Barriers and Facilitators to the Adoption of Evidence-Based Interventions for Adults Within Occupational and Physical Therapy Practice Settings: A Systematic Review.

OBJECTIVE: Synthesize data regarding barriers and facilitators of adoption (ie, adoption determinants) of evidence-based occupational (OT) and physical therapy (PT) interventions within real-world practice. Whether evidence varied across disciplines, settings, and use of theoretical frameworks was also examined. DATA SOURCES: Literature published from database inception to December 9, 2022, in OVID MEDLINE, EMBASE, OVID PsycINFO, Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and Google Scholar. STUDY SELECTION: Original research including: (1) stakeholder insight into adoption determinants; (2) discrete evidence-based interventions delivered/supervised by an OT and/or PT; (3) intervention recipients aged 18 or older; and (4) data regarding adoption determinants. Two reviewers independently screened and evaluated studies for inclusion, with a third resolving discrepancies. Of the 3036 articles identified, 45 articles were included. DATA EXTRACTION: Data were extracted by a primary reviewer, independently evaluated by a second reviewer, and conflicts were resolved via group consensus. DATA SYNTHESIS: A descriptive synthesis approach was used to categorize adoption determinants according to constructs from the Consolidated Framework for Implementation Research. 87% of studies were published after 2014. Many studies: described PT interventions (82%); were within the outpatient setting (44%); had data gathered after implementing the intervention (71%); and did not report use of a theoretical framework to inform data collection (62%). Lack of available resources (64%) and knowledge/beliefs about the intervention (53%) were the most common barrier and facilitator, respectively. Variability in adoption determinants was observed according to discipline, setting, and use of a theoretical framework. CONCLUSIONS: Findings suggest a recent surge of scientific investment in understanding adoption determinants for evidence-based OT and PT interventions. Such knowledge can inform efforts aimed at improving OT and PT quality, thereby enhancing patient outcomes. However, our review highlighted gaps with significant implications for the delivery of evidence-based OT and PT within real-world practice settings.

Mobility Status and Acute Care Physical Therapy Utilization: The Moderating Roles of Age, Significant Others, and Insurance Type.

OBJECTIVE: To investigate whether a direct measure of need for physical therapy (PT), mobility status, was associated with acute care PT utilization and whether this relationship differs across sociodemographic factors and insurance type. DESIGN: In a secondary analysis of electronic health records data, we estimated logistic regression models to determine whether mobility status was associated with acute care PT utilization. Interactions between mobility and both sociodemographic factors (sex, age, significant other, minority status) and insurance type were included to investigate whether the relationship between mobility and PT utilization varied across patient characteristics. SETTING: Five regional hospitals from 1 health system. PARTICIPANTS: A total of 60,459 adults admitted between 2014 and 2018 who received a PT evaluation. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Received acute care PT; Activity Measure for Post-Acute Care "6-Clicks" measure of mobility. RESULTS: Half of patients who received a PT evaluation received subsequent treatment. Patients with mobility limitations were more likely to receive PT. Interaction terms indicated that among patients with mobility limitations, those who (1) were younger, (2) had significant others, and (3) had private insurance (vs public) were more likely to receive PT. Among patients with greater mobility status, older patients and those without a significant other were more likely to receive PT. CONCLUSIONS: The relationship between acute care PT need and utilization differed across sociodemographic factors and insurance type. We offer potential explanations for these findings to guide efforts targeting equitable distribution of beneficial PT services.

Higher Frequency of Acute Occupational Therapy Services Is Associated With Reduced Hospital Readmissions.

