Using Electronic Health Record Data for Occupational Therapy Health Services Research: Invited Commentary.

Health services research (HSR) is a field of study that examines how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and health and well-being. HSR approaches can help build the occupational therapy evidence base, particularly in relation to population health. Data from electronic health record (EHR) systems provide a rich resource for applying HSR approaches to examine the value of occupational therapy services. Transparency about data preparation procedures is important for interpreting results. Based on our findings, we describe a six-step cleaning protocol for preparing EHR and billing data from an inpatient rehabilitation facility for research and provide recommendations for the field based on our experience. Using and reporting similar strategies across studies will improve efficiency and transparency, and facilitate comparability of results.

Using Electronic Health Record Data for Occupational Therapy Health Services ResearchHealth services research (HSR) focuses on the delivery and outcomes of health care systems. HSR methods are beneficial for examining the value of occupational therapy services, and data collected from practice through electronic health records (EHRs) are an important resource for this work. Although EHRs are now used in most health care settings, extracting and using data for research is a complex, multistep process. We describe a six-step process for preparing data extracted from an EHR for a research study. The data preparation process was iterative and required expertise about how data were recorded, institutional billing and data archiving processes, and Medicare reporting requirements during the study period. We advocate for more occupational therapy researchers to be trained in and apply HSR approaches to continue to build evidence for our services. The profession can capitalize on data that are already being collected in health care settings through EHR systems to evaluate real-world occupational therapy processes and health outcomes.

Interpreting Change in Disorders of Consciousness Using the Coma Recovery Scale-Revised.

The purpose of this study was to differentiate clinically meaningful improvement or deterioration from normal fluctuations in patients with disorders of consciousness (DoC) following severe brain injury. We computed indices of responsiveness for the Coma Recovery Scale-Revised (CRS-R) using data from a clinical trial of 180 participants with DoC. We used CRS-R scores from baseline (enrollment in a clinical trial) and a 4-week follow-up assessment period for these calculations. To improve precision, we transformed ordinal CRS-R total scores (0-23 points) to equal-interval measures on a 0-100 unit scale using Rasch Measurement theory. Using the 0-100 unit total Rasch measures, we calculated distribution-based 0.5 standard deviation (SD) minimal clinically important difference, minimal detectable change using 95% confidence intervals, and conditional minimal detectable change using 95% confidence intervals. The distribution-based minimal clinically important difference evaluates group-level changes, whereas the minimal detectable change values evaluate individual-level changes. The minimal clinically important difference and minimal detectable change are derived using the overall variability across total measures at baseline and 4 weeks. The conditional minimal detectable change is generated for each possible pair of CRS-R Rasch person measures and accounts for variation in standard error across the scale. We applied these indices to determine the proportions of participants who made a change beyond measurement error within each of the two subgroups, based on treatment arm (amantadine hydrochloride or placebo) or categorization of baseline Rasch person measure to states of consciousness (i.e., unresponsive wakefulness syndrome and minimally conscious state). We compared the proportion of participants in each treatment arm who made a change according to the minimal detectable change and determined whether they also changed to another state of consciousness. CRS-R indices of responsiveness (using the 0-100 transformed scale) were as follows: 0.5SD minimal clinically important difference = 9 units, minimal detectable change = 11 units, and the conditional minimal detectable change ranged from 11 to 42 units. For the amantadine and placebo groups, 70% and 58% of participants showed change beyond measurement error using the minimal detectable change, respectively. For the unresponsive wakefulness syndrome and minimally conscious state groups, 54% and 69% of participants changed beyond measurement error using the minimal detectable change, respectively. Among 115 participants (64% of the total sample) who made a change beyond measurement error, 29 participants (25%) did not change state of consciousness. CRS-R indices of responsiveness can support clinicians and researchers in discerning when behavioral changes in patients with DoC exceed measurement error. Notably, the minimal detectable change can support the detection of patients who make a "true" change within or across states of consciousness. Our findings highlight that the continued use of ordinal scores may result in incorrect inferences about the degree and relevance of a change score.

