Emergency Department-Based Physical Function Measures for Falls in Older Adults and Outcomes: A Secondary Analysis of GAPcare.

BACKGROUND AND PURPOSE: Falls are the leading reason for injury-related emergency department (ED) visits for older adults. The Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), an in-ED intervention combining a medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist, reduced ED revisits at 6 months among older adults presenting after a fall. Our objective was to evaluate the relationship between measures of function obtained in the ED and clinical outcomes. METHODS: This was a secondary analysis of data from GAPcare, a randomized controlled trial conducted from January 2018 to October 2019 at 2 urban academic EDs. Standardized measures of function (Timed Up and Go [TUG] test, Barthel Activity of Daily Living [ADL], Activity Measure for Post Acute Care [AM-PAC] 6 clicks) were collected at the ED index visit. We performed a descriptive analysis and hypothesis testing (chi square test and analysis of variance) to assess the relationship of functional measures with outcomes (ED disposition, ED revisits for falls, and place of residence at 6 months). Emergency department disposition status refers to discharge location immediately after the ED evaluation is complete (eg, hospital admission, original residence, skilled nursing facility). RESULTS AND DISCUSSION: Among 110 participants, 55 were randomized to the GAPcare intervention and 55 received usual care. Of those randomized to the intervention, 46 received physical therapy consultation. Median age was 81 years; participants were predominantly women (67%) and White (94%). Seventy-three (66%) were discharged to their original residence, 14 (13%) were discharged to a skilled nursing facility and 22 (20%) were admitted. There was no difference in ED disposition status by index visit Barthel ADLs (P = .371); however, TUG times were faster (P = .016), and AM-PAC 6 clicks score was higher among participants discharged to their original residence (P ≤ .001). Participants with slower TUG times at the index ED visit were more likely to reside in nursing homes by six months (P = .002), while Barthel ADL and AM-PAC 6 clicks did not differ between those residing at home and other settings. CONCLUSIONS: Measures of function collected at the index ED visit, such as the AM-PAC 6 clicks and TUG time, may be helpful at predicting clinical outcomes for older adults presenting for a fall. Based on our study findings, we suggest a novel workflow to guide the use of these clinical measures for ED patients with falls.

Relevance and use of health policy, health systems and health services research for strengthening rehabilitation in real-life settings: methodological considerations.

Research on health policy, systems, and services (HPSSR) has seen significant growth in recent decades and received increasing attention in the field of rehabilitation. This growth is driven by the imperative to effectively address real-life challenges in complex healthcare settings. A recent resolution on 'Strengthening rehabilitation in health systems' adopted by the World Health Assembly emphasizes the need to support societal health goals related to rehabilitation, particularly to promote high-quality rehabilitation research, including HPSSR. This conceptual paper, discussed with the participants in the 5th Cochrane Rehabilitation Methodological Meeting held in Milan on September 2023, outlines study designs at diverse levels at which HPSSR studies can be conducted: the macro, meso, and micro levels. It categorizes research questions into four types: those framed from the perspective of policies, healthcare delivery organizations or systems, defined patient or provider populations, and important data sources or research methods. Illustrative examples of appropriate methodologies are provided for each type of research question, demonstrating the potential of HPSSR in shaping policies, improving healthcare delivery, and addressing patient and provider perspectives. The paper concludes by discussing the applicability, usefulness, and implementation of HPSSR findings, and the importance of knowledge translation strategies, drawing insights from implementation science. The goal is to facilitate the integration of research findings into everyday clinical practice to bridge the gap between research and practice in rehabilitation.

Out-of-pocket costs and affordability of upper limb prostheses.