IMPORTANCE: Hospital readmissions are associated with poor patient outcomes, including higher risk for mortality, nutritional concerns, deconditioning, and higher costs. OBJECTIVE: To evaluate how acute occupational therapy service delivery factors affect readmission risk. DESIGN: Cross-sectional, retrospective study. SETTING: Single academic medical center. PARTICIPANTS: Medicare inpatients with a diagnosis included in the Hospital Readmissions Reduction Program (HRRP; N = 17,618). Data were collected from medical records at a large urban hospital in southeastern Wisconsin. Outcomes and Measures: Logistic regression models were estimated to examine the association between acute occupational therapy service delivery factors and odds of readmission. In addition, the types of acute occupational therapy services for readmitted versus not-readmitted patients were compared. RESULTS: Patients had significantly higher odds of readmission if they received occupational therapy services while hospitalized (odds ratio [OR] = 1.18, 95% confidence interval [CI] [1.07, 1.31]). However, patshients who received acute occupational therapy services had significantly lower odds of readmission if they received a higher frequency (OR = 0.99, 95% CI [0.99,1.00]) of acute occupational therapy services. A significantly higher proportion of patients who were not readmitted, compared with patients who were readmitted, received activities of daily living (ADL) or self-care training (p < .01). CONCLUSIONS AND RELEVANCE: For patients with HRRP-qualifying diagnoses who received acute occupational therapy services, higher frequency of acute occupational therapy services was linked with lower odds of readmission. Readmitted patients were less likely to have received ADL or self-care training while hospitalized. What This Article Adds: Identifying factors of acute occupational therapy services that reduce the odds of readmission for Medicare patients may help to improve patient outcomes and further define occupational therapy's role in the U.S. quality-focused health care system.

Impact of Acute Self-Care Indicators and Social Factors on Medicare Inpatient Readmission Risk.

IMPORTANCE: Readmissions are costly for Medicare and are associated with poor patient outcomes. OBJECTIVE: To determine whether two domains relevant to acute occupational therapy practice-self-care status and social factors-were associated with readmissions for Medicare patients in the Medicare Hospital Readmissions Reduction Program (HRRP). DESIGN: Cross-sectional, retrospective study. SETTING: Single academic medical center. PARTICIPANTS: Medicare inpatients with a diagnosis included in the HRRP (N = 17,618). Outcomes and Measures: Three logistic regression models were estimated to examine the associations among (1) self-care status and 30-day readmission, (2) social support and 30-day readmission, and (3) housing situation and 30-day readmission. Subgroup analyses were conducted for the individual HRRP diagnoses. RESULTS: No associations were found between acute self-care status, social support, or housing situation and 30-day readmission when all HRRP diagnoses were examined together. However, higher levels of independence with self-care were significantly associated with reduced odds of readmission for patients with pneumonia. CONCLUSIONS AND RELEVANCE: The findings for patients with pneumonia are consistent with those of other studies done in the acute care setting. Deficiencies in acute occupational therapy documentation may have affected the findings for the other HRRP diagnoses. What This Article Adds: This study is the first to examine the association between acute self-care status (as documented by acute care occupational therapy practitioners) and readmission.

Function and Caregiver Support Associated With Readmissions During Home Health for Individuals With Dementia.

OBJECTIVE: The purpose of this study was to determine the association between mobility, self-care, cognition, and caregiver support and 30-day potentially preventable readmissions (PPR) for individuals with dementia. DESIGN: This retrospective study derived data from 100% national Centers for Medicare and Medicaid Services data files from July 1, 2013, through June 1, 2015. PARTICIPANTS: Criteria from the Home Health Claims-Based Rehospitalization Measure and the Potentially Preventable 30-Day Post Discharge Readmission Measure for the Home Health Quality Reporting Program were used to identify a cohort of 118,171 Medicare beneficiaries. MAIN OUTCOME MEASURE: The 30-day PPR rates with associated 95% CIs were calculated for each patient characteristic. Multilevel logistic regression was used to study the relationship between mobility, self-care, caregiver support, and cognition domains and 30-day PPR during home health, adjusting for patient demographics and clinical characteristics. RESULTS: The overall rate of 30-day PPR was 7.6%. In the fully adjusted models, patients who were most dependent in mobility (odds ratio [OR], 1.59; 95% CI, 1.47-1.71) and self-care (OR, 1.73; 95% CI, 1.61-1.87) had higher odds for 30-day PPR. Patients with unmet caregiving needs had 1.11 (95% CI, 1.05-1.17) higher odds for 30-day PPR than patients whose caregiving needs were met. Patients with cognitive impairment had 1.23 (95% CI, 1.16-1.30) higher odds of readmission than those with minimal to no cognitive impairment. CONCLUSIONS: Decreased independence in mobility and self-care tasks, unmet caregiver needs, and impaired cognitive processing at admission to home health are associated with risk of 30-day PPR during home health for individuals with dementia. Our findings indicate that deficits in mobility and self-care tasks have the greatest effect on the risk for PPR.

