Rural and Urban Home Modification Program Users: A Comparative Study.

OBJECTIVE: To understand the sociodemographic, geographical, and clinical characteristics of rural veterans utilizing home modification (HM) healthcare services under the Home Improvement Structural Alterations (HISA) program, to compare these characteristics between rural and urban veteran users, to estimate the costs of HMs performed, and to present distance that users traveled to HISA-prescribing medical facilities within the Veterans Health Administration (VHA). BACKGROUND: Accessible housing is in short supply. HMs allow veterans with disabilities (VWDs) to remain living at home rather than enter institutional-type settings. HISA is associated with decreased inpatient hospitalization rates and increased use of preventative healthcare via outpatient clinic visits. Home accessibility provides psychological benefits improving social interactions and interaction with the physical environment. METHODS: This retrospective database study analyzes data from the National Prosthetics Patient Database and other medical datasets within the VHA. RESULTS: Results provide a profile of and comparison between rural and urban veteran users. HISA users are substantially older compared to younger VWDs. The frequency of bathroom, railing, and wooden ramp HMs differed significantly between rural and urban users (p values < .001). Rural users traveled more miles than urban users to reach a prescribing facility. CONCLUSIONS: Older adults and individuals with disabilities have unmet housing needs since accessible housing is in short supply. This HM healthcare service is helping to meet the housing accessibility needs of older veterans, VWDs, older adults, and people with disabilities, in general.

Predictors of County-Level Home Modification Use Across the US.

Background: Geospatial analyses illustrating where the Home Improvements and Structural Alterations program (HISA) have been prescribed suggest that home modification (HM) services under US Department of Veterans Affairs (VA) is not prescribed and used uniformly across the US. Methods: The objective of this study was to identify county characteristics associated with HISA use rates, such as county-level measures of clinical care and quality of care, variables related to physical environment, and sociodemographic characteristics. Multiple regression analysis was used to predict county-level utilization rate from county-level variables. Results: County-level HISA use was highly skewed and ranged from 0.09 to 59.7%, with a mean of 6.6% and median of 5%. Percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = -8.99, P = .005). The higher the proportion of uninsured adults the lower the HISA utilization rate. The county rate of preventable hospital stays was positively related to county-level HISA utilization rate (b = .0004, P = .009). County-level predictors of housing quality were not significantly associated with county-level HISA utilization rate. Conclusions: Our research fills a gap in the literature about the impact of county-level variables and the geographic distribution and use of HISA. More research is needed to understand and account for geographical variation in HISA use. This work serves as a first step at quantifying and predicting HISA utilization rate at a broad level, with the goal of increasing access to HMs for veterans with disabilities.

Home Modifications for Rural Veterans With Disabilities.

BACKGROUND: Appropriate home modifications (HMs) can make the home environment accessible and relatively safe by reducing the risk of falls. Of special concern are individuals living alone, living in rural communities, and/or living in substandard housing. The Home Improvements and Structural Alterations (HISA) is a Veterans Health Administration (VHA) benefit program providing HMs for veterans with disabilities. METHODS: The objective of this study was to detail the profile of rural veteran (RV) HISA users and report on national HISA utilization patterns. We compare use at US Department of Veterans Affairs (VA) medical centers of varying complexity levels, and in VA regions. An examination of the relationship between travel time/distance and HISA utilization is also provided. This retrospective database study uses GeoSpatial analyses and 3 VA sources: The National Prosthetics Patient Database, the VHA Medical Inpatient Dataset, and the VHA Outpatient Dataset. RESULTS: From 2015 through 2018, 10,810 RVs used HISA with a mean age of 70.9 years. A majority of participants were White (79.5%), married (74.3%), and male (96.5%) veterans. They traveled a mean of 79.8 miles for 94.5 minutes to reach a facility where they received a HISA prescription. Nearly 75% of HISA users were able to receive a HISA prescription from their nearest facility, while about one-quarter traveled to a facility farther away, of which 43% travelled between 100 and 200 miles to obtain the HISA benefit. The top categories of diagnoses were musculoskeletal (19.1%), neurologic (12.5%), and cardiovascular (5.4%). There were about 11,166 HM prescriptions afforded to rural HISA users during the period, including bathroom (82.4%), doorway (4.9%), and railing (3.6%) modifications. CONCLUSIONS: This study documents the national demographics and clinical characteristics of rural HISA users, data that may be useful to policy makers, HM service providers and advocate as well as HISA administrators in predicting future use and users.

