Canada's health promotion survey as a milestone in public health research.

This commentary describes the contribution of the 1985 Canadian National Health Promotion Survey to the development of public health research and policy-making in Canada and argues that on the basis of that contribution, it should be considered to be a public health research milestone. In terms of research, among its contributions which subsequently have been adopted in other survey studies were: going beyond risk factors to operationalize concepts implicit in the Ottawa Charter for Health Promotion; empowering users to participate in knowledge translation, sharing and transfer; ensuring sufficient sample sizes for each jurisdiction to be able to confidently generalize to its population; establishing a model as well as questions for subsequent health surveys; encouraging widespread use of data through making them available early; and developing and using an explicit social marketing strategy to reach target audiences, including the general public. With regard to policy-making, among its contributions which have been adopted were: using survey data to develop and enhance healthy public policy initiatives; encouraging researchers to work with policy-makers in developing policies; using survey data to contribute to the evaluation of public health initiatives; engaging policy-makers in the development of surveys; and encouraging the use of survey data for advocacy.

Building capacity for risk factor surveillance in developed countries: the need for a vision-driven approach: lessons learned from the Canadian experience.

This paper examines the question of capacity building for risk factor surveillance in developed countries, with reference to the Canadian experience. Special attention is accorded the issue of building capacity for utilization of surveillance information. The paper describes the development, evolution and current status of risk factor surveillance in Canada. It notes that there is evidence of ongoing improvement in surveillance capacities over the past 20 years, but that there remains considerable room for improvement--particularly in relation to building capacity for the utilization of surveillance information. A vision-driven approach to capacity building is recommended and described building upon concepts and principles followed by international organizations addressing analogous issues.

Pattern of functional change during rehabilitation of patients with hip fracture.

OBJECTIVE: To examine the rate of functional change in 2 domains, activities of daily living (ADLs) and mobility, over 2 time periods during hip fracture rehabilitation. DESIGN: Retrospective analysis of data contained in an administrative dataset. SETTING: Seventy skilled nursing facilities (SNFs). PARTICIPANTS: People (N=351) receiving rehabilitation in SNFs from March 1998 to February 2003 after hip fractures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Rate of change in scores in the ADL and mobility domains of the FIM instrument during 2 time intervals of rehabilitation. RESULTS: The rate of functional change across 2 time intervals was constant for mobility (mean change in FIM points per day, .46 vs .49), but declined in the second time period for ADLs (mean change in FIM points per day, .55 vs .41). Executive function, length of stay (LOS), and medical complexity were related to rate of change in mobility, and baseline ADLs, executive function, living setting, and LOS were related to rate of change in ADLs. There was an interaction between rehabilitation phase and baseline mobility. People with lower baseline mobility had an increased rate of change during the second interval (mean change in FIM points per day, .41 vs .55), whereas those with higher baseline mobility had a decreased rate of change (mean change in FIM points per day, .50 vs .43). CONCLUSIONS: The pattern of functional change over time differed for ADL and mobility domains, and for specific groups of patients. The results have implications for goal setting and discharge planning.

The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities.

OBJECTIVE: To examine the relation between therapy intensity, including physical therapy (PT), occupational therapy (OT), and speech and language therapy (SLT), provided in a skilled nursing facility (SNF) setting and patients' outcomes as measured by length of stay (LOS) and stage of functional independence as measured by the FIM instrument. DESIGN: A retrospective analysis of secondary data from an administrative dataset compiled and owned by SeniorMetrix Inc. SETTING: Seventy SNFs under contract with SeniorMetrix health plan clients. PARTICIPANTS: Patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions (N=4988) covered by Medicare+Choice plans, and admitted to an SNF in 2002. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: LOS and improvement in stage of independence in the mobility, activities of daily living (ADLs), and executive control domains of function as determined by the FIM instrument. RESULTS: Higher therapy intensity was associated with shorter LOS ( P <.05). Higher PT and OT intensities were associated with greater odds of improving by at least 1 stage in mobility and ADL functional independence across each condition ( P <.05). The OT intensity was associated with an improved executive control stage for patients with stroke, and PT and OT intensities were associated with improved executive control stage for patients with cardiovascular and pulmonary conditions ( P <.05). The SLT intensity was associated with improved motor and executive control functional stages for patients with stroke ( P <.05). Therapy intensities accounted for small proportions of model variances in all outcomes. CONCLUSIONS: Higher therapy intensity was associated with better outcomes as they relate to LOS and functional improvement for patients who have stroke, orthopedic conditions, and cardiovascular and pulmonary conditions and are receiving rehabilitation in the SNF setting.

