Predicting trends of community participation after hospital discharge for younger adults after stroke.

BACKGROUND: Community participation is an indicator of recovery for younger adults after stroke who generally have a greater need to return to society than do older adults. However, little is known about the trends of participation and their determinants in this population. OBJECTIVE: To explore the trends of community participation by younger (<65 years) adults with stroke in Taiwan after their hospital discharge and to identify predictors of these trends. METHODS: This longitudinal, multicenter, prospective cohort study enrolled 570 relatively young adults (aged 20-65 years) with stroke. Participants were assessed at hospital discharge and at 3-, 6-, and 12-month follow-up. The primary outcome measure was the Participation Measure-3 Domains, 4 Dimensions (PM-3D4D). Sociodemographic and stroke-related variables were derived by using standardized instruments and questionnaires. Mixed models were used to derive the trends of each participation domain and to identify predictors. RESULTS: PM-3D4D score changes showed a positive trend from discharge to 1-year follow-up (particularly in social and community subscales); however, the improvement was mild and mainly occurred in the first 3 months. Sociodemographic factors, such as income and education levels, and stroke-related variables, such as stroke severity, comorbidity, and physical function, significantly predicted changes in PM-3D4D scores over time. Physical function demonstrated the strongest prediction ability for all participation domains and dimensions. CONCLUSION: Multiple sociodemographic and stroke-related variables, particularly physical function, predicted improvement in community participation by younger adults after stroke. These findings may help clinicians identify younger adults at risk of unfavorable long-term participation outcomes after stroke.

Development of an applied cognition scale to measure rehabilitation outcomes.

OBJECTIVE: To examine the structure and content coverage of an item pool of new items based on the Activity categories from the International Classification of Functioning, Disability and Health and items from existing instruments to measure the applied cognition dimension of function. DESIGN: Prospective study. SETTING: Four postacute care rehabilitation settings (inpatient, transitional care, home care, outpatient) in an urban-suburban area of northeast United States. PARTICIPANTS: Convenience sample of 477 patients (mean age, 62.7 y) receiving rehabilitation services for neurologic, orthopedic, or complex medical conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were administered applied cognition items from the new Activity Measure for Post-Acute Care, the Medical Outcomes Study 8-Item Short-Form Health Survey, and an additional setting-specific measure: the FIM instrument (inpatient rehabilitation); the Minimum Data Set (skilled nursing facility); the Minimum Data Set-Post Acute Care (postacute settings); or the Outcome Assessment and Information Set (home care). Rasch (partial-credit model) analyses were conducted to examine item fit, item coverage, scale unidimensionality, and category difficulty estimates. RESULTS: The majority of items (46/59) could be located along a single continuum. Relatively few people were performing at the lower end of the difficulty scale, and about 25% were at ceiling. CONCLUSIONS: The proposed definition of applied cognition dimension provides a useful guide for item development to measure this dimension. Further work is needed to determine how best to measure function in this domain for people at the upper and lower ends of the continuum.

Pediatric physical functioning reference curves.

We developed normative profiles of physical functioning (mobility and self-care) in infancy up through 14 years of age with an expanded version of the Pediatric Evaluation of Disability Inventory. Mobility and self-care reference curves were based on the original Pediatric Evaluation of Disability Inventory standardization data (n = 412) and data from an additional cross-sectional, convenience sample (n = 373) via web-based survey, telephone or in-person interviews of parents. This new sample, which included children up through 14 years-of-age, was stratified for race, age, and sex, but was primarily limited geographically to the Northeast region of the United States. Goodness of fit of male, female, and combined sex (male and female) reference curves was examined. The mobility and self-care reference curves produced efficient and well-fitting estimates of conventional percentiles (3rd, 10th, 25th, 50th, 75th, 97th). Differences between males' and females' reference curves were negligible. This study highlights the use of these reference curves for determining the functional impact of Pompe disease, a lysosomal storage disorder that affects skeletal and cardiac muscle, restricting normal expression of mobility and self-care activities. This physical functioning instrument could also be used to evaluate the impact of muscle weakness in other neuromuscular disorders.

Refining the conceptual basis for rehabilitation outcome measurement: personal care and instrumental activities domain.

BACKGROUND: Rehabilitation outcome measures routinely include content on performance of daily activities; however, the conceptual basis for item selection is rarely specified. These instruments differ significantly in format, number, and specificity of daily activity items and in the measurement dimensions and type of scale used to specify levels of performance. We propose that a requirement for upper limb and hand skills underlies many activities of daily living (ADL) and instrumental activities of daily living (IADL) items in current instruments, and that items selected based on this definition can be placed along a single functional continuum. OBJECTIVE: To examine the dimensional structure and content coverage of a Personal Care and Instrumental Activities item set and to examine the comparability of items from existing instruments and a set of new items as measures of this domain. METHODS: Participants (N = 477) from 3 different disability groups and 4 settings representing the continuum of postacute rehabilitation care were administered the newly developed Activity Measure for Post-Acute Care (AM-PAC), the SF-8, and an additional setting-specific measure: FIM (in-patient rehabilitation); MDS (skilled nursing facility); MDS-PAC (postacute settings); OASIS (home care); or PF-10 (outpatient clinic). Rasch (partial-credit model) analyses were conducted on a set of 62 items covering the Personal Care and Instrumental domain to examine item fit, item functioning, and category difficulty estimates and unidimensionality. RESULTS: After removing 6 misfitting items, the remaining 56 items fit acceptably along the hypothesized continuum. Analyses yielded different difficulty estimates for the maximum score (eg, "Independent performance") for items with comparable content from different instruments. Items showed little differential item functioning across age, diagnosis, or severity groups, and 92% of the participants fit the model. CONCLUSIONS: ADL and IADL items from existing rehabilitation outcomes instruments that depend on skilled upper limb and hand use can be located along a single continuum, along with the new personal care and instrumental items of the AM-PAC addressing gaps in content. Results support the validity of the proposed definition of the Personal Care and Instrumental Activities dimension of function as a guide for future development of rehabilitation outcome instruments, such as linked, setting-specific short forms and computerized adaptive testing approaches.

Is patient-reported function reliable for monitoring postacute outcomes?

OBJECTIVE: A major challenge in the development of a comprehensive measurement system to evaluate effectiveness across a broad range of postacute care settings is the stability and consistency of outcomes measures across respondents and settings. The objective of this study was to investigate the test-retest and subject-proxy reliability of activity scores for use in a new postacute care outcome instrument using an interview format across different care settings. DESIGN: Twenty-five subjects were randomly selected from a larger study of 485 individuals and were interviewed on two occasions within 1 to 4 days to assess self-reported test-retest reliability of summary scores of the Activity Measure-Post-Acute Care item pool. Proxy reliability was tested by interviewing the primary physical or occupational therapist or family member using an identical questionnaire in addition to the subject in 45 patients. RESULTS: Test-retest and subject-proxy reliability was acceptable for the three domains of the activity construct: physical and movement, personal and instrumental, and applied cognition with intraclass correlation coefficients of the summary scores of each of the three domains ranging between 0.91 and 0.97 for test-retest and 0.68 and 0.90 for subject-proxy. CONCLUSIONS: Reliability is adequate to justify use of these activity scales across respondents and settings.