Rasch Analysis of Social Attitude Barriers and Facilitators to Participation for Individuals with Disabilities.

OBJECTIVES: To develop item banks of social attitude barriers and facilitators to participation and validate them with established instruments. DESIGN: We used the Rasch model to identify misfitting items and rating scale problems, calibrate items, and develop KeyForms and short forms. Correlations between the Social Attitude Barriers and Facilitators item banks with the Patient-Reported Outcomes Measurement Information System (PROMIS) Social Health domain and National Institutes of Health Toolbox Emotional Battery Social Relationships domain were computed to evaluate convergent and divergent validity. SETTING: Community-dwelling individuals traveled to 3 academic medical centers for testing. PARTICIPANTS: Participants (N=558) who had a primary impairment of stroke, spinal cord injury, or traumatic brain injury (mean age, 47.0±16.0y) completed 31 social attitude facilitator and 51 barrier items using a 5-point rating scale. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Item banks to measure social attitude barriers and facilitators for individuals with disabilities. RESULTS: After combining the "never" and "rarely" rating scale categories, 30 Facilitator items fit the Rasch model and demonstrated person reliability of 0.93. After collapsing the "never" and "rarely" rating scale categories, 45 Barrier items fit the Rasch model and demonstrated person reliability of 0.95. Ceiling and floor effects were negligible for both item banks. Facilitators and Barriers item banks were negatively correlated, and these banks were moderately correlated with PROMIS and Toolbox measures, providing evidence of convergent and divergent validity. CONCLUSIONS: Findings support the reliability and validity of the Social Attitude Facilitators and Barriers item banks. These item banks allow investigators and clinicians to measure perceptions of social attitudes, providing information that can guide individual interventions to reduce barriers and promote facilitators. Moderate correlations between the Social Attitude banks and PROMIS and Toolbox variables provide support for the measurement and theory of environmental influences on social health and participation.

Inpatient Rehabilitation Quality of Care From the Patient's Perspective: Effect of Data Collection Timing and Patient Characteristics.

OBJECTIVE: To compare, by collection time and patient characteristics, inpatient rehabilitation quality measure scores calculated using patient-reported data. DESIGN: Cohort study of rehabilitation inpatients with neurologic conditions who reported their experience of care and pain status at discharge and 1month after discharge. SETTING: Two inpatient rehabilitation facilities (IRFs). PARTICIPANTS: Patients with neurologic conditions (N=391). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We calculated 18 quality measure scores using participants' responses to 55 experience of care and health status questions addressing communication, support and encouragement, care coordination, discharge information, goals, new medications, responsiveness of staff, cleanliness, quietness, pain management, care transitions, overall hospital rating, willingness to recommend, and pain. RESULTS: Of the 391 participants reporting at discharge, 277 (71%) also reported postdischarge after multiple attempts by e-mail, mail, and telephone. Discharge experience of care quality scores ranged from 25% (responsiveness of hospital staff) to 75% (willingness to recommend hospital); corresponding postdischarge scores were 32% to 87%, respectively. Five of the 16 experience of care quality scores increased significantly between discharge and postdischarge. The percentage of participants reporting high pain levels at discharge did not change across time periods. Patients with less education, older age, higher motor and cognitive function, and those who were not Hispanic or black had more favorable quality measure scores. CONCLUSION: Patients' experience of care responses tended to be more favorable after discharge compared to discharge, suggesting that survey timing is important. Responses were more favorable for patients with selected characteristics, suggesting the possible need for risk adjustment if patient-reported quality measure scores are compared across IRFs.

Mobility Device Quality Affects Participation Outcomes for People With Disabilities: A Structural Equation Modeling Analysis.

OBJECTIVE: To test the effect that indicators of mobility device quality have on participation outcomes in community-dwelling adults with spinal cord injury, traumatic brain injury, and stroke by using structural equation modeling. DESIGN: Survey, cross-sectional study, and model testing. SETTING: Clinical research space at 2 academic medical centers and 1 free-standing rehabilitation hospital. PARTICIPANTS: Community-dwelling adults (N=250; mean age, 48±14.3y) with spinal cord injury, traumatic brain injury, and stroke. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: The Mobility Device Impact Scale, Patient-Reported Outcomes Measurement Information System Social Function (version 2.0) scale, including Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities, and the 2 Community Participation Indicators' enfranchisement scales. Details about device quality (reparability, reliability, ease of maintenance) and device type were also collected. RESULTS: Respondents used ambulation aids (30%), manual (34%), and power wheelchairs (30%). Indicators of device quality had a moderating effect on participation outcomes, with 3 device quality variables (repairability, ease of maintenance, device reliability) accounting for 20% of the variance in participation. Wheelchair users reported lower participation enfranchisement than did ambulation aid users. CONCLUSIONS: Mobility device quality plays an important role in participation outcomes. It is critical that people have access to mobility devices and that these devices be reliable.

