Spillover effect of the Patient Drive Payment Model on skilled nursing facility therapy delivery among Medicare Advantage enrollees.

In a multi-payer health care system, economic theory suggests that different payers can impose spillover effects on one another. This study aimed to evaluate the spillover effect of the Patient Driven Payment Model (PDPM) on Medicare Advantage (MA) enrollees, despite it being designed for Traditional Medicare (TM) beneficiaries. We applied a regression discontinuity approach by comparing therapy utilization before and after the implementation of PDPM in October 2019 focusing on patients newly admitted to skilled nursing facilities. The results showed that both TM and MA enrollees experienced a decrease in individual therapy minutes and an increase in non-individual therapy minutes. The estimated reduction in total therapy use was 9 min per day for TM enrollees and 3 min per day for MA enrollees. The effect of PDPM on MA beneficiaries varied depending on the level of MA penetration, with the smallest effect in facilities with the highest MA penetration quartile. In summary, the PDPM had directionally similar effects on therapy utilization for both TM and MA enrollees, but the magnitudes were smaller for MA beneficiaries. These results suggest that policy changes intended for TM beneficiaries may spillover to MA enrollees and should be assessed accordingly.

Initial treatment approaches and healthcare utilization among veterans with low back pain: a propensity score analysis.

BACKGROUND: Opioid prescriptions for Veterans with low back pain (LBP) persist despite the availability of PT, a lower medical risk treatment option. Patterns of treatment and subsequent healthcare utilization for Veterans with LBP are unknown. The purpose of this study was to evaluate the association of physical therapy (PT) and opioids and outcomes of spinal surgery and chronic opioid use for Veterans with incident LBP. METHODS: We conducted a retrospective cohort study identifying Veterans with a new diagnosis of LBP using ICD codes from the Veterans Administration national database from 2012 to 2017. Veterans were classified into three treatment groups based on the first treatment received within 30 days of incident LBP: receipt of PT, opioids, or neither PT nor opioids. Outcomes, events of spinal surgery and chronic opioid use, were identified beginning on day 31 up to one year following initial treatment. We used propensity score matching to account for the potential selection bias in evaluating the associations between initial treatment and outcomes. RESULTS: There were 373,717 incident cases of LBP between 2012 and 2017. Of those 28,850 (7.7%) received PT, 48,978 (13.1%) received opioids, and 295,889 (79.2%) received neither PT or opioids. Pain, marital status and the presence of cardiovascular, pulmonary, or metabolic chronic conditions had the strongest statistically significant differences between treatment groups. Veterans receiving opioids compared to no treatment had higher odds of having a spinal surgery (2.04, 99% CI: 1.67, 2.49) and progressing to chronic opioid use (11.8, 99% CI: 11.3, 12.3). Compared to Veterans receiving PT those receiving opioids had higher odds (1.69, 99% CI: 1.21, 2.37) of having spinal surgery and progressing to chronic opioid use (17.8, 99% CI: 16.0, 19.9). CONCLUSION: Initiating treatment with opioids compared to PT was associated with higher odds of spinal surgery and chronic opioid use for Veterans with incident LBP. More Veterans received opioids compared to PT as an initial treatment for incident LBP. Our findings can inform rehabilitation care practices for Veterans with incident LBP.

Psychometric evaluation of the Southampton hand assessment procedure (SHAP) in a sample of upper limb prosthesis users.