BACKGROUND: Given the funding policies in the Department of Veterans Affairs, the affordability of prostheses may be less of a concern among Veterans as compared to civilians. OBJECTIVES: Compare rates of out-of-pocket prosthesis-related payments for Veterans and non-Veterans with upper limb amputation (ULA), develop and validate a measure of prosthesis affordability, and evaluate the impact of affordability on prosthesis nonuse. STUDY DESIGN: Telephone survey of 727 persons with ULA; 76% Veterans and 24% non-Veterans. METHODS: Odds of paying out-of-pocket costs for Veterans compared with non-Veterans were computed using logistic regression. Cognitive and pilot testing resulted in a new scale, evaluated using confirmatory factor and Rasch analysis. Proportions of respondents who cited affordability as a reason for never using or abandoning a prosthesis were calculated. RESULTS: Twenty percent of those who ever used a prosthesis paid out-of-pocket costs. Veterans had 0.20 odds (95% confidence interval, 0.14-0.30) of paying out-of-pocket costs compared with non-Veterans. Confirmatory factor analysis supported unidimensionality of the 4-item Prosthesis Affordability scale. Rasch person reliability was 0.78. Cronbach alpha was 0.87. Overall, 14% of prosthesis never-users said affordability was a reason for nonuse; 9.6% and 16.5% of former prosthesis users said affordability of repairs or replacement, respectively, was a reason for abandonment. CONCLUSIONS: Out-of-pocket prosthesis costs were paid by 20% of those sample, with Veterans less likely to incur costs. The Prosthesis Affordability scale developed in this study was reliable and valid for persons with ULA. Prosthesis affordability was a common reason for never using or abandoning prostheses.

Categorization and recommendations for outcome measures for lower limb absence by an expert panel.

BACKGROUND: Understanding the psychometric strengths and limitations of outcome measures for use with people with lower limb absence (LLA) is important for selecting measures suited to evaluating patient outcomes, answering clinical and research questions, and informing health care policy. The aim of this project was to review the current psychometric evidence on outcome measures in people with LLA to determine which measures should be included in a stakeholder consensus process. METHODS: An expert panel was assembled, and a 3-stage review process was used to categorize outcome measures identified in a systematic literature review into 3 distinct categories (recommended for measures with better than adequate psychometric properties; recommended with qualification; and unable to recommend). Panelists were asked to individually categorize measures based on results of a systematic review of identified measures' psychometric properties. Each measure's final categorization was based on ≥70% agreement by all panelists. RESULTS: No outcome measure attained the ≥70% consensus threshold needed to achieve a rating of "recommend." Hence, panelists suggested combining "recommend" and "recommend with qualifications" into a single category of "recommend with qualifications." Using this approach, consensus was reached for 59 of 60 measures. Consensus could not be reached on 1 outcome measure (socket comfort score). Thirty-six outcome measures were categorized as "unable to recommend" based on available evidence; however, 23 (12 patient-reported measures and 11 performance-based measures) demonstrated adequate psychometric properties in LLA samples and were thus rated as "recommend with qualification" by the expert panel. The panel of experts were able to recommend 23 measures for inclusion in the subsequent stakeholder review. A key strength of this process was bringing together international researchers with extensive experience in developing and/or using LLA outcome measures who could assist in identifying psychometrically sound measures to include in a subsequent stakeholder consensus process. CONCLUSION: The above categorizations represent the current state of psychometric evidence on outcome measures for people with LLA and hence may change over time as additional research becomes available. The results will be used to achieve wider consensus from clinicians, health policymakers, health clinic managers, researchers, and end users (i.e., individuals with LLA) on outcome measures for the International Society of Prosthetics and Orthotics lower limb Consensus Outcome Measures for Prosthetic and Amputation ServiceS.

Prosthesis nonuse and discontinuation in United States veterans with major limb amputation: Results of a national survey.