Relationships between environmental factors and participation in adults with traumatic brain injury, stroke, and spinal cord injury: a cross-sectional multi-center study.

PURPOSE: To develop and evaluate a model of environmental factors-participation relationships for persons with traumatic brain injury (TBI), stroke, and spinal cord injury (SCI), and test whether this model differed across three diagnostic groups, as well as other demographic and clinical characteristics. METHODS: A cross-sectional observational study included 545 community-dwelling adults with neurological disorders (TBI = 166; stroke = 189; SCI = 190) recruited at three academic medical centers. Participants completed patient-reported measures of environmental factors and participation. RESULTS: The final structural equation model had acceptable fit to the data (CFI = 0.923; TLI = 0.898; RMSEA = 0.085; SRMR = 0.053), explaining 63% of the variance in participation in social roles and activities. Systems, services, and policies had an indirect influence on participation and this relation was mediated by social attitudes and the built and natural environment. Access to information and technology was associated with the built and natural environment which in turn influence on participation (ps < 0.001). The model was consistent across sex, diagnosis, severity/type of injury, education, race, age, marital status, years since injury, wheelchairs use, insurance coverage, personal or household income, and crystallized cognition. CONCLUSIONS: Social and physical environments appear to mediate the influence of systems, services, and policies on participation after acquired neurological disorders. These relations are stable across three diagnostic groups and many personal and clinical factors. Our findings inform health and disability policy, and provide guidance for implementing the initiatives in Healthy People 2020 in particular for people with acquired neurological disorders.

Using the ICF's environmental factors framework to develop an item bank measuring built and natural environmental features affecting persons with disabilities.

OBJECTIVES: To develop a measure of natural environment and human-made change features (Chapter 2 of the international classification of functioning, disability, and health) and evaluate the influence of perceived barriers on health-related quality of life. METHODS: A sample of 570 adults with stroke, spinal cord injury, and traumatic brain injury residing in community settings reported their functioning in home, outdoor, and community settings (mean age = 47.0 years, SD = 16.1). They rated 18 items with a 5-point rating scale to describe the influence of barriers to moving around, seeing objects, hearing sounds, hearing conversations, feeling safe, and regulating temperature and indicated whether any difficulties were due to environmental features. We used Rasch analysis to identify misfitting items and evaluate differential item functioning (DIF) across impairment groups. We computed correlations between barriers and patient-reported outcomes measurement information system (PROMIS) social domain measures and community participation indicators (CPI) measures. RESULTS: The 18 items demonstrated person reliability of .70, discriminating nearly three levels of barriers. All items fit the Rasch model; impairment-related DIF was negligible. Ceiling effects were negligible, but 25 % of the respondents were at the floor, indicating that they did not experience barriers that they attributed to the built and natural environment. As anticipated, barriers correlated moderately with PROMIS and CPI variables, suggesting that although this new item bank measures a construct that is related to participation and health-related quality of life, it also captures something unique. Known-groups validity was supported by wheelchair users reporting a higher level of barriers than did ambulatory respondents. CONCLUSIONS: Preliminary evidence supports the reliability and validity of this new measure of barriers to the built and natural environment. This measure allows investigators and clinicians to measure perceptions of the natural environment and human-made changes, providing information that can guide interventions to reduce barriers. Moderate relationships between barriers and PROMIS and CPI variables provide support for the measurement and theory of environmental influences on social health and participation.

Perceptions of Person-Centered Care Following Spinal Cord Injury.