BACKGROUND: The 26-item Southampton Hand Assessment Protocol (SHAP) is a test of prosthetic hand function that generates an Index of Functionality (IOF), and prehensile pattern (PP) scores. Prior researchers identified potential issues in SHAP scoring, proposing alternative scoring methods (LIF and W-LIF). STUDY DESIGN: Cross-sectional study. PURPOSE: Evaluate the psychometric properties of the SHAP IOF, LIF, and W-LIF and PP scores and develop the Prosthesis Index of Functionality (P-IOF). METHODS: We examined item completion, floor andceiling effects, concurrent, discriminant, construct and structural validity. The P-IOF used increased boundary limits and information from item completion and completion time. Calibration used a nonlinear mixed model. Scores were estimated using maximum a posteriori Bayesian estimation. Mixed integer linear programing (MILP) informed development of a shorter measure. Validity analyses were repeated using the P-IOF. RESULTS: 126 persons, mean age 57 (sd 15.8), 69% with transradial amputation were included. Floors effects were observed in 18.3%-19.1% for the IOF, LIF, and W-LIF. Ten items were not completed by >15% of participants. Boundary limits were problematic for all but 1 item. Correlations with dexterity measures were strong (r =  0.54-0.73). Scores differed by amputation level (p > .0001). Factor analysis did not support use of PP scores. The P-IOF used expanded boundary limits to decrease floor effects. MILP identified 10 items that could be dropped. The 26-item P-IOF and 16-item P-IOF had reduced floor effects (<7.5%), strong evidence of concurrent and discriminant validity, and construct validity. P-IOF reduced administrative burden by 9.5 (sd 5.6) minutes. DISCUSSION: Floor effects limit a measure's ability to distinguish between persons with low function. CONCLUSION: Analyses supported the validity of the SHAP IOF, LIF, and W-LIF, but identified large floor effects, as well as issues with structural validity of the PP scores. The 16-item P-IOF minimizes floor effects and reduces administrative burden.

Measuring Satisfaction With Upper Limb Prostheses: Orthotics and Prosthetics User Survey Revision That Includes Issues of Concern to Women.

OBJECTIVE: To (1) modify the Orthotics and Prosthetics User Survey (OPUS) Client Satisfaction with Device (CSD) instrument to incorporate issues of concern to women and (2) evaluate measure's structural and concurrent validity and reliability in persons with upper limb amputation (ULA). DESIGN: Cross-sectional survey study with retest after 2 weeks. Exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and Rasch analyses were used to select items and examine differential item functioning, range of coverage, and person and item reliability. Test-retest reliability was evaluated with intraclass correlation coefficients. Pearson correlations were used to estimate associations with other prosthesis satisfaction measures. SETTING: Telephone administered survey. PARTICIPANTS: Convenience sample of 468 participants in the US (N=468; 19.9% women) with ULA, including a 50-person retest subsample (4% female). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Modified OPUS CSD. RESULTS: EFA suggested 3 subscales: Comfort, Appearance, and Utility. CFA found acceptable model fit. After dropping items with poor fit and high pairwise correlations in Rasch partial credit models, CFA model fit indices were acceptable (comparative fit index=0.959, Tucker-Lewis Index=0.954, root mean square error of approximation=0.082). Rasch person reliability was 0.62 (Utility), 0.77 (Appearance), and 0.82 (Comfort). Cronbach α was 0.81, 87, and 0.71 for Comfort and Appearance, and Utility subscales, respectively. Correlations between the modified CSD, the original CSD, and the Trinity Amputation and Prosthesis Experience Satisfaction Scale were 0.54-0.94. CONCLUSIONS: We identified 3 subscales: Comfort (6 items), Appearance (8 items), and Utility (4 items) with 7 new items identified as important to women. The subscales demonstrate evidence of sound concurrent structural and test-retest reliability and concurrent validity. The Appearance and Comfort subscales have good reliability for group-level use in clinical and research applications, whereas the Utility subscale had poor to fair person reliability but excellent item reliability.

Self-reported measures of limitation in physical function in late midlife are associated with incident Alzheimer's disease and related dementias.