Exploratory examination of the scale structure of the Moorong Self-Efficacy Scale: Application of Rasch Measurement Theory.

OBJECTIVE: Exploratory application of the Rasch Measurement (RM) Model for evidence for reproducibility, conceptual/content validity, and structural validity of the Moorong Self-Efficacy Scale (MSES). STUDY DESIGN: Secondary RM analysis of data collected in a randomized controlled trial comparing two exercise interventions for persons living with spinal cord injury (SCI). SETTING: Community-dwelling persons living with SCI enrolled in an exercise study. PARTICIPANTS: Adults (n = 79) enrolled in the parent study had a traumatic SCI > 3 months prior, injury level C5 to T12. INTERVENTIONS: Not applicable. OUTCOME MEASURE: The original MSES is a 16-item measure of self-efficacy with a 7-level response scale for un/certainty which was developed for use with persons living with SCI. RESULTS: We addressed item misfit, infrequent category endorsement, and category step disorder by removing two items and reorganizing the rating scale. Rating scale changes removed category 4 (Neutral), combined categories 1-3 (Very Uncertain, Somewhat Uncertain, and Uncertain) for all items, and further combined certainty categories for two items. Principal components analysis of the residuals indicated a possible second dimension with a first-contrast Eigenvalue of 2.4. However, the contrasted item groups had explained variance <10% and a dis-attenuated correlation = 0.92 indicating they measure the same underlying trait. The small sample size precluded examination of differential item functioning. CONCLUSIONS: Exploratory RM analysis of MSES produced a 14-item Rasch version which identified structural and content validity evidence concerns inherent in the original MSES. However, results could be biased by a small sample size and further study should examine the item content and rating scale structure with larger, more diverse samples of persons living with SCI.

Comparing indices of responsiveness for the Coma Near-Coma Scale with and without pain items: An Exploratory study.

INTRODUCTION: This study aimed to establish the indices of responsiveness for the Coma/Near-Coma (CNC) scale without (8 items) and with (10 items) pain test stimuli. A secondary purpose was to examine whether the CNC 8 items and 10 items differ when detecting change in neurobehavioral function. METHODS: We analyzed CNC data from three studies of participants with disorders of consciousness: one observational study and two intervention studies. We generated Rasch person measures using the CNC 8 items and CNC 10 items for each participant at two time points 14 ± 2 days apart using Rasch Measurement Theory. We calculated the distribution-based minimal clinically important difference (MCID) and minimal detectable change using 95% confidence intervals (MDC95 ). RESULTS: We used the Rasch transformed equal-interval scale person measures in logits. For the CNC 8 items: Distribution-based MCID 0.33 SD = 0.41 logits and MDC95  = 1.25 logits. For the CNC 10 items: Distribution-based MCID 0.33 SD = 0.37 logits and MDC95  = 1.03 logits. Twelve and 13 participants made a change beyond measurement error (MDC95 ) using the CNC 8-item and 10-item scales, respectively. CONCLUSION: Our preliminary evidence supports the clinical and research utility of the CNC 8-item scale for measuring the responsiveness of neurobehavioral function, and that it demonstrates comparable responsiveness to the CNC 10-item scale without administering the two pain items. The distribution-based MCID can be used to evaluate group-level changes while the MDC95 can support clinical, data-driven decisions about an individual patient.

Pressure Injury Data Reconciliation in a Randomized Controlled Trial.