OBJECTIVES: To (1) evaluate perceptions of person-centered care (PCC) in individuals with traumatic spinal cord injury (SCI); and (2) examine perceived differences in PCC concepts between patients continuing to receive any services from a Spinal Cord Injury Model Systems (SCIMS) facility and those who are not. DESIGN: We used a cross-sectional design, mailed a paper survey, and followed up with a second mailing to nonrespondents after 4 weeks. SETTING: Community. PARTICIPANTS: Individuals (N=326) who received initial rehabilitation at an SCIMS facility and agreed to participate in this research study. We distinguished respondents who received any SCIMS outpatient services in the past 2 years (SCIMS users, n=137) or longer ago (SCIMS nonusers, n=189). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed the Patient Activation Measure (PAM), the Patient Assessment of Chronic Illness Care, the Global Practice Experience measure, and 5 Press-Ganey questions that assessed key elements of patient- and family-centered care. RESULTS: Patient perspectives of chronic illness care were more positive in the SCIMS users than nonusers (3.15 vs 2.91, P<.05); the difference is attributable primarily to higher subscale scores on goal setting and tailoring. The SCIMS users and nonusers did not differ in terms of PAM overall score or activation stage, Global Practice Experience, or Press-Ganey scores. CONCLUSIONS: SCIMS users and nonusers differed on perceptions of chronic illness care (largely the goal-setting and tailoring component), which were more favorable for Model System users than nonusers. Results can guide strategies to enhance PCC practices after inpatient rehabilitation.

Measuring Access to Information and Technology: Environmental Factors Affecting Persons With Neurologic Disorders.

OBJECTIVE: To develop and validate a patient-reported measure of access to information and technology (AIT) for persons with spinal cord injury, stroke, or traumatic brain injury. DESIGN: A mixed-methods approach was used to develop items, refine them through cognitive interviews, and evaluate their psychometric properties. Item responses were evaluated with the Rasch rating scale model. Correlational and analysis-of-variance methods were used to evaluate construct validity. SETTING: Community-dwelling individuals participated in telephone interviews or traveled to the academic medical centers where this research took place. PARTICIPANTS: Individuals with a diagnosis of spinal cord injury, stroke, or traumatic brain injury (aged ≥18y, English speaking) participated in cognitive interviews (n=12 persons), field testing of the items (n=305 persons), and validation testing of the final set of items (n=604 persons). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A set of items to measure AIT for people with disabilities. RESULTS: A user-friendly multimedia touchscreen was used for self-administration of the items. A 23-item AIT measure demonstrated good evidence of internal consistency reliability, and content and construct validity. CONCLUSIONS: This new AIT measure will enable researchers and clinicians to determine to what extent environmental factors influence health outcomes and social participation in people with disabilities. The AIT measure could also provide disability advocates with more specific and detailed information about environmental factors to lobby for elimination of barriers.

An Item Bank to Measure Systems, Services, and Policies: Environmental Factors Affecting People With Disabilities.

OBJECTIVES: To develop a measure of perceived systems, services, and policies facilitators (see Chapter 5 of the International Classification of Functioning, Disability and Health) for people with neurologic disabilities and to evaluate the effect of perceived systems, services, and policies facilitators on health-related quality of life. DESIGN: Qualitative approaches to develop and refine items. Confirmatory factor analysis including 1-factor confirmatory factor analysis and bifactor analysis to evaluate unidimensionality of items. Rasch analysis to identify misfitting items. Correlational and analysis of variance methods to evaluate construct validity. SETTING: Community-dwelling individuals participated in telephone interviews or traveled to the academic medical centers where this research took place. PARTICIPANTS: Participants (N=571) had a diagnosis of spinal cord injury, stroke, or traumatic brain injury. They were 18 years or older and English speaking. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: An item bank to evaluate environmental access and support levels of services, systems, and policies for people with disabilities. RESULTS: We identified a general factor defined as "access and support levels of the services, systems, and policies at the level of community living" and 3 local factors defined as "health services," "community living," and "community resources." The systems, services, and policies measure correlated moderately with participation measures: Community Participation Indicators (CPI) - Involvement, CPI - Control over Participation, Quality of Life in Neurological Disorders - Ability to Participate, Quality of Life in Neurological Disorders - Satisfaction with Role Participation, Patient-Reported Outcomes Measurement Information System (PROMIS) Ability to Participate, PROMIS Satisfaction with Role Participation, and PROMIS Isolation. CONCLUSIONS: The measure of systems, services, and policies facilitators contains items pertaining to health services, community living, and community resources. Investigators and clinicians can measure perceptions of systems, services, and policies resources reliably with the items described here. Moderate relations between systems, services, and policies facilitators and PROMIS and CPI variables provide support for the measurement and theory of environmental effects on social functioning related to participation.