Disentangling neural processes of egocentric and allocentric mental spatial transformations using whole-body photos of self and other.

Mental imagery of one's body moving through space is important for imagining changing visuospatial perspectives, as well as for determining how we might appear to other people. Previous neuroimaging research has implicated the temporoparietal junction (TPJ) in this process. It is unclear, however, how neural activity in the TPJ relates to the rotation perspectives from which mental spatial transformation (MST) of one's own body can take place, i.e. from an egocentric or an allocentric perspective. It is also unclear whether TPJ involvement in MST is self-specific or whether the TPJ may also be involved in MST of other human bodies. The aim of the current study was to disentangle neural processes involved in egocentric versus allocentric MSTs of human bodies representing self and other. We measured functional brain activity of healthy participants while they performed egocentric and allocentric MSTs in relation to whole-body photographs of themselves and a same-sex stranger. Findings indicated higher blood oxygen level-dependent (BOLD) response in bilateral TPJ during egocentric versus allocentric MST. Moreover, BOLD response in the TPJ during egocentric MST correlated positively with self-report scores indicating how awkward participants felt while viewing whole-body photos of themselves. These findings considerably advance our understanding of TPJ involvement in MST and its interplay with self-awareness.

Healthcare utilization following mild traumatic brain injury in female veterans.

BACKGROUND: Mild traumatic brain injury (TBI) is a significant problem for Veterans. Gender differences in mild TBI outcomes such as return-to-work, resolution of symptoms and mental health diagnoses have been reported. The purpose of the study is to characterize gender differences in VA healthcare utilization in the year following mild TBI diagnosis. METHODS: This was a retrospective database study of 12 144 Veterans diagnosed with mild TBI in fiscal year 2008 and their healthcare utilization in the following year. RESULTS: The mean age was 43.6 ± 17 and the majority were men (94.1%). Overall, women had more outpatient utilization than men with mild TBI (mean: 48 vs. 37 visits; p ≤ 0.001). Adjusted analyses indicated that women had a rate of outpatient utilization 25% higher than men (IRR = 1.25, 95% CI = 1.17-1.33). It was found that 13.6% of the difference in outpatient utilization by gender could be explained by other factors such as race, age, marital status, geographic location and illness burden. CONCLUSION: Male Veterans had less outpatient utilization than females in the year following mild TBI diagnosis. Gender and other factors only accounted for a small portion of the differences observed; therefore, gender only partially accounts for differences in healthcare utilization following mild TBI.

Medical comorbidities in disorders of consciousness patients and their association with functional outcomes.

OBJECTIVE: To identify, for patients in states of seriously impaired consciousness, comorbid conditions present during inpatient rehabilitation and their association with function at 1 year. DESIGN: Abstracted data from a prospective cross-sectional observational study with data collection occurring January 1996 through December 2007. SETTING: Four inpatient rehabilitation facilities in metropolitan areas. PARTICIPANTS: The study sample of 68 participants is abstracted from a database of 157 patients remaining in states of seriously impaired consciousness for at least 28 days. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: One-year cognitive, motor, and total FIM score. RESULTS: The most common medical complications during inpatient rehabilitation for the study sample are active seizures (46%), spasticity (57%), urinary tract infections (47%), and hydrocephalus with and without shunt (38%). Presence of ≥3 medical complications during inpatient rehabilitation, controlling for injury severity, is significantly (P<.05) associated with poorer total FIM and FIM motor scores 1 year after injury. The presence of hydrocephalus with and without shunt (r=-.20, -.21, -.18; P ≤.15), active seizures (r=-.31, -.22, -.42), spasticity (r=-.38, -.28, -.40), and urinary tract infections (r=-.25, -.24, -.26) were significantly (P<.10) associated with total FIM, FIM cognitive, and FIM motor scores, respectively. CONCLUSIONS: Reported findings indicate that persons in states of seriously impaired consciousness with higher numbers of medical complications during inpatient rehabilitation are more likely to have lower functional levels 1-year postinjury. The findings indicate that persons with ≥3 medical complications during inpatient rehabilitation are at a higher risk for poorer functional outcomes at 1 year. It is, therefore, prudent to evaluate these patients for indications of these complications during inpatient rehabilitation.

