehabilitation Facility Change in Self-Care and Change in Mobility Quality Measures: Development and Reliability and Validity Testing.

OBJECTIVE: To describe the development, implementation and reliability and validity testing of the inpatient rehabilitation facility (IRF) Change in Self-Care and Change in Mobility quality measures. DESIGN: We describe the activities involved in developing and implementing the 2 facility-level quality measures, including public comment opportunities. We examined facility-level reliability using split-half testing and Pearson product-moment correlations, Spearman rank correlations, and intraclass correlation coefficients (ICC2,1). We examined validity by comparing facility-level quality measure scores and facility disease-specific certification status. SETTING: All 1117 IRFs in the United States with at least 20 Medicare stays that ended in 2017. PARTICIPANTS: Facility-level quality measure scores (N=1117) were derived from data from 427,517 (self-care) and 427,956 (mobility) Medicare fee-for-service and Medicare Advantage IRF patient stays in 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Facility-level Change in Self-Care and Change in Mobility quality measure scores and facility Disease-Specific Certification for Stroke Rehabilitation from The Joint Commission were used in validity analysis. RESULTS: The split-half quality measure scores showed strong, positive correlations for the facility-level self-care (Pearson=0.903, Spearman=0.884, ICC=0.903, P<.0001) and mobility (Pearson=0.903, Spearman=0.884, ICC= 0.903, P<.0001) quality measure scores, providing evidence of reliability. ICCs remained strong when stratifying by provider volume. IRFs with stroke certification had slightly higher mean and median quality measure scores than IRFs without certification, and IRFs with the higher quality measure scores tended to have a higher percentage of certified IRFs. CONCLUSIONS: Our analyses support the reliability and validity of the Change in Self-Care and Change in Mobility quality measure scores in IRFs.

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.

Longitudinal parental perception of COVID-19 vaccines for children in a multi-site, cohort study.

OBJECTIVES: Pediatric COVID-19 vaccine hesitancy and uptake is not well understood. Among parents of a prospective cohort of children aged 6 months-17 years, we assessed COVID-19 vaccine knowledge, attitudes, and practices (KAP), and uptake over 15 months. METHODS: The PROTECT study collected sociodemographic characteristics of children at enrollment and COVID-19 vaccination data and parental KAPs quarterly. Univariable and multivariable logistic regression models were used to test the effect of KAPs on vaccine uptake; McNemar's test for paired samples was used to evaluate KAP change over time. RESULTS: A total of 2,837 children were enrolled, with more than half (61 %) vaccinated by October 2022. Positive parental beliefs about vaccine safety and effectiveness strongly predicted vaccine uptake among children aged 5-11 years (aOR 13.1, 95 % CI 8.5-20.4 and aOR 6.4, 95 % CI 4.3-9.6, respectively) and children aged 12+ years (aOR 7.0, 95 % CI 3.8-13.0 and aOR 8.9, 95 % CI 4.4-18.0). Compared to enrollment, at follow-up parents (of vaccinated and unvaccinated children) reported higher self-assessed vaccine knowledge, but more negative beliefs towards vaccine safety, effectiveness, and trust in government. Parents unlikely to vaccinate their children at enrollment reported more positive beliefs on vaccine knowledge, safety, and effectiveness at follow-up. CONCLUSION: The PROTECT cohort allows for an examination of factors driving vaccine uptake and how beliefs about COVID-19 and the COVID-19 vaccines change over time. Findings of the current analysis suggest that these beliefs change over time and policies aiming to increase vaccine uptake should focus on vaccine safety and effectiveness.

Evaluating Immunologic and Illness Outcomes of SARS-CoV-2 Infection in Vaccinated and Unvaccinated Children Aged ≥ 5 Years, in a Multisite Longitudinal Cohort.

Hybrid immunity, as a result of infection and vaccination to SARS-CoV-2, has been well studied in adults but limited evidence is available in children. We evaluated the antibody responses to primary SARS-CoV-2 infection among vaccinated and unvaccinated children aged ≥ 5 years. METHODS: A longitudinal cohort study of children aged ≥ 5 was conducted during August 2021-August 2022, at sites in Arizona, Texas, Utah, and Florida. Children submitted weekly nasal swabs for PCR testing and provided sera 14-59 days after PCR-confirmed SARS-CoV-2 infection. Antibodies were measured by ELISA against the receptor-binding domain (RBD) and S2 domain of ancestral Spike (WA1), in addition to Omicron (BA.2) RBD, following infection in children, with and without prior monovalent ancestral mRNA COVID-19 vaccination. RESULTS: Among the 257 participants aged 5 to 18 years, 166 (65%) had received at least two mRNA COVID-19 vaccine doses ≥ 14 days prior to infection. Of these, 53 occurred during Delta predominance, with 37 (70%) unvaccinated at the time of infection. The remaining 204 infections occurred during Omicron predominance, with 53 (26%) participants unvaccinated. After adjusting for weight, age, symptomatic infection, and gender, significantly higher mean RBD AUC values were observed among the vaccinated group compared to the unvaccinated group for both WA1 and Omicron (p < 0.0001). A smaller percentage of vaccinated children reported fever during illness, with 55 (33%) reporting fever compared to 44 (48%) unvaccinated children reporting fever (p = 0.021). CONCLUSIONS: Children with vaccine-induced immunity at the time of SARS-CoV-2 infection had higher antibody levels during convalescence and experienced less fever compared to unvaccinated children during infection.