Implementing stratified care for acute low back pain in primary care using the STarT Back instrument: a process evaluation within the context of a large pragmatic cluster randomized trial.

BACKGROUND: Although risk-stratifying patients with acute lower back pain is a promising approach for improving long-term outcomes, efforts to implement stratified care in the US healthcare system have had limited success. The objectives of this process evaluation were to 1) examine variation in two essential processes, risk stratification of patients with low back pain and referral of high-risk patients to psychologically informed physical therapy and 2) identify barriers and facilitators related to the risk stratification and referral processes. METHODS: We used a sequential mixed methods study design to evaluate implementation of stratified care at 33 primary care clinics (17 intervention, 16 control) participating in a larger pragmatic trial. We used electronic health record data to calculate: 1) clinic-level risk stratification rates (proportion of patients with back pain seen in the clinic over the study period who completed risk stratification questionnaires), 2) rates of risk stratification across different points in the clinical workflow (front desk, rooming, and time with clinician), and 3) rates of referral of high-risk patients to psychologically informed physical therapy among intervention clinics. We purposively sampled 13 clinics for onsite observations, which occurred in month 24 of the 26-month study. RESULTS: The overall risk stratification rate across the 33 clinics was 37.8% (range: 14.7-64.7%). Rates were highest when patients were identified as having back pain by front desk staff (overall: 91.9%, range: 80.6-100%). Rates decreased as the patient moved further into the visit (rooming, 29.3% [range: 0-83.3%]; and time with clinician, 11.3% [range: 0-49.3%]. The overall rate of referrals of high-risk patients to psychologically informed physical therapy across the 17 intervention clinics was 42.1% (range: 8.3-70.8%). Barriers included staffs' knowledge and beliefs about the intervention, patients' needs, technology issues, lack of physician engagement, and lack of time. Adaptability of the processes was a facilitator. CONCLUSIONS: Adherence to key stratified care processes varied across primary care clinics and across points in the workflow. The observed variation suggests room for improvement. Future research is needed to build on this work and more rigorously test strategies for implementing stratified care for patients with low back pain in the US healthcare system. TRIAL REGISTRATION: Trial registration: ClinicalTrials.gov ( NCT02647658 ). Registered January 6, 2016.

Functional Status Is Associated With 30-Day Potentially Preventable Readmissions Following Home Health Care.

BACKGROUND: Beginning in 2019, home health agencies' rates of potentially preventable hospital readmissions over the 30 days following discharge will be publicly reported. OBJECTIVES: Our primary objective was to determine the association between patients' functional status at discharge from home health care and 30-day potentially preventable readmissions. A secondary objective was to identify the most common conditions resulting in potentially preventable readmissions. DESIGN: This was a retrospective cohort study. PARTICIPANTS: A total of 1,510,297 Medicare fee-for-service beneficiaries discharged from home health care in 2013-2015. Average age was 75.9 (SD, 10.9) years, 60.0% were female, and 84.2% non-Hispanic white. MEASUREMENTS: Thirty-day potentially preventable readmissions following home health discharge. Functional status measures included mobility, self-care, and impaired cognition. RESULTS: The overall rate of 30-day potentially preventable readmissions was 2.6% (N=39,452), which accounted for 40% of all 30-day readmissions. After adjusting for sociodemographic and clinical characteristics, the odds ratios for the most dependent score quartile versus the most independent was 1.58 [95% confidence interval (CI), 1.53-1.63] for mobility and 1.65 (95% CI, 1.59-1.69) for self-care. The odds ratios for impaired versus intact cognition was 1.21 (95% CI, 1.18-1.24). The 5 most common conditions resulting in a potentially preventable readmission were congestive heart failure (23.6%), septicemia (16.7%), bacterial pneumonia (9.8%), chronic obstructive pulmonary disease (9.4%), and renal failure (7.5%). CONCLUSIONS: Functional limitations at discharge from home health are associated with increased risk for potentially preventable readmissions. Future research is needed to determine whether improving functional independence decreases the risk for potentially preventable readmissions following home health care.