BACKGROUND: Even small improvements in modifiable Alzheimer's disease and related dementias (ADRD) risk factors could lead to a substantial reduction of dementia cases. AIMS: To determine if self-reported functional limitation associates with ADRD symptoms 4-18 years later. METHODS: We conducted a prospective longitudinal study using the Health and Retirement Study of adults aged 51-59 years in 1998 without symptoms of ADRD by 2002 and followed them to 2016. Main exposure variables were difficulty with activities of daily living, mobility, large muscle strength, gross motor and upper limb activities. The outcome was incident ADRD identified by the Lange-Weir algorithm, death, or alive without ADRD. We fit two GEE multinomial models for each measure: (1) baseline measure of function and (2) change in function over time. RESULTS: In the model with baseline only and outcome, only difficulty with mobility associated with future ADRD across levels of difficulty with near dose-response effect (risk ratios (RR) difficulty with 1-5 functions respectively, compared with no difficulty: 1.82; 2.70; 1.73 2.81; 4.03). Mobility also significantly associated with ADRD when allowing for change over time among those with 3, 4 or 5 versus no mobility limitations (RR 1.76; 2.36; 2.37). DISCUSSION: The results infer that an adult in midlife reporting difficulty with mobility as well as those with no mobility limitations in midlife but who later report severe limitations may be at increased risk of incident ADRD. CONCLUSIONS: Self-reported measures of mobility limitation may be early indicators of ADRD and may be useful for public health planning.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury in Skilled Nursing Facilities.

OBJECTIVE: To identify patient, injury, and functional status characteristics associated with successful discharge to the community following a skilled nursing facility (SNF) stay among older adults hospitalized following traumatic brain injury (TBI). SETTING: Skilled nursing facilities. PARTICIPANTS: Medicare fee-for-service beneficiaries admitted to an SNF after hospitalization for TBI. DESIGN: Retrospective cohort study using Medicare administrative data merged with the National Trauma Data Bank using a multilayered Bayesian record linkage approach. MAIN OUTCOME MEASURE: Successful community discharge: discharged alive within 100 days of SNF admission and remaining in the community for 30 days or more without dying or admission to a healthcare facility. RESULTS: Medicaid enrollment, incontinence, decreased independence with activities of daily living, and cognitive impairment were associated with lower odds of successful discharge, whereas race "other" was associated with higher odds of successful discharge. Injury factors including worse injury severity (Glasgow Coma Scale and Abbreviated Injury Scale scores) and fall-related injury mechanism were not associated with successful discharge. CONCLUSION: Among older adults with TBI who discharge to an SNF, sociodemographic and functional status characteristics are associated with successful discharge and may be useful to clinicians for discharge planning. Acute injury severity indices may have limited utility in predicting discharge disposition once a patient is admitted to an SNF for post-acute care.

Can an Emergency Department-Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial.

STUDY OBJECTIVE: We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults. METHODS: The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians. RESULTS: Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed. CONCLUSION: Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults.

Function and Quality of Life of Unilateral Major Upper Limb Amputees: Effect of Prosthesis Use and Type.

OBJECTIVE: To compare patient-reported outcomes of disability, activity difficulty, and health-related quality of life (HRQOL) by prosthetic device use and configuration and to identify factors associated with these outcomes. DESIGN: Telephone survey. SETTING: General community. PARTICIPANTS: Population-based sample of veterans (N=755) with unilateral upper limb amputation recruited from a national sample of veterans with upper limb amputation who received care at the Veterans Affairs clinic from 2010-2015. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Upper limb-related disability was measured using Disabilities of the Arm, Shoulder, and Hand score (QuickDASH). HRQOL was measured using the Veterans RAND 12-item Health Survey Mental and Physical Component scores. Activity difficulty was assessed for 1-handed and 2-handed tasks and by questions about the need for help with activities of daily living (ADLs). RESULTS: Patients who did not use a prosthesis had more difficulty performing 1-handed tasks using the residual limb as compared with those who used body-powered prostheses. Cosmetic device users had more task difficulty than body-powered or myoelectric users. Linear regression models did not show an association between type of prosthesis used and HRQOL scores, but did show that those who did not use a prosthesis (non-users) had worse QuickDASH scores (ß=9.4; P=.0004) compared to body-powered users. In logistic regression modeling, the odds of needing help with ADLs were 1.84 times higher (95% confidence interval, 1.16-2.92) for non-users compared with body-powered users. CONCLUSIONS: Amputees who did not use a prosthesis or used a cosmetic prosthesis reported more difficulty in activities and greater disability as compared with those who use body-powered and myoelectric devices. Non-users were more likely to need help with ADLs as compared with those who used a body-powered prosthesis. Our findings highlight the clinical importance of encouraging prosthesis use. Further research is needed to compare physical performance by prosthesis configuration.