Reliability and Validity of the Inpatient Rehabilitation Facility Discharge Mobility and Self-Care Quality Measures.

OBJECTIVE: To describe the reliability and validity of the publicly reported facility-level quality measures Inpatient Rehabilitation Facility (IRF) Discharge Mobility Score for Medical Rehabilitation Patients ("Discharge mobility score") and IRF Discharge Self-Care Score for Medical Rehabilitation Patients ("Discharge self-care score"). DESIGN: Observational study using standardized patient assessment data to examine facility-level split-half reliability and construct validity of quality measure scores. SETTING AND PARTICIPANTS: All IRFs (n = 1117) in the United States with at least 20 Medicare stays. Facility-level quality measure scores were calculated from 2017 data on 428,192 Medicare (fee-for-service and Medicare Advantage) IRF patient stays. METHODS: Using clinician-reported assessment data, we calculated facility-level mobility and self-care quality measure scores and examined reliability of these scores using split-half analysis and Pearson product-moment correlations, Spearman rank correlations, and intraclass correlation coefficients (ICC2,1). We examined construct validity of these scores by comparing facility-level quality measure scores by facility stroke disease-specific certification status. RESULTS: Reported as percentages meeting or exceeding expectations, IRF quality measure scores ranged from 8.3% to 90.1% for mobility and 9.0% to 90.3% for self-care. IRF scores, when split in half to examine reliability, showed strong, positive correlations for the mobility (Pearson = 0.898, Spearman = 0.898, ICC = 0.898) and self-care (Pearson = 0.886, Spearman = 0.874, ICC = 0.886) scores. When stratified by provider volume, ICCs remained strong. Construct validity analyses showed IRFs with stroke disease-specific certification had higher mean and median scores than IRFs without certification, and a greater proportion of IRFs that were certified had higher scores. CONCLUSION AND IMPLICATIONS: Our results support the reliability and construct validity of the IRF quality measures Discharge mobility and Discharge self-care scores. Reported as percentages meeting or exceeding expectations, these quality measures are designed to be more consumer-friendly compared to change scores.

Recruitment cost and outcomes for an arthritis work disability prevention randomized clinical trial: The Work It study.

BACKGROUND: Despite the recommendations to increase recruitment of participants into clinical trials, investigators face costly challenges in trials investigating work disability interventions for people with arthritis and rheumatological conditions. This study aims to evaluate the recruitment costs and outcomes from a randomized controlled trial of an arthritis work disability prevention program conducted between 2011 and 2015, to inform planning and monitoring recruitment in similar studies. METHODS: Data were obtained from enrollment and financial records pertaining to recruitment costs for each recruitment approach employed. The cost for each recruitment method was calculated for total cost and cost per number of participants screened, eligible, and enrolled in the trial. Then the yield of each possible recruitment method was also determined based on the ratio of the number of randomized participants divided by the number of people contacted through each recruitment method. Finally, the. RESULTS: Recruitment rate was lower than projected. Community advertising, specifically newspapers, was the most successful method of recruitment in terms of numbers, but social media, specifically Craigslist, was the least costly method used to recruit. Some social media approaches, including Facebook and LinkedIn, yielded few if any participants. Recruitment efforts used successfully in the past are not always effective. CONCLUSIONS: Costs to recruit large numbers of people with arthritis into clinical trials are high. Investigators are encouraged to monitor recruitment efforts and evaluate the costs and outcomes of their strategies throughout the study period. Close consideration to recruitment costs should be considered as part of the research fiscal resources prior to and during the study period for long-term outcomes like work disability. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01387100, date: 06/01/2011.

"Fear of the Known and Unknown": Factors Affecting Participation Following Knee Replacement Among Persons With Participation Restriction.