BACKGROUND: Prosthesis use in persons with amputation can improve mobility and functional independence. Better understanding of the reasons for and outcomes associated with prosthesis nonuse is important to optimize function and long-term health in persons with amputation. OBJECTIVES: Study objectives were to describe the rate, reasons for, and factors associated with never using or discontinuing prosthesis use in United States (US) veterans with amputation. STUDY DESIGN: Cross-sectional study design. METHODS: The study used an online survey to assess prosthesis use and satisfaction in veterans with upper-limb and lower-limb amputation. Survey participation invitations were distributed by email, text message, and mail to 46,613 potential participants. RESULTS: The survey response rate was 11.4%. After exclusions, an analytic sample of 3,959 respondents with a major limb amputation was identified. The sample was 96.4% male; 78.3% White, with mean age of 66.9; and mean of 18.2 years since amputation. The rate of never using a prosthesis was 8.2%, and the rate of prosthesis discontinuation was 10.5%. Functionality (62.0%), undesirable prosthesis characteristics (56.9%), and comfort (53.4%) were the most common reasons for discontinuation. After controlling for the amputation subgroup, the odds of prosthesis discontinuation were higher for those with unilateral upper-limb amputation, female gender, White race (compared with Black race), diabetes, above-knee amputation, and lower prosthesis satisfaction. Prosthesis satisfaction and quality of life were highest for current prosthesis users. CONCLUSIONS: This study adds new understanding regarding the rate and reasons for prosthesis nonuse in veterans and highlights the important relationship between prosthesis discontinuation and prosthesis satisfaction, quality of life, and satisfaction with life.

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.

Increased Medicare Advantage Penetration Is Associated With Lower Postacute Care Use For Traditional Medicare Patients.

Medicare Advantage (MA) plans, which accounted for 45 percent of total Medicare enrollment in 2022, are incentivized to minimize spending on low-value services. Prior research indicates that MA plan enrollment is associated with reduced postacute care use without adverse impacts on patient outcomes. However, it is unclear whether a rising MA enrollment level is associated with a change in postacute care use in traditional Medicare, especially given growing participation in traditional Medicare Alternative Payment Models that have been found to be associated with lower postacute care spending. We hypothesize that market-level MA expansion is associated with reduced postacute care use among traditional Medicare beneficiaries-a "spillover" effect of providers modifying their practice patterns in response to MA plans' incentives. We found increased MA market penetration associated with reduced postacute care use among traditional Medicare beneficiaries, without a corresponding increase in hospital readmissions. This association was generally stronger in markets with a greater share of traditional Medicare beneficiaries attributed to accountable care organizations, suggesting that policy makers should account for MA penetration when evaluating potential savings in Alternative Payment Models within traditional Medicare.

Learning Health Systems Research Competencies: A Survey of the Rehabilitation Research Community.

OBJECTIVE: The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources. METHODS: The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements. RESULTS: Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed "a lot" or "some" interest in learning more, but only 19% reported "a lot" of knowledge. Respondents reported "a lot" of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). "None" or "some" knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%). CONCLUSION: Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training. IMPACT: Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed.

Measuring residual limb health in persons with upper limb amputation: Modifications of the Prosthetic Evaluation Questionnaire residual limb health scale.

BACKGROUND: Assessing the user perspective on residual limb health problems is particularly important for amputation care, given the relationship between residual limb health and prosthetic satisfaction. Only 1 measure, the Residual Limb Health scale of the Prosthetic Evaluation Questionnaire (PEQ) has been validated for use in lower limb amputation, but not examined in persons with upper limb amputation (ULA). OBJECTIVES: The objective of this study was to examine the psychometric properties of a modified PEQ Residual Limb Health scale in a sample of persons with ULA. STUDY DESIGN: The study involved a telephone survey of 392 prosthesis users with ULA, with a 40-person retest sample. METHODS: The PEQ item response scale was modified to a Likert scale. The item set and instructions were refined in cognitive and pilot testing. Descriptive analyses characterized the prevalence of residual limb issues. Factor analyses and Rasch analyses evaluated unidimensionality, monotonicity, item fit, differential item functioning, and reliability. Test-retest reliability was assessed by an intraclass correlation coefficient. RESULTS: Sweating and prosthesis odor were prevalent at 90.7% and 72.5%, respectively; blisters/sores (12.1%) and ingrown hairs (7.7%) were the least prevalent problems. Response categories were dichotomized for 3 items and trichotomized for 3 items to improve monotonicity. After adjusting for residual correlations, confirmatory factor analyses showed acceptable fit (comparative fit index = 0.984, Tucker-Lewis index = 0.970, and root mean square error approximation = 0.032). Person reliability was 0.65. No items had moderate-to-severe differential item functioning by age or sex. Intraclass correlation coefficient for test-retest reliability was 0.87 (95% CI, 0.76-0.93). CONCLUSIONS: The modified scale had excellent structural validity, fair person reliability, very good test-retest reliability, and no floor or ceiling effects. The scale is recommended for use with persons with wrist disarticulation, transradial amputation, elbow disarticulation, and above-elbow amputation.