Use of Hospital-Based Rehabilitation Services and Hospital Readmission Following Ischemic Stroke in the United States.

OBJECTIVE: To examine the association between hospital-based rehabilitation service use and all-cause 30-day hospital readmission among patients with ischemic stroke. DESIGN: Secondary analysis of inpatient Medicare claims data using Standard Analytical Files. SETTING: Acute hospitals across the United States. PARTICIPANTS: From nationwide data, Medicare fee-for-service beneficiaries (N=88,826) aged 66 years or older hospitalized for ischemic stroke between January to November 2010. INTERVENTIONS: Hospital-based rehabilitation services were quantified using Medicare inpatient claims revenue center codes for evaluation (occupational therapy [OT] and physical therapy [PT]), as well as the number of therapy units delivered. Therapy minutes for both OT and PT services were categorized into none, low, medium, and high. MAIN OUTCOME MEASURES: All-cause 30-day hospital readmission. A generalized linear mixed model was used to examine the effect of hospital-based rehabilitation services on 30-day hospital readmission, after adjusting for patient and hospital characteristics. RESULTS: In fully adjusted models, compared to patients who received no PT, we observed a monotonic inverse relationship between the amount of PT and hospital readmission. For low PT (30 minutes), the odds ratio (OR) was 0.90 (95% confidence interval [CI], 0.83-0.96). For medium PT (>30 to ≤75 minutes), the OR was 0.89 (95% CI, 0.82-0.95). For high PT (>75 minutes), the OR was 0.86 (95% CI, 0.80-0.93). CONCLUSION: Hospital-based PT services were associated with lower risk of 30-day hospital readmission in patients with ischemic stroke.

Psychometric Properties of Functional, Ambulatory, and Quality of Life Instruments in Lower Limb Amputees: A Systematic Review.

OBJECTIVE: Summarize the psychometric properties of functional, ambulatory, and quality of life instruments among adult lower limb amputees, highlighting evidence deemed generalizable to the United States Medicare population. DATA SOURCES: Six databases and existing systematic reviews through October 30, 2017. Searches included terms for lower limb amputation or prostheses and outcome measures in humans, without language restriction. STUDY SELECTION: We included peer-reviewed studies of at least 20 adults (≥18 years) with lower limb amputation. Eligible studies reported on psychometric properties of functional, ambulatory, or quality of life instruments. Fifty-three of 425 retrieved articles (12%) met criteria. DATA EXTRACTION: Study characteristics and psychometric property data (validity, reliability, responsiveness, minimum detectable change, minimal important difference, or floor or ceiling effect) were extracted into a customized form based on standardized criteria. All extracted data were confirmed by 2 experts in systematic review and rehabilitation outcome measurement. Instruments were categorized regarding having been validated and found reliable. Other reported psychometric properties were recorded. Studies were also assessed for applicability to the Medicare population based on age and amputation etiology (dysvascular). DATA SYNTHESIS: Fifty-six studies (in 53 articles) reported psychometric properties of 50 instruments. There is evidence for both validity and reliability for 30 instruments, 17 of which have evidence that was deemed generalizable to the Medicare population. Most of the remaining instruments have evidence of either validity or reliability, but not both. Twelve instruments have been assessed specifically among lower limb amputees prior to prosthesis prescription. Thirteen instruments have been assessed regarding their predictive properties for future outcomes. CONCLUSIONS: Numerous instruments assessing ambulation, function, quality of life, and other patient-centered outcomes have evidence of validity and reliability for adults with lower limb amputations. Researchers and clinicians should use validated, reliable instruments when feasible. Many existing and new instruments require validation for use with lower limb amputees.

Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data.

BACKGROUND: Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees. METHODS AND FINDINGS: This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation. CONCLUSIONS: Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs.