BACKGROUND/PURPOSE: Evidence suggests that more than 30% of patients post-total knee replacement (TKR) are living with participation restrictions, yet little is known about their perceptions of and factors contributing to these restrictions. The purpose of this study was to identify emergent or recurring themes behind participation restrictions after TKR. METHODS: Nineteen participants between 50 and 85 years old reporting participation restrictions 1 to 5 years post-TKR completed semistructured qualitative interviews about their participation experience after TKR. Participants provided background information in written questionnaires. Data collected from in-person interviews were analyzed qualitatively using a grounded theory approach. RESULTS: Participants discussed 3 major themes with regard to participation post-TKR: (1) limiting activities requiring long-distance walking due to continued knee impairments, (2) avoiding activities with negative or unknown outcome expectancies, and (3) using problem solving to identify strategies to participate in important activities. CONCLUSIONS: An unknown or negative outcome expectancy, particularly with regard to activities requiring long-distance walking, may lead to participation restrictions in some patients post-TKR. As participants reported using self-efficacy and coping strategies to improve participation, further physical rehabilitation or interdisciplinary rehabilitation incorporating the identified strategies may be effective with some patients post-TKR.

Efficacy of a Work Disability Prevention Program for People with Rheumatic and Musculoskeletal Conditions: A Single-Blind Parallel-Arm Randomized Controlled Trial.

OBJECTIVE: Work disability rates are high among people with rheumatic and musculoskeletal conditions. Effective disability preventive programs are needed. We examined the efficacy of a modified vocational rehabilitation approach delivered by trained occupational therapists and physical therapists on work limitation and work loss over 2 years among people with rheumatic and musculoskeletal conditions. METHODS: Eligibility criteria for this single-blind, parallel-arm randomized trial included ages 21-65 years, 15 or more hours/week employment, a self-reported doctor-diagnosed rheumatic or musculoskeletal condition, and concern about staying employed. The intervention consisted of a 1.5-hour meeting, an action plan, written materials on employment supports, and telephone calls at 3 weeks and 3 months. Control group participants received the written materials. The primary outcome was the Work Limitations Questionnaire (WLQ) output job demand subscale. The secondary outcome was work loss. Intent-to-treat analyses were performed. RESULTS: Between October 2011 and January 2014, 652 individuals were assessed for eligibility. A total of 287 participants were randomized: 143 intervention and 144 control participants. In total, 264 participants (92%) completed 2-year data collection. There was no difference in the mean ± SD WLQ change scores from baseline to 2-year followup (-8.6 ± 1.9 intervention versus -8.3 ± 2.2 control; P = 0.93). Of the 36 participants who experienced permanent work loss at 2 years, 11 (8%) were intervention participants and 25 (18%) control participants (P = 0.03). CONCLUSION: The intervention did not have an effect on work limitations but reduced work loss. The intervention can be delivered by trained rehabilitation therapists.

Affect and Incident Participation Restriction in Adults With Knee Osteoarthritis.

OBJECTIVE: Participation restriction, common among people with knee osteoarthritis (OA), may be influenced by affect. We examined the risk of incident participation restriction over 84 months conferred by positive and negative affect among people with knee OA. METHODS: Participants were from the Multicenter Osteoarthritis Study and had or were at high risk of knee OA. Participation restriction was measured using the Instrumental Role Limitation subscale of the Late-Life Disability Index, and affect was measured using the positive affect and depressed mood subscales of the Center for Epidemiologic Studies Depression Scale. Robust Poisson regression was used to calculate the risk of incident participation restriction over 84 months conferred by combinations of low and high positive and negative affect, adjusting for covariates. RESULTS: Of 1,810 baseline participants (mean age 62.1 years, 56% female), 470 (26%) had incident participation restriction over 84 months. Participants with low positive affect had 20% greater risk of incident participation restriction than those with high positive affect; participants with high negative affect had 50% greater risk of incident participation restriction compared to those with low negative affect. Participants with both low positive and high negative affect had 80% greater risk of incident participation restriction compared to other combinations of positive and negative affect. CONCLUSION: Low positive and high negative affect, both alone and in combination, increase the risk of participation restriction among adults with knee OA. Efforts aimed at preventing participation restriction in this population should consider these mood states.

Perceived Community Environmental Factors and Risk of Five-Year Participation Restriction Among Older Adults With or at Risk of Knee Osteoarthritis.