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.

Trends in post-acute care and outcomes for Medicare beneficiaries hospitalized for heart failure between 2008 and 2015.

BACKGROUND: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty. METHODS: Annual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status. RESULTS: Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients. CONCLUSIONS: Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF.

The Upper Extremity Functional Scale for Prosthesis Users (UEFS-P): subscales for one and two-handed tasks.

PURPOSE: To develop a self-report measure of activity performance for upper limb prosthesis users that quantifies outcomes by level of amputation and prosthesis type. MATERIALS AND METHODS: Telephone survey of 423 adults with major upper limb amputation (ULA) who used a prosthesis. Item generation, cognitive, and pilot testing were followed by field testing. Items were categorized as one- or two-handed. Factor and Rasch analyses evaluated unidimensionality, monotonicity, item fit, differential item functioning (DIF), and reliability. Test-retest reliability was evaluated with intraclass correlation coefficients (ICCs). Known group validity was assessed with ANOVAs. RESULTS: Respondents with unilateral ULA utilized prosthesis for 24% of unilateral and 38% of bilateral tasks. Those with bilateral ULA utilized prostheses for 64% of unilateral and 46% of bilateral tasks. Factor analyses identified a One-handed Task factor (CFI = 0.963, TLI = 0.950, and RMSEA = 0.064) and a Two-Handed Task factor (CFI = 0.958, TLI = 0.953, and RMSEA = 0.053). Response categories were collapsed to address monotonicity. After DIF adjustment, person reliability was 0.49 and 0.82 for One-handed and Two-handed Task scales, respectively, and ICCs were 0.88 and 0.91. Both scales differed by amputation level (p < 0.001). CONCLUSIONS: The Upper Extremity Functional Scale for Prosthesis Users (UEFS-P) measure of upper limb function of prosthesis users has promising psychometric properties.Implications for rehabilitationMeasurement of upper limb function in persons with amputation is challenging, given currently available measures which do not explicitly grade activity performance with a prosthesis.The Upper Extremity Functional Scale for Prosthesis Users (UEFS-P) builds upon the original Orthotics and Prosthetics User Survey (OPUS) UEFS Scale with modified instructions, a revised item set, response categories and scoring algorithm.The UEFS-P consists of two unidimensional scales, the One-handed Tasks scale and the Two-handed Tasks scale.The UEFS-P scales have clear advantages over existing self-report measures of upper limb function that ask about difficulty with performing functional activities without accounting for prosthesis use, and do not differentiate persons who use and do not use a prosthesis.

Assessment of Patient-Reported Physical Function in Persons With Upper Extremity Amputation: Comparison of Short Form Instruments.