Measuring Environmental Factors: Unique and Overlapping International Classification of Functioning, Disability and Health Coverage of 5 Instruments.

OBJECTIVES: To describe the unique and overlapping content of the newly developed Environmental Factors Item Banks (EFIB) and 7 legacy environmental factor instruments, and to evaluate the EFIB's construct validity by examining associations with legacy instruments. DESIGN: Cross-sectional, observational cohort. SETTING: Community. PARTICIPANTS: A sample of community-dwelling adults with stroke, spinal cord injury, and traumatic brain injury (N=568). INTERVENTIONS: None. MAIN OUTCOME MEASURES: EFIB covering domains of the built and natural environment; systems, services, and policies; social environment; and access to information and technology; the Craig Hospital Inventory of Environmental Factors (CHIEF) short form; the Facilitators and Barriers Survey/Mobility (FABS/M) short form; the Home and Community Environment Instrument (HACE); the Measure of the Quality of the Environment (MQE) short form; and 3 of the Patient Reported Outcomes Measurement Information System's (PROMIS) Quality of Social Support measures. RESULTS: The EFIB and legacy instruments assess most of the International Classification of Functioning, Disability and Health (ICF) environmental factors chapters, including chapter 1 (products and technology; 75 items corresponding to 11 codes), chapter 2 (natural environment and human-made changes; 31 items corresponding to 7 codes), chapter 3 (support and relationships; 74 items corresponding to 7 codes), chapter 4 (attitudes; 83 items corresponding to 8 codes), and chapter 5 (services, systems, and policies; 72 items corresponding to 16 codes). Construct validity is provided by moderate correlations between EFIB measures and the CHIEF, MQE barriers, HACE technology mobility, FABS/M community built features, and PROMIS item banks and by small correlations with other legacy instruments. Only 5 of the 66 legacy instrument correlation coefficients are moderate, suggesting they measure unique aspects of the environment, whereas all intra-EFIB correlations were at least moderate. CONCLUSIONS: The EFIB measures provide a brief and focused assessment of ICF environmental factor chapters. The pattern of correlations with legacy instruments provides initial evidence of construct validity.

Agreement Between Responses From Community-Dwelling Persons With Stroke and Their Proxies on the NIH Neurological Quality of Life (Neuro-QoL) Short Forms.

OBJECTIVE: To examine agreement between patient and proxy responses on the Quality of Life in Neurological Disorders (Neuro-QoL) instruments after stroke. DESIGN: Cross-sectional observational substudy of the longitudinal, multisite, multicondition Neuro-QoL validation study. SETTING: In-person, interview-guided, patient-reported outcomes. PARTICIPANTS: Convenience sample of dyads (N=86) of community-dwelling persons with stroke and their proxy respondents. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Dyads concurrently completed short forms of 8 or 9 items for the 13 Neuro-QoL adult domains using the patient-proxy perspective. Agreement was examined at the scale-level with difference scores, intraclass correlation coefficients (ICCs), effect size statistics, and Bland-Altman plots, and at the item-level with kappa coefficients. RESULTS: We found no mean differences between patients and proxies on the Applied Cognition-General Concerns, Depression, Satisfaction With Social Roles and Activities, Stigma, and Upper Extremity Function (Fine Motor, activities of daily living) short forms. Patients rated themselves more favorably on the Applied Cognition-Executive Function, Ability to Participate in Social Roles and Activities, Lower Extremity Function (Mobility), Positive Affect and Well-Being, Anxiety, Emotional and Behavioral Dyscontrol, and Fatigue short forms. The largest mean patient-proxy difference observed was 3 T-score points on the Lower Extremity Function (Mobility). ICCs ranged from .34 to .59. However, limits of agreement showed dyad differences exceeding ±20 T-score points, and item-level agreement ranged from not significant to weighted kappa=.34. CONCLUSIONS: Proxy responses on Neuro-QoL short forms can complement responses of moderate- to high-functioning community-dwelling persons with stroke and augment group-level analyses, but do not substitute for individual patient ratings. Validation is needed for other stroke populations.

Feasibility of computerized adaptive testing for collection of patient-reported outcomes after inpatient rehabilitation.