Cortical disconnection of the ipsilesional primary motor cortex is associated with gait speed and upper extremity motor impairment in chronic left hemispheric stroke.

Advances in neuroimaging have enabled the mapping of white matter connections across the entire brain, allowing for a more thorough examination of the extent of white matter disconnection after stroke. To assess how cortical disconnection contributes to motor impairments, we examined the relationship between structural brain connectivity and upper and lower extremity motor function in individuals with chronic stroke. Forty-three participants [mean age: 59.7 (±11.2) years; time poststroke: 64.4 (±58.8) months] underwent clinical motor assessments and MRI scanning. Nonparametric correlation analyses were performed to examine the relationship between structural connectivity amid a subsection of the motor network and upper/lower extremity motor function. Standard multiple linear regression analyses were performed to examine the relationship between cortical necrosis and disconnection of three main cortical areas of motor control [primary motor cortex (M1), premotor cortex (PMC), and supplementary motor area (SMA)] and motor function. Anatomical connectivity between ipsilesional M1/SMA and the (1) cerebral peduncle, (2) thalamus, and (3) red nucleus were significantly correlated with upper and lower extremity motor performance (P ≤ 0.003). M1-M1 interhemispheric connectivity was also significantly correlated with gross manual dexterity of the affected upper extremity (P = 0.001). Regression models with M1 lesion load and M1 disconnection (adjusted for time poststroke) explained a significant amount of variance in upper extremity motor performance (R2  = 0.36-0.46) and gait speed (R2  = 0.46), with M1 disconnection an independent predictor of motor performance. Cortical disconnection, especially of ipsilesional M1, could significantly contribute to variability seen in locomotor and upper extremity motor function and recovery in chronic stroke. Hum Brain Mapp 39:120-132, 2018. © 2017 Wiley Periodicals, Inc.

Same But Different: FIM Summary Scores May Mask Variability in Physical Functioning Profiles.

OBJECTIVE: To examine how similar summary scores of physical functioning using the FIM can represent different patient clinical profiles. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Medicare fee-for-service beneficiaries (N=765,441) discharged from inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We used patients' scores on items of the FIM to quantify their level of independence on both self-care and mobility domains. We then identified patients as requiring "no physical assistance" at discharge from inpatient rehabilitation by using a rule and score-based approach. RESULTS: In those patients with FIM self-care and mobility summary scores suggesting no physical assistance needed, we found that physical assistance was in fact needed frequently in bathroom-related activities (eg, continence, toilet and tub transfers, hygiene, clothes management) and with stairs. It was not uncommon for actual performance to be lower than what may be suggested by a summary score of those domains. CONCLUSIONS: Further research is needed to create clinically meaningful descriptions of summary scores from combined performances on individual items of physical functioning.

Functional Status Is Associated With 30-Day Potentially Preventable Hospital Readmissions After Inpatient Rehabilitation Among Aged Medicare Fee-for-Service Beneficiaries.

OBJECTIVES: To determine the association between patients' functional status at discharge from inpatient rehabilitation and 30-day potentially preventable hospital readmissions. A secondary objective was to examine the conditions resulting in these potentially preventable readmissions. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities submitting claims to Medicare. PARTICIPANTS: National cohort (N=371,846) of inpatient rehabilitation discharges among aged Medicare fee-for-service beneficiaries in 2013 to 2014. The average age was 79.1±7.6 years. Most were women (59.7%) and white (84.5%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: (1) Observed rates and adjusted odds of 30-day potentially preventable hospital readmissions after inpatient rehabilitation and (2) primary diagnoses for readmissions. RESULTS: The overall rate of any 30-day hospital readmission after inpatient rehabilitation was 12.4% (n=46,265), and the overall rate of potentially preventable readmissions was 5.0% (n=18,477). Functional independence was associated with lower observed rates and adjusted odds ratios for potentially preventable readmissions. Observed rates for the highest versus lowest quartiles within each functional domain were as follows: self-care: 3.4% (95% confidence interval [CI], 3.3-3.5) versus 6.9% (95% CI, 6.7-7.1), mobility: 3.3% (95% CI, 3.2-3.4) versus 7.2% (95% CI, 7.0-7.4), and cognition: 3.5% (95% CI, 3.4-3.6) versus 6.2% (95% CI, 6.0-6.4), respectively. Similarly, adjusted odds ratios were as follows: self-care: .70 (95% CI, .67-.74), mobility: .64 (95% CI, .61-.68), and cognition: .84 (95% CI, .80-.89). Infection-related conditions (44.1%) were the most common readmission diagnoses followed by inadequate management of chronic conditions (31.2%) and inadequate management of other unplanned events (24.7%). CONCLUSIONS: Functional status at discharge from inpatient rehabilitation was associated with 30-day potentially preventable readmissions in our sample of aged Medicare beneficiaries. This information may help identify at-risk patients. Future research is needed to determine whether follow-up programs focused on improving functional independence will reduce readmission rates.