OBJECTIVE: The aim of the study was to compare psychometric properties of the Patient-Reported Outcomes Measurement Information System upper extremity measure (PROMIS UE) 7-item short form with 6- and 13-item versions for persons with upper limb amputation. DESIGN: The study used a telephone survey of 681 persons with upper limb amputation. Versions were scored two ways: PROMIS health measure scoring (PROMIS UE HMSS) and sample-specific calibration (PROMIS UE AMP). Factor analyses and Rasch analyses evaluated unidimensionality, monotonicity, item fit, differential item functioning, and reliability. Known group validity was compared for all versions. RESULTS: Model fit was acceptable for PROMIS-6 UE AMP and marginally acceptable for PROMIS-13 UE AMP and PROMIS-7 UE AMP. Item response categories were collapsed because of disordered categories. A total of 91.4% of participants had PROMIS-13 UE AMP scores with reliability greater than 0.8, compared with 70.4% for PROMIS-7 UE AMP, and 72.1% for PROMIS-6 UE AMP versions. No differences were observed by prosthesis use. Scores differed by amputation for all measures except the HMSS scored 13- and 7-item versions. CONCLUSIONS: The PROMIS-13 UE AMP short form was superior to the health measures scoring system scored PROMIS-7 UE or PROMIS-6 UE, and to the PROMIS-7 UE AMP and PROMIS-6 UE AMP. Issues with known group validation suggest a need for a population-specific measure of upper extremity function for persons with upper limb amputation.

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.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury Admitted to Inpatient Rehabilitation Facilities.

Objective: To identify admission characteristics that predict a successful community discharge from an inpatient rehabilitation facility (IRF) among older adults with traumatic brain injury (TBI). Design: In a retrospective cohort study, we leveraged probabilistically linked Medicare Administrative, IRF-Patient Assessment Instrument, and National Trauma Data Bank data to build a parsimonious logistic model to identify characteristics associated with successful discharge. Multiple imputation methods were used to estimate effects across linked datasets to account for potential data linkage errors. Setting: Inpatient Rehabilitation Facilities in the U.S. Participants: The sample included a mean of 1060 community-dwelling adults aged 66 years and older across 30 linked datasets (N=1060). All were hospitalized after TBI between 2011 and 2015 and then admitted to an IRF. The mean age of the sample was 79.7 years, and 44.3% of the sample was women. Interventions: Not applicable. Main Outcome Measures: Successful discharge home. Results: Overall, 64.6% of the sample was successfully discharged home. A logistic model including 4 predictor variables: Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) scores, pre-injury chronic conditions, and pre-injury living arrangement, that were significantly associated with successful discharge, resulted in acceptable discrimination (area under the curve: 0.76, 95% confidence interval [CI]: 0.72-0.81). Higher scores on the FIM-M (odds ratio [OR]:1.07, 95% CI: 1.05-1.09) and FIM-C (OR: 1.05, 95% CI: 1.02-1.08) were associated with greater odds of successful discharge, whereas living alone vs with others (OR: 0.46, 95% CI: 0.30-0.71) and a greater number of chronic conditions (OR: 0.94, 95% CI: 0.90-0.99) were associated with lower odds of successful discharge. Conclusions: The results provide a parsimonious model for predicting successful discharge among older adults admitted to an IRF after a TBI-related hospitalization and provide clinically useful information to inform discharge planning.

Association Between the Patient Driven Payment Model and Therapy Utilization and Patient Outcomes in US Skilled Nursing Facilities.