OBJECTIVE: To evaluate the feasibility of computer adaptive testing (CAT) using an Internet or telephone interface to collect patient-reported outcomes after inpatient rehabilitation and to examine patient characteristics associated with completion of the CAT-administered measure and mode of administration. DESIGN: Prospective cohort study of patients contacted approximately 4 weeks after discharge from inpatient rehabilitation. Patients selected an Internet or telephone interface. SETTING: Rehabilitation hospital. PARTICIPANTS: Patients (N=674) with diagnoses of neurologic, orthopedic, or medically complex conditions. INTERVENTIONS: None. MAIN OUTCOME MEASURE: CAT version of the Community Participation Indicators (CAT-CPI). RESULTS: From an eligible pool of 3221 patients, 674 (21%) agreed to complete the CAT-CPI. Patients who agreed to complete the CAT-CPI were younger and reported slightly higher satisfaction with overall care than those who did not participate. Among these patients, 231 (34%) actually completed the CAT-CPI; 141 (61%) selected telephone administration, and 90 (39%) selected Internet administration. Decreased odds of completing the CAT-CPI were associated with black and other race; stroke, brain injury, or orthopedic and other impairments; and being a Medicaid beneficiary, whereas increased odds of completing the CAT-CPI were associated with longer length of stay and higher discharge FIM cognition measure. Decreased odds of choosing Internet administration were associated with younger age, retirement status, and being a woman, whereas increased odds of choosing Internet administration were associated with higher discharge FIM motor measure. CONCLUSIONS: CAT administration by Internet and telephone has limited feasibility for collecting postrehabilitation outcomes for most rehabilitation patients, but it is feasible for a subset of patients. Providing alternative ways of answering questions helps assure that a larger proportion of patients will respond.

Fast, Reliable, and Simple Point-of-Care-like Adaptation of RT-qPCR for the Detection of SARS-CoV-2 for Use in Hospital Emergency Departments.

During COVID-19 pandemics, the availability of testing has often been a limiting factor during patient admissions into the hospital. To circumvent this problem, we adapted an existing diagnostic assay, Seegene Allplex SARS-CoV-2, into a point-of-care-style direct qPCR (POC dqPCR) assay and implemented it in the Emergency Department of Clinical Hospital Center Rijeka, Croatia. In a 4-month analysis, we tested over 10,000 patients and demonstrated that POC-dqPCR is robust and reliable and can be successfully implemented in emergency departments and similar near-patient settings and can be performed by medical personnel with little prior experience in qPCR.

Feasibility of Collecting Patient-Reported Outcomes for Inpatient Rehabilitation Quality Reporting.

OBJECTIVE: To evaluate rehabilitation inpatients' willingness and ability to complete patient-reported outcomes (PROs) and the burden of completion on patients and staff. DATA SOURCES/STUDY SETTING: Two inpatient rehabilitation facilities. STUDY DESIGN: Patients with neurological disorders were assigned randomly to receive a nominal monetary incentive during or 1 month after the stay. DATA COLLECTION: Patients responded using a tablet computer or paper. PRINCIPAL FINDINGS: Of the 1,055 admissions, 74 percent were eligible, and 51 percent of eligible patients completed the survey. Most answered without assistance. A majority completed the survey 1 month after discharge; incentive timing was unrelated to postdischarge completion. Half of the 285 follow-up respondents required at least two reminder calls. CONCLUSIONS: Collection of PROs from rehabilitation patients is feasible. Results inform policy makers regarding feasibility of PRO data in evaluating rehabilitation quality.

Relational empathy and holistic care in persons with spinal cord injuries.

OBJECTIVE: Describe perceptions of persons with SCI on their receipt of holistic care and relational empathy during health care encounters. DESIGN: Mailed survey. PARTICIPANTS/SETTING: Individuals with SCI who received care from the largest suppliers of SCI care and rehabilitation (Veterans Health Administration and SCI Model Systems). OUTCOME MEASURES: Using a survey and administrative databases, we collected demographic and injury characteristics, health status, health conditions, and the main outcome: Consultation and Relational Empathy (CARE) measure. RESULTS: The sample included 450 individuals with SCI (124 Veterans and 326 civilians). Response rate was 39% (450/1160). Analyses were conducted on patients with complete data (n = 389). Veterans and civilians with SCI differed across many demographic characteristics, age at injury, and etiology, but mean CARE scores were equivalent. Fewer than half of the full SCI cohort had CARE scores above the normative value of 43. Having a recent pressure ulcer showed a trend for lower odds of having a normative or higher CARE score. Odds of having an above-normative CARE score were nearly 2 times greater for individuals with tetraplegia, and odds were higher for those with higher physical and mental health status. CONCLUSIONS: Higher physical and mental health status and tetraplegia were each independently associated with greater perceptions of holistic care and empathy in the therapeutic patient-provider relationship. Limited empathy, communication, and holistic care may arise when providers focus on disease/disease management, rather than on patients as individuals. Frequent health care use and secondary conditions may affect empathy and holistic care in encounters, making it essential to understand and employ efforts to improve the therapeutic relationship between patients with SCI and their providers.