OBJECTIVE: To advance pressure injury (PrI) research in individuals with spinal cord injury (SCI) by describing lessons learned and recommendations for future research, ultimately promoting PrI prevention and more effective wound care. This paper describes the detailed procedures undertaken to collect and reconcile PrI data and summarizes the types of discrepancies identified. DESIGN: Secondary analyses of PrI data collected between 2009 and 2014 in a randomized controlled trial (parent study). SETTING: Participants in the parent study were recruited from a large rehabilitation center in the Los Angeles area that serves primarily individuals with limited resources. PARTICIPANTS: 232 participants with SCI and a history of 1 or more medically serious PrI (MSPrI) in the previous 5 years. INTERVENTIONS: Participants in the parent study were randomized to a 12-month PrI prevention intervention led by an occupational therapist, or to usual care. MAIN OUTCOME MEASURES: Relations among PrI characteristics, data sources (phone interviews, skin checks, paper and electronic medical records [MRs]), and treatment condition, and sensitivity of 6 different data sources in detecting MSPrIs. RESULTS: The majority (62%) of MSPrIs were in the pelvic region. MRs detected 82% of the MSPrIs overall, making it the most sensitive data source, and scheduled skin checks were the second-most sensitive data source, finding 37% of the MSPrIs. CONCLUSIONS: MR review is the preferred method for ascertaining MSPrIs in clinical trials of interventions designed to reduce the incidence of these injuries. When multiple sources of information are used, careful reconciliation of reports is necessary to ensure accuracy.

Association of Cognitive Impairment With Rate of Functional Gain Among Older Adults With Stroke.

OBJECTIVES: This study explored the association between cognitive impairment at admission with self-care and mobility gain rate (amount of change per week) during a post-acute care stay (admission to discharge) for older adults with stroke. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Four inpatient rehabilitation and 6 skilled nursing facilities. A total of 100 adults with primary diagnosis of stroke; mean age 79 years (SD 7.7); 67% women. METHODS: Retrospective cohort study. We evaluated the extent to which cognitive impairment at admission explained variation in weekly gain rate separately for self-care and mobility. Additional covariates were occupational and physical therapy minutes per day, self-care and mobility function at admission, age, and number of comorbidities. RESULTS: Participants were classified as having severe (n = 16), moderate (n = 39), or mild (n = 45) cognitive impairment at admission. Occupational therapy minutes per day (ß = 0.04; P < .01) and Functional Independence Measure (FIM) self-care function at admission (ß = 0.48; P < .01) were both significantly associated with self-care gain rate (Adjusted R2 = 0.18); cognitive impairment group, age, and number of comorbidities were not significant. Only FIM mobility function at admission (ß = 0.29; P < .001) was significantly associated with mobility gain rate (Adjusted R2 = 0.18); cognitive impairment group, physical therapy minutes, age, and number of comorbidities were not significant. CONCLUSIONS AND IMPLICATIONS: These results provide preliminary evidence that patients with stroke who have severe cognitive impairment may benefit from intensive therapy services as well as less severely impaired patients, particularly occupational therapy for improvement in self-care function.

Mapping outcomes for recovery of consciousness in studies from 1986 to 2020: a scoping review protocol.

INTRODUCTION: Historically, heterogeneous outcome assessments have been used to measure recovery of consciousness in patients with disorders of consciousness (DoC) following traumatic brain injury (TBI), making it difficult to compare across studies. To date, however, there is no comprehensive review of clinical outcome assessments that are used in intervention studies of adults with DoC. The objective of this scoping review is to develop a comprehensive inventory of clinical outcome assessments for recovery of consciousness that have been used in clinical studies of adults with DoC following TBI. METHODS AND ANALYSIS: The methodological framework for this review is: (1) identify the research questions, (2) identify relevant studies, (3) select studies, (4) chart the data, (5) collate, summarise and report results and (6) consult stakeholders to drive knowledge translation. We will identify relevant studies by searching the following electronic bibliographic databases: PubMed, Scopus, EMBASE, PsycINFO and The Cochrane Library (including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and Cochrane Methodology Register). Criteria for article inclusion are published in the English-language, peer-reviewed studies of interventions aimed at facilitating recovery of consciousness among adults (> 18 years) with DoC following a severe TBI, published from January 1986 to December 2020. Articles meeting inclusion criteria at this stage will undergo a full text review. We will chart the data by applying the WHO International Classification of Functioning, Disability and Health Framework to identify the content areas of clinical outcome assessments. To support knowledge translation efforts, we will involve clinicians and researchers experienced in TBI care throughout the project from conceptualisation of the study through dissemination of results. ETHICS AND DISSEMINATION: No ethical approval is required for this study as it is not determined to be human subjects research. Results will be presented at national conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: CRD42017058383.