Importance: In October 2019, Medicare changed its skilled nursing facility (SNF) reimbursement model to the Patient Driven Payment Model (PDPM), which has modified financial incentives for SNFs that may relate to therapy use and health outcomes. Objective: To assess whether implementation of the PDPM was associated with changes in therapy utilization or health outcomes. Design Setting and Participants: This cross-sectional study used a regression discontinuity (RD) approach among Medicare fee-for-service postacute-care patients admitted to a Medicare-certified SNF following hip fracture between January 2018 and March 2020. Exposures: Skilled nursing facility admission after PDPM implementation. Main Outcomes and Measures: Main outcomes were individual and nonindividual (concurrent and group) therapy minutes per day, hospitalization within 40 days of SNF admission, SNF length of stay longer than 40 days, and discharge activities of daily living score. Results: The study cohort included 201 084 postacute-care patients (mean [SD] age, 83.8 [8.3] years; 143 830 women [71.5%]; 185 854 White patients [92.4%]); 147 711 were admitted pre-PDPM, and 53 373 were admitted post-PDPM. A decrease in individual therapy (RD estimate: -15.9 minutes per day; 95% CI, -16.9 to -14.6) and an increase in nonindividual therapy (RD estimate: 3.6 minutes per day; 95% CI, 3.4 to 3.8) were observed. Total therapy use in the first week following admission was about 12 minutes per day (95% CI, -13.3 to -11.3) (approximately 13%) lower for residents admitted post-PDPM vs pre-PDPM. No consistent and statistically significant discontinuity in hospital readmission (0.31 percentage point increase; 95% CI, -1.46 to 2.09), SNF length of stay (2.7 percentage point decrease in likelihood of staying longer than 40 days; 95% CI, -4.83 to -0.54), or functional score at discharge (0.04 point increase in activities of daily living score; 95% CI, -0.19 to 0.26) was observed. Nonindividual therapy minutes were reduced to nearly zero in late March 2020, likely owing to COVID-19-related restrictions on communal activities in SNFs. Conclusions and Relevance: In this cross-sectional study of SNF admission after PDPM implementation, a reduction of total therapy minutes was observed following the implementation of PDPM, even though PDPM was designed to be budget neutral. No significant changes in postacute outcomes were observed. Further study is needed to understand whether the PDPM is associated with successful discharge outcomes.

Patterns of Limitation in Physical Function in Late Midlife Associated with Late-Onset Alzheimer's Disease and Related Dementias: A Cluster Analysis.

BACKGROUND: To reduce the increasing societal and financial burden of Alzheimer's disease and related dementias (ADRD), prevention is critical. Even small improvements of the modifiable dementia risk factors on the individual level have the potential to lead to a substantial reduction of dementia cases at the population level. OBJECTIVE: To determine if pattern(s) of functional decline in midlife associate with late-onset ADRD years later. METHODS: Using a longitudinal study of adults aged 51-59 years in 1998 without symptoms of ADRD by 2002 and followed them from 2002 to 2016 (n = 5404). The outcome was incident ADRD identified by the Lange-Weir algorithm, death, or alive with no ADRD. We used cluster analysis to identify patterns of functional impairment at baseline and multinomial regression to assess their association with future ADRD. RESULTS: Three groups of adults with differing patterns of functional impairment were at greater risk of future ADRD. Difficulty with climbing one flight of stairs was observed in all adults in two of these groups. In the third group, 100% had difficulty with lifting 10 pounds and pushing or pulling a large object, but only one-fourth had difficulty in climbing stairs. CONCLUSION: Results imply that improved large muscle strength could decrease future risk of ADRD. If confirmed in other studies, screening for four self-reported measures of function among adults in midlife may be used for targeted interventions.

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.

Development of a rehabilitation researcher survey of knowledge and interest in learning health systems research.

Introduction: LeaRRn, an NIH-funded rehabilitation resource center, is dedicated to developing learning health systems (LHS) research competencies within the rehabilitation community. To appropriately target resources and training opportunities for rehabilitation researchers, we developed and pilot tested a survey based on AHRQ LHS research core competencies to assess the training needs of rehabilitation researchers interested in LHS research. Methods: Survey items were developed by the investigative team and iteratively refined with the assistance of an expert panel using two rounds of content validation. Survey items addressed knowledge of, ability to apply, and interest in LHS research competencies. The survey was pre-pilot tested with six rehabilitation professionals, refined again, and then pilot tested. Time to complete the survey was measured. Spearman correlations examined relationships between knowledge and ability. Results: A 78-item survey was pilot tested. Forty-five individuals completed the pilot survey in full (71% female, 84% white, and 93% non-Hispanic). Due to concerns about response burden (mean 15 minutes to complete) and strong correlation between "knowledge" and "ability" ratings (all rho >0.57), "ability" was dropped, resulting in a 55-item survey assessing "knowledge" and "interest" in LHS research competencies. Conclusions: We developed a survey of knowledge and interest in LHS research competencies for rehabilitation researchers. The resulting survey may be used to assess training needs and guide LHS research content development by educators, programs directors, and other initiatives within the rehabilitation research community.