Health Services Research in Rehabilitation and Disability-The Time is Now.

Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.

Intrarater and interrater reliability of a hand-held dynamometric technique to quantify palmar thumb abduction strength in individuals with and without carpal tunnel syndrome.

STUDY DESIGN: Clinical measurement. INTRODUCTION: Individuals with carpal tunnel syndrome (CTS) sometimes exhibit weakness of palmar abduction strength (TAS). Reliable assessment of this strength in both subjects with and without CTS with the commonly available Microfet 2 is not known. PURPOSE OF THE STUDY: The purpose of this study was to determine the intrarater and interrater reliabilities of a handheld dynamometric (HHD) method to assess TAS in individuals with and without CTS using the commercially available MicroFET2 and to examine the association between TAS in individuals with CTS and the Carpal Tunnel Symptom Questionnaire (CTSQ) scores. METHODS: In 2 different study phases, individuals with and without CTS were assessed for TAS by 2 different examiners. The CTSQ was administered to the individuals with CTS. RESULTS: Intrarater and interrater reliability coefficients (0.89-0.93 and 0.82-0.90, respectively) were excellent in individuals with and without CTS. Weak negative correlations were found between TAS and overall CTSQ and symptom severity subscale scores, and a moderate negative correlation was found between TAS and functional Status Subscale score. DISCUSSION: This HHD method of reliably assessing TAS better quantifies deficits and progress than traditional manual muscle testing for muscle grades greater than 3/5. CONCLUSION: This method of HHD reliably quantifies TAS but is more reliable with the same than different raters.

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.

Effect of Home- and Community-Based Physical Activity Interventions on Physical Function Among Cancer Survivors: A Systematic Review and Meta-Analysis.

OBJECTIVE: To examine the effect of home- and community-based physical activity interventions on physical functioning among cancer survivors based on the most prevalent physical function measures, randomized trials were reviewed. DATA SOURCES: Five electronic databases-Medline Ovid, PubMed, CINAHL, Web of Science, and PsycINFO-were searched from inception to March 2016 for relevant articles. STUDY SELECTION: Search terms included community-based interventions, physical functioning, and cancer survivors. A reference librarian trained in systematic reviews conducted the final search. DATA EXTRACTION: Four reviewers evaluated eligibility and 2 reviewers evaluated methodological quality. Data were abstracted from studies that used the most prevalent physical function measurement tools-Medical Outcomes Study 36-Item Short-Form Health Survey, Late-Life Function and Disability Instrument, European Organisation for the Research and Treatment of Cancer Quality-of-Life Questionnaire, and 6-minute walk test. Random- or fixed-effects models were conducted to obtain overall effect size per physical function measure. DATA SYNTHESIS: Fourteen studies met inclusion criteria and were used to compute standardized mean differences using the inverse variance statistical method. The median sample size was 83 participants. Most of the studies (n=7) were conducted among breast cancer survivors. The interventions produced short-term positive effects on physical functioning, with overall effect sizes ranging from small (.17; 95% confidence interval [CI], .07-.27) to medium (.45; 95% CI, .23-.67). Community-based interventions that met in groups and used behavioral change strategies produced the largest effect sizes. CONCLUSIONS: Home and community-based physical activity interventions may be a potential tool to combat functional deterioration among aging cancer survivors. More studies are needed among other cancer types using clinically relevant objective functional measures (eg, gait speed) to accelerate translation into the community and clinical practice.