Determining the Hierarchy of Coma Recovery Scale-Revised Rating Scale Categories and Alignment with Aspen Consensus Criteria for Patients with Brain Injury: A Rasch Analysis.

This study aimed to empirically evaluate the hierarchical structure of the Coma Recovery Scale-Revised (CRS-R) rating scale categories and their alignment with the Aspen consensus criteria for determining disorders of consciousness (DoC) following a severe brain injury. CRS-R data from 262 patients with DoC following a severe brain injury were analyzed applying the partial credit Rasch Measurement Model. Rasch Analysis produced logit calibrations for each rating scale category. Twenty-eight of the 29 CRS-R rating scale categories were operationalized to the Aspen consensus criteria. We expected the hierarchical order of the calibrations to reflect Aspen consensus criteria. We also examined the association between the CRS-R Rasch person measures (indicative of performance ability) and states of consciousness as determined by the Aspen consensus criteria. Overall, the order of the 29 rating scale category calibrations reflected current literature regarding the continuum of neurobehavioral function: category 6 "Functional Object Use" of the Motor item was hardest for patients to achieve; category 0 "None" of the Oromotor/Verbal item was easiest to achieve. Of the 29 rating scale categories, six were not ordered as expected. Four rating scale categories reflecting the Vegetative State (VS)/Unresponsive Wakefulness Syndrome (UWS) had higher calibrations (reflecting greater neurobehavioral function) than the easiest Minimally Conscious State (MCS) item (category 2 "Fixation" of the Visual item). Two rating scale categories, one reflecting MCS and one not operationalized to the Aspen consensus criteria, had higher calibrations than the easiest eMCS item (category 2 "Functional: Accurate" of the Communication item). CRS-R person measures (indicating amount of neurobehavioral function) and states of consciousness, based on Aspen consensus criteria, showed a strong correlation (rs = 0.86; p < 0.01). Our study provides empirical evidence for revising the diagnostic criteria for MCS to also include category 2 "Localization to Sound" of the Auditory item and for Emerged from Minimally Conscious State (eMCS) to include category 4 "Consistent Movement to Command" of the Auditory item.

Reporting Guideline for RULER: Rasch Reporting Guideline for Rehabilitation Research: Explanation and Elaboration.

The Rasch Reporting Guideline for Rehabilitation Research (RULER) provides peer-reviewed, evidence-based, transparent, and consistent recommendations for reporting studies that apply Rasch Measurement (RM) Theory in a rehabilitation context. The purpose of the guideline is to ensure that authors, reviewers, and editors have uniform guidance about how to write and evaluate research on rehabilitation outcome assessments. The RULER statement includes an organizing framework and a checklist of 59 recommendations. This companion article supports the RULER statement by providing details about the framework, rationale for the domains and recommendations in the checklist and explaining why these considerations are important for improving consistency and transparency in reporting the results of RM studies. This article is not intended to describe how to conduct RM studies but provides rationale for the essential elements that authors should address in each domain. Consistency and transparency in reporting RM studies will advance rehabilitation research if authors consider these issues when planning their study and include the checklist when they submit their manuscript for peer review. A copy of the checklist can be found at [table 2 in https://doi.org/10.1016/j.apmr.2022.03.013].

"Fluctuation is the norm": Rehabilitation practitioner perspectives on ambiguity and uncertainty in their work with persons in disordered states of consciousness after traumatic brain injury.