Evaluation of EMG pattern recognition for upper limb prosthesis control: a case study in comparison with direct myoelectric control.

BACKGROUND: Although electromyogram (EMG) pattern recognition (PR) for multifunctional upper limb prosthesis control has been reported for decades, the clinical benefits have rarely been examined. The study purposes were to: 1) compare self-report and performance outcomes of a transradial amputee immediately after training and one week after training of direct myoelectric control and EMG pattern recognition (PR) for a two-degree-of-freedom (DOF) prosthesis, and 2) examine the change in outcomes one week after pattern recognition training and the rate of skill acquisition in two subjects with transradial amputations. METHODS: In this cross-over study, participants were randomized to receive either PR control or direct control (DC) training of a 2 DOF myoelectric prosthesis first. Participants were 2 persons with traumatic transradial (TR) amputations who were 1 DOF myoelectric users. Outcomes, including measures of dexterity with and without cognitive load, activity performance, self-reported function, and prosthetic satisfaction were administered immediately and 1 week after training. Speed of skill acquisition was assessed hourly. One subject completed training under both PR control and DC conditions. Both subjects completed PR training and testing. Outcomes of test metrics were analyzed descriptively. RESULTS: Comparison of the two control strategies in one subject who completed training in both conditions showed better scores in 2 (18%) dexterity measures, 1 (50%) dexterity measure with cognitive load, and 1 (50%) self-report functional measure using DC, as compared to PR. Scores of all other metrics were comparable. Both subjects showed decline in dexterity after training. Findings related to rate of skill acquisition varied considerably by subject. CONCLUSIONS: Outcomes of PR and DC for operating a 2-DOF prosthesis in a single subject cross-over study were similar for 74% of metrics, and favored DC in 26% of metrics. The two subjects who completed PR training showed decline in dexterity one week after training ended. Findings related to rate of skill acquisition varied considerably by subject. This study, despite its small sample size, highlights a need for additional research quantifying the functional and clinical benefits of PR control for upper limb prostheses.

Neuropsychological assessment without upper limb involvement: a systematic review of oral versions of the Trail Making Test and Symbol-Digit Modalities Test.

The Trail Making Test (TMT) and written version of the Symbol Digit Modalities Test (SDMT) assess attention, processing speed, and executive functions but their utility is limited in populations with upper limb dysfunction. Oral versions of the TMT and SDMT exist, but a systematic review of their psychometric properties and clinical utility has not been conducted, which was the goal of this study. Searches were conducted in PubMed and PsycINFO, test manuals, and the reference lists of included articles. Four measures were identified: the SDMT-oral, oral TMT-A, oral TMT-B, and the Mental Alternation Test (MAT). Two investigators independently reviewed abstracts to identify peer-reviewed articles that reported on these measures in adult populations. From each article, one investigator extracted information on reliability, validity, responsiveness, minimum detectable change, normative data, and demographic influences. A second investigator verified the accuracy of the data in a random selection of 10% of papers. The quality of the evidence for each psychometric property was rated on a 4-point scale (unknown, poor, adequate, excellent). Results showed excellent evidence for the SDMT-oral, adequate evidence for the oral TMT-B and MAT, and adequate to poor evidence for the oral TMT-A. These findings inform the clinical assessment of attention, processing speed, and executive functions in individuals with upper limb disability.

Measuring Community Integration in Persons With Limb Trauma and Amputation: A Systematic Review.