Outcomes Over 90-Day Episodes of Care in Medicare Fee-for-Service Beneficiaries Receiving Joint Arthroplasty.

BACKGROUND: In an effort to improve quality and reduce costs, payments are being increasingly tied to value through alternative payment models, such as episode-based payments. The objective of this study was to better understand the pattern and variation in outcomes among Medicare beneficiaries receiving lower extremity joint arthroplasty over 90-day episodes of care. METHODS: Observed rates of mortality, complications, and readmissions were calculated over 90-day episodes of care among Medicare fee-for-service beneficiaries who received elective knee arthroplasty and elective or nonelective hip arthroplasty procedures in 2013-2014 (N = 640,021). Post-acute care utilization of skilled nursing and inpatient rehabilitation facilities was collected from Medicare files. RESULTS: Mortality rates over 90 days were 0.4% (knee arthroplasty), 0.5% (elective hip arthroplasty), and 13.4% (nonelective hip arthroplasty). Complication rates were 2.1% (knee arthroplasty), 3.0% (elective hip arthroplasty), and 8.5% (nonelective hip arthroplasty). Inpatient rehabilitation facility utilization rates were 6.0% (knee arthroplasty), 6.7% (elective hip arthroplasty), and 23.5% (nonelective hip arthroplasty). Skilled nursing facility utilization rates were 33.9% (knee arthroplasty), 33.4% (elective hip arthroplasty), and 72.1% (nonelective hip arthroplasty). Readmission rates were 6.3% (knee arthroplasty), 7.0% (elective hip arthroplasty), and 19.2% (nonelective hip arthroplasty). Patients' age and clinical characteristics yielded consistent patterns across all outcomes. CONCLUSION: Outcomes in our national cohort of Medicare beneficiaries receiving lower extremity joint arthroplasties varied across procedure types and patient characteristics. Future research examining trends in access to care, resource use, and care quality over bundled episodes will be important for addressing the challenges of value-based payment reform.

Motor and Cognitive Functional Status Are Associated with 30-day Unplanned Rehospitalization Following Post-Acute Care in Medicare Fee-for-Service Beneficiaries.

BACKGROUND: The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood. OBJECTIVE: To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care. DESIGN: This was a retrospective cohort study. SETTING: Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013. PARTICIPANTS: Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406). INTERVENTIONS: Not applicable. MAIN MEASURES: Thirty-day unplanned rehospitalization following post-acute rehabilitation. KEY RESULTS: The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %). CONCLUSIONS: The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care.

Self-Selected Walking Speed is Predictive of Daily Ambulatory Activity in Older Adults.

Daily ambulatory activity is associated with health and functional status in older adults; however, assessment requires multiple days of activity monitoring. The objective of this study was to determine the relative capabilities of self-selected walking speed (SSWS), maximal walking speed (MWS), and walking speed reserve (WSR) to provide insight into daily ambulatory activity (steps per day) in community-dwelling older adults. Sixty-seven older adults completed testing and activity monitoring (age 80.39 [6.73] years). SSWS (R2 = .51), MWS (R2 = .35), and WSR calculated as a ratio (R2 = .06) were significant predictors of daily ambulatory activity in unadjusted linear regression. Cutpoints for participants achieving < 8,000 steps/day were identified for SSWS (≤ 0.97 m/s, 44.2% sensitivity, 95.7% specificity, 10.28 +LR, 0.58 -LR) and MWS (≤ 1.39 m/s, 60.5% sensitivity, 78.3% specificity, 2.79 +LR, 0.50 -LR). SSWS may be a feasible proxy for assessing and monitoring daily ambulatory activity in older adults.

Walking speed: the functional vital sign.