The purpose of this study is to describe the clinical lifeworld of rehabilitation practitioners who work with patients in disordered states of consciousness (DoC) after severe traumatic brain injury (TBI). We interviewed 21 practitioners using narrative interviewing methods from two specialty health systems that admit patients in DoC to inpatient rehabilitation. The overarching theme arising from the interview data is "Experiencing ambiguity and uncertainty in clinical reasoning about consciousness" when treating persons in DoC. We describe practitioners' practices of looking for consistency, making sense of ambiguous and hard to explain patient responses, and using trial and error or "tinkering" to care for patients. Due to scientific uncertainty about diagnosis and prognosis in DoC and ambiguity about interpretation of patient responses, working in the field of DoC disrupts the canonical meaning-making processes that practitioners have been trained in. Studying the lifeworld of rehabilitation practitioners through their story-making and story-telling uncovers taken-for-granted assumptions and normative structures that may exist in rehabilitation medical and scientific culture, including practitioner training. We are interested in understanding these canonical breaches in order to make visible how practitioners make meaning while treating patients.

Rasch Reporting Guideline for Rehabilitation Research (RULER): the RULER Statement.

The application of Rasch Measurement (RM) Theory to rehabilitation assessments has proliferated in recent years. RM Theory helps design and refine assessments so that items reflect a unidimensional construct in an equal interval metric that distinguishes among persons of different abilities in a manner that is consistent with the underlying trait. Rapid growth of RM in rehabilitation assessment studies has led to inconsistent results reporting. Clear, consistent, transparent reporting of RM Theory results is important for advancing rehabilitation science and practice based on precise measures. Precise measures, in turn, provide researchers, practitioners, patients, and other stakeholders with tools for effective decision making. The goal of this Rasch Reporting Guideline for Rehabilitation Research (RULER: Rasch Reporting Guideline for Rehabilitation Research) is to provide peer-reviewed, evidence-based, transparent, and consistent recommendations for reporting studies that apply RM Theory in a rehabilitation context. The purpose of the guideline is to ensure that authors, reviewers, and editors have uniform expectations about how to write and evaluate research on rehabilitation outcome assessments. A task force of rehabilitation researchers, clinicians, and editors met regularly between November 2018 and August 2020 to identify the need for the guideline, develop an organizing framework, identify content areas, and develop the recommendations. This RULER: Rasch Reporting Guideline for Rehabilitation Research statement includes the organizing framework and a checklist of 59 recommendations. The guideline is supported by an Explanation and Elaboration article that provides more detail about the framework and recommendations in the checklist. A glossary of key terms and a recommended iterations table are provided in supplemental online only materials.

Characterizing Standardized Functional Data at Inpatient Rehabilitation Facilities.

OBJECTIVE: The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates using standardized patient functional data across post-acute settings. This study characterized similarities and differences in clinician-observed scores of self-care and transfer items for the standardized section GG functional domain and the functional independent measure (FIM) at inpatient rehabilitation facilities. DESIGN: We conducted secondary analyses of 2017 Uniform Data System for Medical Rehabilitation national data. Patients were assessed by clinicians on both section GG and FIM at admission and discharge. We identified 7 self-care items and 6 transfer items in section GG conceptually equivalent with FIM. Clinician-assessed scores for each pair of items were examined using score distributions, Bland-Altman plot, correlation (Pearson coefficients), and agreement (kappa and weighted kappa) analyses. SETTING AND PARTICIPANTS: In all, 408,491 patients were admitted to Uniform Data System for Medical Rehabilitation-affiliated inpatient rehabilitation facilities with one of the following impairments: stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility. MEASURES: Section GG and FIM. RESULTS: Patients were scored as more functionally independent in section GG compared with FIM, but change score distributions and score orders within impairment groups were similar. Total scores in section GG had strong positive correlations (self-care: r = 0.87 and 0.95; transfer: r = 0.82 and 0.90 at admission and discharge, respectively) with total FIM scores. Weak to moderate ranking agreements with total FIM scores were observed (self-care: kappa = 0.49 and 0.60; transfers: kappa = 0.43 and 0.52 at admission and discharge, respectively). Lower agreements were observed for less able patients at admission and for higher ability patients of their change scores. CONCLUSIONS AND IMPLICATIONS: Overall, response patterns were similar in section GG and FIM across impairments. However, variations exist in score distributions and ranking agreement. Future research should examine the use of GG codes to maintain effective care, outcomes, and unbiased reimbursement across post-acute settings.