OBJECTIVES: To conduct a systematic review of community integration measures used with populations with limb trauma, amputation, or both, and to evaluate each measure's focus, content, and psychometric properties. DATA SOURCES: Searches of PubMed and CINAHL for the terms social participation, community integration, social function, outcome assessment, wounds and injuries, and amputation/rehabilitation. STUDY SELECTION: Included English-language articles with a sample size of ≥20 adults with limb trauma or amputation. Measures were deemed eligible if they contained a majority of items related to the construct of participation as defined by the International Classification of Functioning, Disability and Health. DATA EXTRACTION: Data on internal consistency; test-retest, interrater, and intrarater reliability; content, structural, construct, concurrent, and predictive validity; responsiveness; and floor/ceiling effects were extracted from each article and confirmed by a second investigator. DATA SYNTHESIS: A total of 156 articles containing 34 measures and 94 subscales were reviewed. Psychometric properties were rated, and an overall score was calculated for each measure. Content of the highest scoring measures was examined. Scant evidence was found regarding the psychometric properties of most measures. Eight scales from 5 instruments had the strongest measurement properties: the Trinity Amputation and Prosthesis Experience (TAPES) social restriction and adjustment to limitation scales; Community Reintegration of Injured Service Members (CRIS) extent of participation and perceived limitations scales; Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) role-physical and social functioning scales; the 136-item Sickness Impact Profile (SIP) psychosocial domain scale; and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS-II) 12-item total score. CONCLUSIONS: Eights scales from 5 instruments-the TAPES, CRIS, SF-36, the 136-item SIP, and the WHODAS-II 12-item measure-had the strongest measurement properties.

Systematic Review of Measures of Impairment and Activity Limitation for Persons With Upper Limb Trauma and Amputation.

OBJECTIVE: (1) To identify outcome measures used in studies of persons with traumatic upper limb injury and/or amputation; and (2) to evaluate focus, content, and psychometric properties of each measure. DATA SOURCES: Searches of PubMed and CINAHL for terms including upper extremity, function, activities of daily living, outcome assessment, amputation, and traumatic injuries. STUDY SELECTION: Included articles had a sample of ≥10 adults with limb trauma or amputation and were in English. Measures containing most items assessing impairment of body function or activity limitation were eligible. DATA EXTRACTION: There were 260 articles containing 55 measures that were included. Data on internal consistency; test-retest, interrater, and intrarater reliability; content, structural, construct, concurrent, and predictive validity; responsiveness; and floor/ceiling effects were extracted and confirmed by a second investigator. DATA SYNTHESIS: The mostly highly rated performance measures included 2 amputation-specific measures (Activities Measure for Upper Limb Amputees and University of New Brunswick Test of Prosthetic Function skill and spontaneity subscales) and 2 non-amputation-specific measures (Box and Block Test and modified Jebsen-Taylor Hand Function Test light and heavy cans tests). Most highly rated self-report measures were Disabilities of the Arm, Shoulder and Hand; Patient Rated Wrist Evaluation; QuickDASH; Hand Assessment Tool; International Osteoporosis Foundation Quality of Life Questionnaire; and Patient Rated Wrist Evaluation functional recovery subscale. None were amputation specific. CONCLUSIONS: Few performance measures were recommended for patients with limb trauma and amputation. All top-rated self-report measures were suitable for use in both groups. These results will inform choice of outcome measures for these patients.

Which Homeless Veterans Benefit From a Peer Mentor and How?

OBJECTIVE: Veterans Affairs (VA) is expanding peer support. Research is limited on Veterans' perspective on benefits from peer services. We describe homeless Veteran perceptions of value and examine characteristics associated with benefit. METHOD: From a sample of Veterans in a multisite randomized control trial, we studied addition of peers in VA Primary Care and homeless-oriented primary care clinics. We used qualitative methods to study the perceptions of peer services among a subsample of homeless Veterans. Quantitative methods were used to validate findings in both samples. RESULTS: Sixty-five percent of the subsample and 83% of the full sample benefited from a peer mentor. Participants who benefited had more peer visits and minutes of intervention (p<.05), were more likely to be minority, and were less likely to have posttraumatic stress disorder. CONCLUSION: The majority of Veteran participants in this study benefited from receiving peer mentor intervention. African American Veterans were more likely to benefit and Veterans with PTSD were less likely to benefit. Client endorsement of the peer's role influenced outcomes.

Timed activity performance in persons with upper limb amputation: A preliminary study.

