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.

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.

A National Survey of Prosthesis Use in Veterans with Major Upper Limb Amputation: Comparisons by Gender.

BACKGROUND: A better understanding of women veterans with upper limb amputation is needed. OBJECTIVE: To compare prosthetic use and outcomes of female and male veterans with upper limb amputation. DESIGN: Cross-sectional survey: Amputation characteristics, prosthesis use, and quality of life outcomes were compared by gender. Separate logistic regression models examined association of gender with prosthesis use and receipt of training to use a prosthesis. Separate linear regression models examined the relationship between gender and health-related quality of life (HRQoL) outcomes. PARTICIPANTS: Participants were veterans with major upper limb amputation who received care at the Department of Veterans Affairs (VA) in 2010-2015, identified from VA data sources. A total of 808 individuals (755 men, 21 women) were surveyed by telephone. MAIN OUTCOME MEASURES: Disabilities of the Arm, Shoulder and Hand (QuickDASH), VR-12 Physical Component Summary (PCS) and VR-12 Mental Component Summary (MCS), Trinity Amputation and Prosthetic Experience Scale satisfaction scale, Orthotics and Prosthetic User's Survey client satisfaction with devices scale. SETTING: Telephone survey of community dwelling participants. INTERVENTIONS: Not applicable. RESULTS: Survey response rate was 47.3% for men and 62.8% for women. Women were less likely to have ever used a prosthesis (adjusted odds ratio [aOR] = 0.26; confidence interval [CI] 0.08-0.88), have received training for an initial prosthesis (aOR: 0.24; CI 0.08-0.70), be current users (aOR = 0.34; CI 0.12-1.01), and have received training for a current prosthesis (aOR: 0.15; 0.03-0.87). A greater proportion of women used cosmetic and a smaller proportion used body-powered devices compared to men (P < .05). Device heaviness or fatigue was the most common reason for abandonment. There were no significant differences in outcome measures by gender. CONCLUSIONS: Women were less likely than men to have ever used and currently use prostheses or to have received prosthetic training, more likely to use cosmetic devices, and less likely to use body-powered devices. Efforts to develop prostheses that are cosmetically acceptable, yet lightweight and functional, are needed.

How do the outcomes of the DEKA Arm compare to conventional prostheses?

OBJECTIVES: Objectives were to 1) compare self-reported function, dexterity, activity performance, quality of life and community integration of the DEKA Arm to conventional prostheses; and 2) examine differences in outcomes by conventional prosthesis type, terminal device type and by DEKA Arm configuration level. METHODS: This was a two-part study; Part A consisted of in-laboratory training. Part B consisted of home use. Study participants were 23 prosthesis users (mean age = 45 ± 16; 87% male) who completed Part A, and 15 (mean age = 45 ± 18; 87% male) who completed Parts A and B. Outcomes including self-report and performance measures, were collected at Baseline using participants' personal prostheses and at the End of Parts A and B. Scores were compared using paired t-tests. Wilcoxon signed-rank tests were used to compare outcomes for the full sample, and for the sample stratified by device and terminal device type. Analysis of outcomes by configuration level was performed graphically. RESULTS: At the End of Part A activity performance using the DEKA Arm and conventional prosthesis was equivalent, but slower with the DEKA Arm. After Part B, performance using the DEKA Arm surpassed conventional prosthesis scores, and speed of activity completion was equivalent. Participants reported using the DEKA Arm to perform more activities, had less perceived disability, and less difficulty in activities at the End of A and B as compared to Baseline. No differences were observed in dexterity, prosthetic skill, spontaneity, pain, community integration or quality of life. Comparisons stratified by device type revealed similar patterns. Graphic comparisons revealed variations by configuration level. CONCLUSION: Participants using the DEKA Arm had less perceived disability and more engagement of the prosthesis in everyday tasks, although activity performance was slower. After home use experience, activity performance was improved and activity speed equivalent to using conventional prostheses.

Perceptions of satisfaction, usability and desirability of the DEKA Arm before and after a trial of home use.

OBJECTIVES: To: 1) describe perceptions of satisfaction with and usability of the DEKA Arm and preferences for the DEKA Arm or personal prosthesis; 2) compare perceptions of satisfaction and usability by DEKA Arm configuration level; and 3) evaluate satisfaction and usability for study completers and non-completers; and for those who did and did not want to receive a DEKA Arm. METHODS: The study had 2 phases: in-laboratory (Part A) and home trial (Part B). 32 participants with amputation, (50% transradial, 38% transhumeral and 13% shoulder) completed Part A and 18 completed Part B 16 (89%) of whom were prosthesis users at baseline. Measures of satisfaction, usability and user preferences were administered. Responses were compared for completers of Part A only and completers of Parts A and B. Preferences for the DEKA Arm over personal prosthesis and proportion of participants who wanted to receive a DEKA Arm were evaluated. Relationships between satisfaction, usability and desire to receive a DEKA Arm were examined. RESULTS: At end of Part A, 22 (69%) of the 32 participants who completed in-laboratory training wanted to receive a DEKA Arm and 5 (16%) might want one. At end of Part B, 14 (88%) of 16 prosthesis users who completed the home trial preferred the overall function of the DEKA Arm, 13 (81%) preferred DEKA hand function and 14 (88%) preferred DEKA wrist function to their own prosthesis. In contrast, 14 (88%) preferred the weight and 13 (81%) preferred the look of their own prosthesis. Most aspects of the DEKA Arm were rated "easy" to use. No items were rated as "difficult". Users were satisfied with most aspects of the DEKA Arm, except for the weight, shoulder appearance and harnessing. There were few differences in perceived usability or satisfaction by configuration level. Findings about desire to receive a DEKA Arm pertain only to study completers. Non-completers viewed the DEKA Arm less favorably than completers. Satisfaction was strongly related to participants' expressed desire to receive a DEKA Arm in the future. SIGNIFICANCE: To maximize likelihood of adoption of the DEKA Arm, findings suggest that both an in-laboratory and a home use trial may be useful prior to finalizing a recommendation for prescription.

Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial.

BACKGROUND: Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve. OBJECTIVE: We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans. DESIGN: This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans. PARTICIPANTS: Homeless Veterans not receiving primary care participated in the study. INTERVENTIONS: An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented. MAIN MEASURE: We measured receipt of primary care within 4 weeks of study enrollment. KEY RESULTS: Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6% were male, 43.0% were from a minority population, 12.0% were unsheltered, 25.5% were staying in a dusk-to-dawn emergency shelter, 26.1% were in transitional housing, while 27.7% were in an unstable, doubled-up arrangement. At one month, 77.3% of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7% had been seen in primary care. This was followed by the CO-only group, 50.0% of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0% and the Usual Care arm at 30.6%. Chi-squared tests by group were significant (p < 0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care. CONCLUSIONS: Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.

Factors associated with utilization of preoperative and postoperative rehabilitation services by patients with amputation in the VA system: an observational study.

BACKGROUND: The Department of Veterans Affairs (VA) and the Department of Defense published evidence-based guidelines to standardize and improve rehabilitation of veterans with lower limb amputations; however, no studies have examined the guidelines' impact. OBJECTIVES: The purposes of this study were: (1) to describe the utilization of rehabilitative services in the acute care setting by people who underwent major lower limb amputation in the VA from 2005 to 2010, (2) to identify factors associated with receipt of rehabilitation services, and (3) to examine the impact of the guidelines on service receipt. DESIGN: A cross-sectional study of 12,599 patients, who underwent major surgical amputation of the lower limb at a VA medical center from January 1, 2005, to December 31, 2010, was conducted. Data were obtained from main and surgical inpatient datasets and the inpatient encounters files of the Veterans Health Administration databases. METHODS: Rehabilitation services were categorized as physical therapy, occupational therapy, and either (any therapy), before or after amputation. Separate multivariate logistic regressions examined the impact of guideline implementation and identified factors associated with service receipt. RESULTS: Patients were 1.45 and 1.73 times more likely to receive preoperative physical therapy and occupational therapy and 1.68 and 1.79 times more likely to receive postoperative physical therapy and occupational therapy after guideline implementation. Patients in the Northeast had the lowest likelihood of receiving preoperative and postoperative rehabilitation services, whereas patients in the West had the highest likelihood. Other patient characteristics associated with service receipt were identified. LIMITATIONS: The sample included only veterans who had surgeries at VA Medical Centers and cannot be generalized to veterans with surgeries outside the VA or to nonveteran patients and settings. CONCLUSIONS: Further quality improvement efforts are needed to standardize delivery of rehabilitation services for veterans with amputations in the acute care setting.

Association of change in depression and anxiety symptoms with functional outcomes in pulmonary rehabilitation patients.

OBJECTIVE: Pulmonary rehabilitation (PR) has emerged over the last decade as an essential component of an integrated approach to managing patients with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD). We sought to examine how depression and anxiety symptom changes relate to disease-specific quality of life outcomes following PR. METHODS: We performed a cohort study of 81 patients with COPD who completed PR at a Veterans Administration Medical Center. Pulmonary rehabilitation consisted of supervised exercise training and education twice weekly for 8 weeks. Beck Depression and Anxiety Inventories (BDI and BAI) assessed symptom burden at baseline and completion of PR. We measured change in disease-specific quality of life using the dyspnea, mastery, emotion and fatigue domains of the Chronic Respiratory Questionnaire Self-Reported (CRQ-SR) from baseline to completion of PR. RESULTS: Participants were 69.8±9.1 years old and all male. Forced expiratory volume in 1 s (FEV1) was 1.23±0.39 L. The CRQ-SR scores improved significantly: dyspnea (P<.0001), mastery (P=.015) and fatigue (P=.017). The BDI scores improved significantly (13.1±10.5 to 10.8±9.9, P=.003; BAI: 13.1±10.1 to 12.1±11.7). Multivariate regression models controlling for age, FEV1, depression treatment and anxiety treatment showed that improvement in depressive symptoms were associated with improvement in fatigue (P=.003), emotion (P=.003) and mastery (P=.01). Anxiety symptom change was not significantly associated with change in disease-specific quality of life domains. CONCLUSION: Addressing anxiety symptoms in PR patients may be indicated because disease-specific quality of life improvement appears to be associated with mood.