Psychometric Properties and Sex Differences on the Mayo-Portland Adaptability Inventory Participation Subscale (M2PI) in Veterans With Traumatic Brain Injury.

OBJECTIVE: To evaluate the structural validity of the Mayo-Portland Adaptability Inventory Participation Index (M2PI) in a sample of veterans and to assess whether the tool functioned similarly for male and female veterans. DESIGN: Rasch analysis of M2PI records from the National Veterans Traumatic Brain Injury Health Registry database from 2012-2018. SETTING: National VA Polytrauma System of Care outpatient settings. PARTICIPANTS: Veterans with a clinically confirmed history of traumatic brain injury (TBI) (N=6065; 94% male). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: M2PI, a 5-point Likert-type scale with 8 items. For this analysis, the 2 employment items were treated individually for a total of 9 items. RESULTS: The employment items misfit the Rasch Measurement model (paid employment mean square [MnSq]=1.40; other employment MnSq=1.34) and were removed from subsequent iterations. The final model had eigenvalue 1.87 on the first contrast, suggesting unidimensionality of the remaining 7 items. Item order from least to most participation restriction was transportation, self-care, residence management, financial management, initiation, leisure, and social contact. Wright's person separation reliability for nonnormal distributions was 0.93, indicating appropriateness of M2PI for making individual-level treatment decisions. Mean person measure was -0.92±1.34 logits, suggesting that participants did not report restrictions on most items (item mean=0 logits). A total of 3.8% of the sample had the minimum score (no impairment on all items), and 0.2% had the maximum score. Four items had different item calibrations (≥0.25 logits) for female compared with male veterans, but the hierarchy of items was unchanged when the female sample was examined separately. CONCLUSIONS: These findings suggest that, although employment is a poor indicator of participation restrictions among veterans with TBI, the M2PI is unidimensional. Because of subtle differences in scale function between male and female participants, M2PI should be part of a more thorough clinical interview about participation strengths and restrictions.

Psychometric measurement properties of the world health organization disability assessment schedule 2.0 (WHODAS) evaluated among veterans with mild traumatic brain injury and behavioral health conditions.

PURPOSE: Examine the psychometric properties of the World Health Organization Disability Assessment Schedule 2.0 among U.S. Iraq/Afghanistan Veterans with a combination of mild traumatic brain injury and behavioral health conditions using Rasch analysis. METHODS: 307 Veterans were classified as either combat control (n = 141), or one of three clinical groups: mild traumatic brain injury (n = 10), behavioral health conditions (n = 24), or both (n = 128). Data from the three clinical groups were used to establish step and item calibrations serving as anchors when including the control group. RESULTS: Measurement precision was excellent (person separation reliability = 0.93). Ordering of item calibrations formed a logical hierarchy. Test items were off-target (too easy) for the clinical groups. Principal component analysis indicated unidimensionality although 4/36 items misfit the measurement model. No meaningful differential item functioning was detected. There was a moderate effect size (Hedge's g = 1.64) between the control and clinical groups. CONCLUSIONS: The World Health Organization Disability Assessment Schedule was suitable for our study sample, distinguishing 4 levels of functional ability. Although items may be easy for some Veterans with mild traumatic brain injury and/or behavioral health conditions, the World Health Organization Disability Assessment Schedule can be used to capture disability information for those with moderate to severe disability.Implications for rehabilitationPersistent functional disability is seen in military and civilian populations with mild traumatic brain injury which often co-occurs with behavioral health conditions.A comprehensive measure of disability is needed to distinguish between levels of disability to inform clinical decisions for individual patients and to detect treatment effects between groups in research.Results of this analysis indicate the World Health Organization Disability Assessment Schedule items are sufficiently unidimensional to evaluate level of disability in the moderate and severe range among persons with mild traumatic brain injury with and without behavioral health conditions.Further examination of the psychometric properties of the World Health Organization.Disability Assessment Schedule is necessary before measurement of disability is recommended for those with less than moderate levels of disability.