Prevalence of chronic kidney disease in patients with spinal cord injuries/disorders.

BACKGROUND AND OBJECTIVES: Chronic kidney disease (CKD) and spinal cord injury and disorders (SCI/D) are common and costly conditions among Veterans. However, little is known about CKD among adults with SCI/D. METHODS: We conducted cross-sectional analyses of Veterans with SCI/D across all VA facilities in 2006. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) and categorized by standard eGFR strata. eGFR was calculated in two ways: (a) the Modification of Diet in Renal Disease (MDRD) equation and (b) the MDRD equation + an empirically derived correction factor for SCI/D (MDRD-SCI/D). Logistic regression models were used to examine the relationship between patient characteristics and CKD. RESULTS: Among 9,333 SCI/D Veterans with an available eGFR, the proportion with CKD was substantially higher based on the MDRD-SCI/D equation (35.2%) than based on the MDRD equation (10.2%). In adjusted analyses, while older age (OR for >65 years = 2.53; 95% CI: 2.21-2.89), female sex (OR 2.18; 95% CI: 1.62-2.92), and a non-traumatic cause for injury (OR 1.39; 95% CI: 1.23-1.57) were associated with an increased odds of CKD, black race (OR 0.64; 95% CI: 0.56-0.72) and a duration of injury of ≥10 years (OR 0.76; 95% CI: 0.67-0.86) were associated with a decreased odds of CKD. Diagnostic codes for CKD and nephrology visits were infrequent for SCI/D Veterans with CKD (27.51 and 6.58%, respectively). CONCLUSION: Using a recently validated version of the MDRD equation with a correction factor for SCI/D, over 1 in 3 Veterans with SCI/D had CKD, which is more than 3-fold higher than when traditional MDRD estimation is used.

The accuracy of new wheelchair users' predictions about their future wheelchair use.

OBJECTIVE: This study examined the accuracy of new wheelchair user predictions about their future wheelchair use. DESIGN: This was a prospective cohort study of 84 community-dwelling veterans provided a new manual wheelchair. RESULTS: The association between predicted and actual wheelchair use was strong at 3 mos (ϕ coefficient = 0.56), with 90% of those who anticipated using the wheelchair at 3 mos still using it (i.e., positive predictive value = 0.96) and 60% of those who anticipated not using it indeed no longer using the wheelchair (i.e., negative predictive value = 0.60, overall accuracy = 0.92). Predictive accuracy diminished over time, with overall accuracy declining from 0.92 at 3 mos to 0.66 at 6 mos. At all time points, and for all types of use, patients better predicted use as opposed to disuse, with correspondingly higher positive than negative predictive values. Accuracy of prediction of use in specific indoor and outdoor locations varied according to location. CONCLUSIONS: This study demonstrates the importance of better understanding the potential mismatch between the anticipated and actual patterns of wheelchair use. The findings suggest that users can be relied upon to accurately predict their basic wheelchair-related needs in the short-term. Further exploration is needed to identify characteristics that will aid users and their providers in more accurately predicting mobility needs for the long-term.

How the human brain goes virtual: distinct cortical regions of the person-processing network are involved in self-identification with virtual agents.