Walking speed (WS) is a valid, reliable, and sensitive measure appropriate for assessing and monitoring functional status and overall health in a wide range of populations. These capabilities have led to its designation as the "sixth vital sign". By synthesizing the available evidence on WS, this scholarly review article provides clinicians with a reference tool regarding this robust measure. Recommendations on testing procedures for assessing WS, including optimal distance, inclusion of acceleration and deceleration phases, instructions, and instrumentation are given. After assessing an individual's WS, clinicians need to know what this value represents. Therefore, WS cut-off values and the corresponding predicted outcomes, as well as minimal detectable change values for specific populations and settings are provided.

Individuals with chronic traumatic brain injury improve walking speed and mobility with intensive mobility training.

OBJECTIVE: To determine the feasibility and impact of different dosages of Intensive Mobility Training (IMT) on mobility, balance, and gait speed in individuals with chronic traumatic brain injury (TBI). DESIGN: Prospective, single group design with 3-month follow-up. SETTING: University research laboratory. PARTICIPANTS: Volunteer sample of participants with chronic TBI (N=10; ≥3 mo post-TBI; able to ambulate 3.05 m with or without assistance; median age, 35.4 y; interquartile range, 23.5-46 y; median time post-TBI, 9.91 y; interquartile range, 6.3-14.2 y). Follow-up data were collected for all participants. INTERVENTIONS: Twenty days (5 d/wk for 4 wk), with 150 min/d of repetitive, task-specific training equally divided among balance; gait training; and strength, coordination, and range. MAIN OUTCOME MEASURES: Pain and fatigue were recorded before and after each session to assess feasibility. Treatment outcomes were assessed before training (pre), after 10 sessions (interim), after 20 sessions (post), and at 3-months follow-up and included the Berg Balance Scale and gait speed. RESULTS: Participants averaged 150.1±2.7 minutes per session. Median presession and postsession pain scores were 0 (out of 10) for 20 sessions; median presession fatigue scores ranged from 0 to 2.5 (out of 10); and postsession scores ranged from 3 to 5.5 (out of 10). Four outcome measures demonstrated significant improvement from the pretest to interim, with 7 out of 10 participants exceeding the minimal detectable change (MDC) for fast walking speed. At the posttest, 2 additional measures were significant, with more participants exceeding the MDCs. Changes in fast walking speed and Timed Up and Go test were significant at follow-up. CONCLUSIONS: Limited fluctuations in pain and fatigue scores indicate feasibility of IMT in this population. Participants demonstrated improvements in walking speed, mobility, and balance postintervention and maintained gains in fast walking speed and mobility at 3 months.

Body weight-supported treadmill training is no better than overground training for individuals with chronic stroke: a randomized controlled trial.

BACKGROUND: Body weight-supported treadmill training (BWSTT) has produced mixed results compared with other therapeutic techniques. OBJECTIVE: The purpose of this study was to determine whether an intensive intervention (intensive mobility training) including BWSTT provides superior gait, balance, and mobility outcomes compared with a similar intervention with overground gait training in place of BWSTT. METHODS: Forty-three individuals with chronic stroke (mean [SD] age, 61.5 [13.5] years; mean [SD] time since stroke, 3.3 [3.8] years), were randomized to a treatment (BWSTT, n = 23) or control (overground gait training, n = 20) group. Treatment consisted of 1 hour of gait training; 1 hour of balance activities; and 1 hour of strength, range of motion, and coordination for 10 consecutive weekdays (30 hours). Assessments (step length differential, self-selected and fast walking speed, 6-minute walk test, Berg Balance Scale [BBS], Dynamic Gait Index [DGI], Activities-specific Balance Confidence [ABC] scale, single limb stance, Timed Up and Go [TUG], Fugl-Meyer [FM], and perceived recovery [PR]) were conducted before, immediately after, and 3 months after intervention. RESULTS: No significant differences (α = 0.05) were found between groups after training or at follow-up; therefore, groups were combined for remaining analyses. Significant differences (α = 0.05) were found pretest to posttest for fast walking speed, BBS, DGI, ABC, TUG, FM, and PR. DGI, ABC, TUG, and PR results remained significant at follow-up. Effect sizes were small to moderate in the direction of improvement. CONCLUSIONS: Future studies should investigate the effectiveness of intensive interventions of durations greater than 10 days for improving gait, balance, and mobility in individuals with chronic stroke.