Combining Items From 3 Federally Mandated Assessments Using Rasch Measurement to Reliably Measure Cognition Across Postacute Care Settings.

OBJECTIVE: To combine items from the Functional Independence Measure, Minimum Data Set (MDS) 2.0, and the Outcome and Assessment Information Set (OASIS)-B to reliably measure cognition across postacute care settings and facilitate future studies of patient cognitive recovery. DESIGN: Rasch analysis of data from a prospective, observational cohort study. SETTING: Postacute care inclusive of inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies. PARTICIPANTS: Patients (N=147) receiving rehabilitation services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional Independence Measure, MDS 2.0, and the OASIS-B. RESULTS: Six cognition items demonstrated good construct validity with no misfitting items, unidimensionality, good precision (person separation reliability, 0.95), and an item hierarchy that reflected a clinically meaningful continuum of cognitive challenge. CONCLUSIONS: This is the first attempt to combine the cognition items from the 3 historically, federally mandated assessments to create a common metric for cognition. These 6 items could be adopted as standardized patient assessment data elements to improve cognitive assessment across postacute care settings.

Cognition and Other Predictors of Functional Disability Among Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder.

BACKGROUND: Limitations in everyday functioning are frequently reported by veterans with a history of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). Multiple factors are associated with functional disability among veterans, including depression, poor social support, cognition, and substance use. However, the degree to which these factors, particularly cognitive capacities, contribute to functional limitations remains unclear. METHODS: We evaluated performance on tests of processing speed, executive functioning, attention, and memory as predictors of functioning on the World Health Organization Disability Assessment Scale (WHODAS) 2.0 in 288 veterans. Participants were placed in one of the following groups: PTSD-only, mTBI-only, mTBI + PTSD, and neither PTSD nor mTBI (deployed control group). Cognitive test performances were evaluated as predictors of WHODAS 2.0 functional ratings in regression models that included demographic variables and a range of mood, behavioral health, and postconcussive symptom ratings. RESULTS: Multiple cognitive test performances predicted WHODAS 2.0 scores in the deployed control group, but they generally did not predict functioning in the clinical groups when accounting for demographics, mood, behavioral health, and postconcussive symptoms. CONCLUSIONS: In veterans with mTBI and/or PTSD, cognitive test performances are less associated with everyday functioning than mood and postconcussive symptoms.

Association of Therapy Time Per Day With Functional Outcomes and Rate of Recovery in Older Adults After Elective Joint Replacement Surgery.

OBJECTIVES: To explore the association between therapy minutes per length of stay (LOS) day (TMLD), functional outcomes, and rate of functional recovery among older adults after elective hip or knee replacement surgery across postacute (PAC) settings. DESIGN: Secondary analysis of data collected for an observational cohort study from 2005 to 2010. SETTING: Four inpatient rehabilitation facilities (IRF) and 7 skilled nursing facilities (SNF). PARTICIPANTS: Adults aged 65 years or older (N=162) with Medicare fee-for-service insurance and a primary diagnosis of elective hip or knee replacement. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM mobility and self-care measures at discharge. RESULTS: The TMLD was divided into high, medium, and low categories. Participants were grouped into low, medium, and high gain rate groups based on their average change in mobility and self-care FIM measures per LOS day. Gain rate and TMLD groups were crossmapped to create 9 gain-TMLD groups separately for mobility and self-care. There were no significant differences in admission mobility or self-care measures by gain rate and TMLD trajectory or by facility type (IRF or SNF). TMLD was not significantly associated with discharge mobility measures. Participants in high gain trajectories attained independence with mobility and self-care tasks at discharge regardless of TMLD. Those in low gain trajectories needed supervision or assistance on all mobility tasks. Older age and greater pain at discharge were significantly associated with lower odds of being in the medium or high gain rate groups. CONCLUSIONS: For clinicians and facility managers who must care for patients with constrained resources, the shift to value-based reimbursement for rehabilitation services in PAC settings has reinvigorated the question of whether the duration of therapy provided influences patient outcomes. Three hours of daily therapy after joint replacement surgery may exceed what is necessary for recovery. Postsurgical pain management remains a significant challenge in older adults.