Millions of people worldwide engage in online role-playing with their avatar, a virtual agent that represents the self. Previous behavioral studies have indicated that many gamers identify more strongly with their avatar than with their biological self. Through their avatar, gamers develop social networks and learn new social-cognitive skills. The cognitive neurosciences have yet to identify the neural processes that underlie self-identification with these virtual agents. We applied functional neuroimaging to 22 long-term online gamers and 21 nongaming controls, while they rated personality traits of self, avatar, and familiar others. Strikingly, neuroimaging data revealed greater avatar-referential cortical activity in the left inferior parietal lobe, a region associated with self-identification from a third-person perspective. The magnitude of this brain activity correlated positively with the propensity to incorporate external body enhancements into one's bodily identity. Avatar-referencing furthermore recruited greater activity in the rostral anterior cingulate gyrus, suggesting relatively greater emotional self-involvement with one's avatar. Post-scanning behavioral data revealed superior recognition memory for avatar relative to others. Interestingly, memory for avatar positively covaried with play duration. These findings significantly advance our knowledge about the brain's plasticity to self-identify with virtual agents and the human cognitive-affective potential to live and learn in virtual worlds.

Males aging with a spinal cord injury: prevalence of cardiovascular and metabolic conditions.

OBJECTIVE: To compare the prevalence of cardiovascular and metabolic conditions in male veterans aging with spinal cord injury (SCI) with that of older men comparison groups. DESIGN: Cross-sectional survey. SETTING: National community dwelling. PARTICIPANTS: Men 65 years and older (veterans with SCI [n=794] injured at least 20y, veterans [n=13,528], and general population [n=6105]). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence of diabetes, myocardial infarction (MI), stroke, and coronary heart disease (CHD). RESULTS: In older adult men with SCI, prevalences of diabetes, MI, stroke, and CHD were 20.30%, 18.70%, 9.84%, and 15.47%, respectively. The odds for stroke were 1.4 times higher in veterans with SCI than general veterans (P<.05), and there was a trend to higher odds for stroke in men with SCI than in the general population (P=.06). The odds for CHD were significantly lower for veterans with SCI than both comparison groups. Being a past smoker was associated with greater odds for diabetes, MI, and CHD, and being a current smoker was associated with higher odds for stroke. High blood pressure and high cholesterol levels were associated with higher odds for all conditions examined. CONCLUSIONS: Diabetes and MI were most prevalent in older adults, but the presence was similar in men with SCI (vs other men). In older adult men, SCI appeared to be protective of CHD. Stroke was most prevalent in veterans with SCI, and controlling for demographic and risk factors, SCI was associated independently with stroke. These findings may be useful for prioritizing preventive health strategies and planning long-term care for men aging with SCI.

Lower extremity physical performance, self-reported mobility difficulty, and use of compensatory strategies for mobility by elderly women.

OBJECTIVE: To describe the relationship between lower extremity physical performance, self-reported mobility difficulty, and self-reported use of compensatory strategies (CSs) for mobility inside the home. DESIGN: Cross-sectional exploratory study. SETTING: Community-dwelling elders. PARTICIPANTS: Disabled, cognitively intact women 65 years or older (N=1002), from the Women's Health and Aging Study I. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: CS scale: no CS, behavioral modifications (BMs) only, durable medical equipment (DME) with or without use of BMs, and any use of human help (HH); and 3 dichotomous CS measures: any CS (vs none); DME+HH (vs BMs only, among users of any CS); any HH (vs DME only, among users of any DME/HH). RESULTS: Self-reported mobility difficulty and physical performance were significantly correlated with one another (r=-.57, P<.0001) and with the CS scale ([r=.51, P<.001] and [r=-.54, P<.0001], respectively). Sequential logistic regressions showed self-reported difficulty and physical performance were significant independent predictors of each category of CS. For the any CS and DME+HH models, the odds ratio for self-reported difficulty decreased by approximately 50% when physical performance was included in the model, compared with difficulty alone ([18.0 to 8.6] and [7.3 to 3.8], respectively), but both physical performance and difficulty remained significant predictors (P<.0001). The effects of covariates differed for the various CS categories, with some covariates having independent relationships to CS, and others appearing to have moderating or mediating effects on the relationship of self-reported difficulty or physical performance to CS. CONCLUSIONS: Physical performance, self-reported difficulty, health conditions, and contextual factors have complex effects on the way elders carry out mobility inside the home.