Health and Functional Literacy in Physical Rehabilitation Patients.

BACKGROUND: People with disabilities, who face multiple barriers to care, experience health disparities, yet few studies have measured health literacy in this population. OBJECTIVE: This study evaluated functional literacy, health literacy, fluid cognitive function, and self-reported health in people who live in community dwellings with spinal cord injury, stroke, or traumatic brain injury. METHODS: Participants with a traumatic spinal cord injury, stroke, or traumatic brain injury, one-year postinjury, and age 18 to 85 years, completed a battery of instruments at three medical centers in the Midwestern U.S.: functional literacy (word recognition, vocabulary knowledge), health literacy (comprehension of prose, document, and quantitative health information), fluid cognitive function (memory, executive function, and processing speed), and patient-reported outcomes (mobility, fatigue, sadness, anxiety, social function, and overall health). KEY RESULTS: There were strong correlations between functional literacy, health literacy, and fluid cognitive function. After adjustment for sociodemographic and clinical characteristics, higher health literacy was associated with better mobility, less anxiety, and better overall health; higher functional literacy was associated with less anxiety and better overall health; and higher fluid cognitive function was associated with better mobility, less sadness, better social function, and better overall health. CONCLUSIONS: To effectively address limited health literacy among people with spinal cord injury, stroke, and traumatic brain injury, and ensure that they are able to be informed partners in their health care, intervention is required at the level of patients, providers, and health care delivery systems. A special consideration is to ensure that health information is both well-targeted to people's health literacy levels and accessible for people with a range of physical, cognitive, and sensory limitations. The multimedia self-administered health literacy measure used in this study could be useful to rehabilitation providers and designers of health information and interfaces. [Health Literacy Research and Practice. 2017;1(2):e71-e85.]. PLAIN LANGUAGE SUMMARY: Health literacy represents people's abilities to obtain, understand, and use health information to make informed decisions about their health and health care. People with disabilities face physical, attitudinal, economic, and structural barriers to care. Consideration of health literacy in rehabilitation practice can enhance the effectiveness of the patient-clinician relationship and help address the needs of this population.

Perceptions of Shared Decision Making Among Patients with Spinal Cord Injuries/Disorders.

Background: Individuals with spinal cord injuries/disorders (SCI/D) are interested in, and benefit from, shared decision making (SDM). Objective: To explore SDM among individuals with SCI/D and how demographics and health and SCI/D characteristics are related to SDM. Method: Individuals with SCI/D who were at least 1 year post injury, resided in the Chicago metropolitan area, and received SCI care at a Veterans Affairs (VA; n = 124) or an SCI Model Systems facility (n = 326) completed a mailed survey measuring demographics, health and SCI/D characteristics, physical and mental health status, and perceptions of care, including SDM, using the Combined Outcome Measure for Risk Communication and Treatment Decision-Making Effectiveness (COMRADE) that assesses decision-making effectiveness (effectiveness) and risk communication (communication). Bivariate analyses and multiple linear regression were used to identify variables associated with SDM. Results: Participants were mostly male (83%) and White (70%) and were an average age of 54 years (SD = 14.3). Most had traumatic etiology, 44% paraplegia, and 49% complete injury. Veteran/civilian status and demographics were unrelated to scores. Bivariate analyses showed that individuals with tetraplegia had better effectiveness scores than those with paraplegia. Better effectiveness was correlated with better physical and mental health; better communication was correlated with better mental health. Multiple linear regressions showed that tetraplegia, better physical health, and better mental health were associated with better effectiveness, and better mental health was associated with better communication. Conclusion: SCI/D and health characteristics were the only variables associated with SDM. Interventions to increase engagement in SDM and provider attention to SDM may be beneficial, especially for individuals with paraplegia or in poorer physical and mental health.