Functional independence domains in patients receiving rehabilitation in skilled nursing facilities: evaluation of psychometric properties.

OBJECTIVE: To provide evidence for the validity of using FIM items to derive 4 domains of functional independence (mobility, activities of daily living [ADLs], sphincter management, executive function) in patients receiving rehabilitation in skilled nursing facilities (SNFs). DESIGN: A retrospective analysis of secondary data using data from a privately owned administrative dataset. Setting Seventy SNFs under contract with SeniorMetrix Inc health plan clients. PARTICIPANTS: Patients (N=7536) with a variety of conditions, covered by Medicare+Choice plans, and admitted to an SNF in 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Item score distributions, corrected item-total correlations, factor correlations, internal consistency, and stage ceiling and floor effects for each hypothesized functional independence domain. RESULTS: With the exception of 2 items, the items within a domain had similar standard deviations and distributions of items were not highly skewed. Four factors accounted for 73.4% of the variance in functional independence. Corrected item-total correlations ranged from .58 to .80 for the ADL domain, from .23 to .71 for the mobility domain, and from .78 to .88 for the executive function domain. The correlation between bowel and bladder management items was .84. Cronbach alpha coefficients ranged from .76 for the mobility domain to .96 for the executive function domain. At admission, there were substantial floor effects for the sphincter management (34.4%) and mobility domains (43.1%) and ceiling effects for the executive function domain (26.7%). CONCLUSIONS: With a few exceptions, the items proposed for each functional independence domain met the criteria for supporting the validity of the domains.

Validity of functional independence staging in patients receiving rehabilitation in skilled nursing facilities.

OBJECTIVES: To determine the psychometric performance and clinical applicability of the Functional Independence Staging (FIS) system for activities of daily living (ADLs), sphincter management, mobility, and executive function in patients receiving rehabilitation in the skilled nursing facility (SNF) setting. DESIGN: A retrospective analysis of secondary data using data from a privately owned administrative dataset. Setting Seventy SNFs under contract with SeniorMetrix Inc health plan clients. PARTICIPANTS: Patients (N=7526) covered by Medicare+Choice plans and admitted to an SNF in 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Analysis of construct validity, sensitivity to change, and predictive validity. RESULTS: The FIS score in each domain except mobility at admission was higher for patients with no concomitant disease than for patients classified as moribund ( P <.001). The odds of being discharged to the community were consistently greater for patients with higher discharge FIS scores in sphincter management (odds ratio [OR] range, 1.32-1.76), mobility (OR range, 1.93-4.66), and executive function (OR range, 1.50-4.15). Discharge FIS score was greater than admission FIS score for all domains ( P <.001). The odds of being discharged to the community were fairly consistently predicted by admission FIS score in ADLs (OR range, 1.26-3.73) and executive function (OR range, 1.60-5.05). CONCLUSIONS: The FIS system has reasonable psychometric properties that suggest it may be applied to the assessment and monitoring of functional status in patients admitted for rehabilitation in SNF settings. The system may be useful for determining the type of therapy that might be required or to predict the likely discharge needs of the patient.

Rehabilitation in skilled nursing facilities: effect of nursing staff level and therapy intensity on outcomes.

OBJECTIVE: To explore the relationship of patients' outcomes with nursing staff levels and therapy intensity within skilled nursing facilities. DESIGN: Secondary analysis using administrative dataset of 6,897 patients from 68 skilled nursing facilities providing rehabilitation and reimbursed through Medicare+Choice. Independent measures were facility level nursing hours-to-resident ratio and total therapy hours per day. Outcomes included discharge to community and length of stay efficiency. RESULTS: Patients were 1.53 times more likely to be discharged to the community when nursing staff level was > or = 3.5 hrs per resident per day as compared with <3.5, and patients were 1.22 and 2.02 times more likely to be discharged to the community when therapy averaged 1-1.5 hrs/day and >1.5 hrs/day, respectively, as compared with <1 hr/day. The adjusted mean length-of-stay efficiency was 0.21 points greater in facilities where the nursing staff level was > or = 3.5 hrs per resident per day than in facilities where the level was <3.5 and 0.43 and 0.70 points greater in facilities where patients received 1-1.5 hrs/day and >1.5 hrs/day of therapy, respectively, than in facilities where the average therapy intensity was <1 hr/day. CONCLUSIONS: Higher nursing staff levels and therapy intensity are related to improved length-of-stay efficiency and increase the likelihood of patients' being discharged to the community.