STUDY DESIGN: 55 subjects with upper limb amputation were administered the T-MAP twice within one week. PURPOSE: To develop a timed measure of activity performance for persons with upper limb amputation (T-MAP); examine the measure's internal consistency, test-retest reliability and validity; and compare scores by prosthesis use. INTRODUCTION: Measures of activity performance for persons with upper limb amputation are needed The time required to perform daily activities is a meaningful metric that implication for participation in life roles. METHODS: Internal consistency and test-retest reliability were evaluated. Construct validity was examined by comparing scores by amputation level. Exploratory analyses compared sub-group scores, and examined correlations with other measures. RESULTS: Scale alpha was 0.77, ICC was 0.93. Timed scores differed by amputation level. Subjects using a prosthesis took longer to perform all tasks. T-MAP was not correlated with other measures of dexterity or activity, but was correlated with pain for non-prosthesis users. DISCUSSION: The timed scale had adequate internal consistency and excellent test-retest reliability. CONCLUSIONS: Analyses support reliability and construct validity of the T-MAP. LEVEL OF EVIDENCE: 2c "outcomes" research.

Range of Motion Requirements for Upper-Limb Activities of Daily Living.

OBJECTIVE: We quantified the range of motion (ROM) required for eight upper-extremity activities of daily living (ADLs) in healthy participants. METHOD: Fifteen right-handed participants completed several bimanual and unilateral basic ADLs while joint kinematics were monitored using a motion capture system. Peak motions of the pelvis, trunk, shoulder, elbow, and wrist were quantified for each task. RESULTS: To complete all activities tested, participants needed a minimum ROM of -65°/0°/105° for humeral plane angle (horizontal abduction-adduction), 0°-108° for humeral elevation, -55°/0°/79° for humeral rotation, 0°-121° for elbow flexion, -53°/0°/13° for forearm rotation, -40°/0°/38° for wrist flexion-extension, and -28°/0°/38° for wrist ulnar-radial deviation. Peak trunk ROM was 23° lean, 32° axial rotation, and 59° flexion-extension. CONCLUSION: Full upper-limb kinematics were calculated for several ADLs. This methodology can be used in future studies as a basis for developing normative databases of upper-extremity motions and evaluating pathology in populations.

Reliability, Validity, and Responsiveness of the QuickDASH in Patients With Upper Limb Amputation.

OBJECTIVES: To examine the internal consistency, test-retest reliability, validity, and responsiveness of the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire in persons with upper limb amputation. DESIGN: Cross-sectional and longitudinal. SETTING: Three sites participating in the U.S. Department of Veterans Affairs Home Study of the DEKA Arm. PARTICIPANTS: A convenience sample of upper limb amputees (N=44). INTERVENTIONS: Training with a multifunction upper limb prosthesis. MAIN OUTCOME MEASURES: Multiple outcome measures including the QuickDASH were administered twice within 1 week, and for a subset of 20 persons, after completion of in-laboratory training with the DEKA Arm. Scale alphas and intraclass correlation coefficient type 3,1 (ICC3,1) were used to examine reliability. Minimum detectable change (MDC) scores were calculated. Analyses of variance, comparing QuickDASH scores by the amount of prosthetic use and amputation level, were used for known-group validity analyses with alpha set at .05. Pairwise correlations between QuickDASH and other measures were used to examine concurrent validity. Responsiveness was measured by effect size (ES) and standardized response mean (SRM). RESULTS: QuickDASH alpha was .83, and ICC was .87 (95% confidence interval, .77-.93). MDC at the 95% confidence level (MDC95%) was 17.4. Full- or part-time prosthesis users had better QuickDASH scores compared with nonprosthesis users (P=.021), as did those with more distal amputations at both baseline (P=.042) and with the DEKA Arm (P=.024). The QuickDASH was correlated with concurrent measures of activity limitation as expected. The ES and SRM after training with the DEKA Arm were 0.6. CONCLUSIONS: This study provides evidence of reliability and validity of the QuickDASH in persons with upper limb amputation. Results provide preliminary evidence of responsiveness to prosthetic device type/training. Further research with a larger sample is needed to confirm results.