Psychometric Properties of the Coma Near-Coma Scale for Adults in Disordered States of Consciousness: A Rasch Analysis.

OBJECTIVES: To examine the construct validity and measurement precision of the Coma Near-Coma scale (CNC) in measuring neurobehavioral function (NBF) in patients with disorders of consciousness receiving postacute care rehabilitation. DESIGN: Rasch analysis of retrospective data. PARTICIPANTS: Participants (N=48) with disordered consciousness who were admitted to postacute care rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: CNC. RESULTS: Assessment with CNC repeated weekly until the participant was conscious or discharged from the postacute care facility (451 participant records). Rating scale steps were ordered for all items. Eight of the 10 CNC items evaluated in this study fit the measurement model (χ2=5332.58; df=11; P=.17); pain items formed a distinct construct. The ordering of the 8 items from most to least challenging makes clinical sense and compares favorably with other published hierarchies of NBF. Tactile items are more easily responded to. Visual and auditory items requiring higher cognitive processing were more challenging. In the full sample, the CNC achieved good measurement precision, with a person separation reliability of 0.87. CONCLUSIONS: The items of the CNC reflect good construct validity and acceptable interrater reliability. The measurement precision achieved indicates that the CNC may be used to make decisions about groups of individuals but that these items may not be sufficiently precise for individual patient treatment decision-making.

Association of Therapy Time and Cognitive Recovery in Stroke Patients in Post-Acute Rehabilitation.

OBJECTIVES: Cognitive impairment is highly prevalent after stroke, with 77% of people having impairment in at least 2 cognitive domains. The purpose of this study is to describe the association between therapy minutes per length of stay (LOS) day and cognitive recovery in patients receiving rehabilitation services in inpatient post-acute care facilities following a stroke. DESIGN: Secondary analyses of data collected in inpatient rehabilitation and skilled nursing facilities from 2005 to 2010 for an observational cohort study. SETTING AND PARTICIPANTS: Participants were adults aged ≥65 years with Medicare insurance and primary diagnosis of stroke (N = 100). Participants who met criteria for dementia (n = 5) were excluded from analyses. We calculated therapy minutes per LOS day for occupational therapy, physical therapy, speech-language pathology, and all therapies combined; therapy times were dichotomized into high or low minutes per LOS day (MLD). We used an ordinary least squares regression model for cognitive outcome at discharge to control for cognitive status at admission, therapy intensity by discipline, and LOS. RESULTS: At baseline, participants were classified as having severe (n = 11), moderate (n = 39), or mild (n = 45) cognitive impairment. Impairment groups were not significantly different on any demographic variables. The adjusted regression model showed that high occupational therapy MLD (>50 minutes per LOS day) (P = .028) was significantly associated with cognitive measure at discharge compared with low occupational therapy MLD when controlling for cognitive impairment group at baseline (P < .001). Neither high physical therapy MLD nor speech-language pathology MLD was significantly associated with cognitive outcome relative to their respective low TMLD groups. CONCLUSIONS AND IMPLICATIONS: Our results show that higher-intensity occupational therapy services were associated with better cognitive outcome at discharge from inpatient rehabilitation after stroke. Findings also suggest that volume of therapy alone does not necessarily produce optimal outcomes. Both amount and type of therapy should be tailored to meet the needs of individual patients.