OBJECTIVE: Older adults with knee osteoarthritis (OA) who live in environments with mobility barriers may be at greater risk of developing participation restrictions, defined as difficulties in engagement in life situations. We investigated the risk of participation restriction over 5 years due to self-reported environmental features among older adults with knee OA. METHODS: Participants from the Multicenter Osteoarthritis (MOST) Study self-reported participation at baseline, 30 months, and 60 months using the instrumental role subscale of the Late Life Disability Index (LLDI). Data on self-reported environmental features were from the Home and Community Environment questionnaire administered in the MOST Knee Pain and Disability study, an ancillary study of MOST. The relative risks (RRs) of developing participation restriction at 60 months, indicated by an LLDI score <67.6 out of a possible 100, due to reported high community mobility barriers and high transportation facilitators, were calculated using robust Poisson regression, adjusting for covariates. RESULTS: Sixty-nine of the 322 participants (27%) developed participation restriction by 60 months. Participants reporting high community mobility barriers at baseline had 1.8 times the risk (95% confidence interval [95% CI] 1.2-2.7) of participation restriction at 60 months, after adjusting for covariates. Self-report of high transportation facilitators at baseline resulted in a reduced but statistically nonsignificant risk of participation restriction at 60 months (RR 0.7, 95% CI 0.4-1.1). CONCLUSION: Higher perceived environmental barriers impact the risk of long-term participation restriction among older adults with or at risk of knee OA. Approaches aimed at reducing the development of participation restrictions in this population should consider decreasing environmental barriers.

Which Features of the Environment Impact Community Participation of Older Adults? A Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this study is to identify features of the environment associated with community participation of older adults. METHOD: A systematic review of studies that examined associations between environment and community participation in older adults was conducted. Environmental features were extracted and grouped using the International Classification of Functioning, Disability, and Health's environmental categories. Meta-analysis of environmental categories was conducted by calculating combined effect size (ES) estimates. RESULTS: Significant, small to moderate, random ESs were found for six of seven environmental categories: neighborliness (ES = 0.52, 95% confidence interval [CI] = [0.18, 0.87]), social support (ES = 0.38, 95% CI = [0.13, 0.62]), land-use diversity (ES = 0.29, 95% CI = [0.16, 0.42]), transportation (ES = 0.29, 95% CI = [0.15, 0.43]), civil protection (e.g., safety; ES = 0.27, 95% CI = [0.0, 0.54]), and street connectivity/walkability (ES = 0.20, 95% CI = [0.15, 0.26]). DISCUSSION: Community initiatives that address specific features of the social environment and street-level environment may increase community participation of older adults.

Critical Appraisal of the Quality of Literature Evaluating Psychometric Properties of Arthritis Work Outcome Assessments: A Systematic Review.

OBJECTIVE: To systematically rate the evidence on the measurement properties of work functioning instruments for people with arthritis and other rheumatologic conditions. METHODS: A systematic review was conducted through a structured search to identify the quality of articles describing studies of assessment development and studies of their psychometric properties. The Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist was used to appraise the included studies. Finally, an evidence synthesis was performed to combine findings. RESULTS: Nine arthritis-specific work outcome assessments were identified; 17 articles examining the psychometric properties of these instruments were identified and their quality was reviewed. Quality of studies was highly variable. The evidence synthesis showed that the Work Limitations Questionnaire had the strongest quality evidence of internal consistency and content validity (including structural validity and hypothesis testing), followed by the Work Instability Scale. None of the instruments had strong quality evidence of criterion validity or responsiveness. CONCLUSION: Considering the high variability and the low quality of the literature, we recommend that instrument developers integrate a full psychometric assessment of their instruments, including responsiveness and criterion validity, and consult guidelines (i.e., COSMIN) in reporting their findings.

The Work-It Study for people with arthritis: Study protocol and baseline sample characteristics.

BACKGROUND: People with arthritis are at risk of work disability. Job accommodation and educational programs delivered before imminent work loss can minimize work disability, yet are not currently being widely implemented. The Work-It Study is a randomized controlled trial testing the efficacy of a problem solving program delivered by physical and occupational therapy practitioners to prevent work loss over a two-year period among people with arthritis and rheumatological conditions. OBJECTIVE: The purpose of this paper is to describe the protocol of the randomized controlled trial, and describe the baseline characteristics of the subjects and their work outcomes. METHODS: 287 participants were recruited from the Boston area in Massachusetts, USA. Eligible participants were aged between 21-65, self-reported a physicians' diagnosis of arthritis, rheumatic condition, or chronic back pain, reported a concern about working now or in the near future due to your health, worked at least 15 hours a week, had plans to continue working, and worked or lived in Massachusetts. Subjects were recruited through community sources and rheumatology offices. Participants in the experimental group received a structured interview and an education and resource packet, while participants in the control received the resource packet only. The baseline characteristics and work related outcomes of the participants were analyzed. CONCLUSIONS: To our knowledge, the Work-It Study is the largest and most diverse randomized controlled trial to date aiming to identify and problem solve work-related barriers, promote advocacy, and foster work disability knowledge among people with chronic disabling musculoskeletal conditions. Despite advances in medical management of arthritis and other rheumatological and musculoskeletal conditions, many people still have concerns about their ability to remain employed and are seeking strategies to help them sustain employment.