Self-identification and empathy modulate error-related brain activity during the observation of penalty shots between friend and foe.

The ability to detect and process errors made by others plays an important role is many social contexts. The capacity to process errors is typically found to rely on sites in the medial frontal cortex. However, it remains to be determined whether responses at these sites are driven primarily by action errors themselves or by the affective consequences normally associated with their commission. Using an experimental paradigm that disentangles action errors and the valence of their affective consequences, we demonstrate that sites in the medial frontal cortex (MFC), including the ventral anterior cingulate cortex (vACC) and pre-supplementary motor area (pre-SMA), respond to action errors independent of the valence of their consequences. The strength of this response was negatively correlated with the empathic concern subscale of the Interpersonal Reactivity Index. We also demonstrate a main effect of self-identification by showing that errors committed by friends and foes elicited significantly different BOLD responses in a separate region of the middle anterior cingulate cortex (mACC). These results suggest that the way we look at others plays a critical role in determining patterns of brain activation during error observation. These findings may have important implications for general theories of error processing.

Wheelchair use by veterans newly prescribed a manual wheelchair.

OBJECTIVE: To describe the characteristics of the wheelchairs, the users, and their wheelchair use among persons newly prescribed a manual wheelchair. DESIGN: Cohort study. SETTING: Veterans Affairs teaching hospital. PARTICIPANTS: Ninety-nine consecutive, cognitively intact veterans prescribed a manual wheelchair. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported difficulty transferring into and propelling the wheelchair; and bathroom mobility method. RESULTS: Study patients had a mean age of 66 and a mean of 10 comorbid medical conditions. Parkinsonism, osteoporosis, joint replacement, and amputation were uncommon (<30% of patients), but had a high impact on need for a wheelchair (when present were reported by >50% of patients as causing need for a wheelchair). Falls and arthritis were common (>50% of patients) and highly impacted need for a wheelchair. At 1 month, over 30% of patients had wheelchairs that did not meet common criteria for wheelchair fit; 36% and 61%, respectively, reported difficulty transferring and propelling the wheelchair. The wheelchairs were used for bathroom mobility by 38% of the patients. CONCLUSIONS: The typical manual wheelchair recipient in this study sample was old with multiple medical problems. Despite provision of manual wheelchairs by trained professionals and availability of diverse wheelchair types, new wheelchair users commonly reported difficulty using the wheelchair.

Lower extremity physical performance and use of compensatory strategies for mobility.

OBJECTIVES: To compare measured lower extremity physical performance in the clinic with the methods used to carry out mobility tasks at home and to identify key factors influencing day-to-day task performance. DESIGN: Cross-sectional analysis of the Women's Health and Aging Study I. SETTING: Community-dwelling female residents of Baltimore, Maryland. PARTICIPANTS: One thousand two cognitively intact women aged 65 and older with moderate to severe physical limitations. MEASUREMENTS: Compensatory strategies reportedly used for mobility in the home, distinguishing between use of no compensatory strategies, behavioral changes only, durable medical equipment (DME) with or without behavioral change, and human help; measured lower extremity (LE) physical performance (gait speed, timed chair stands, balance). RESULTS: There was a statistically significant difference in LE physical performance between women using the four types of compensatory strategy (P < .001). Women who used DME for mobility in the home had worse performance than those using human help who in turn had worse performance than those with behavioral changes only; women reporting no compensatory strategies for in-home mobility performed best. Sequential multivariate logistic regressions identified several factors other than LE physical performance that were associated with use of specific compensatory strategies. Medical conditions, education, and environmental barriers influenced whether compensatory strategies were used at all, whereas income, contact with health providers, and availability of help in the home influenced the type of compensatory strategy. CONCLUSION: Physical abilities are an important factor influencing use of compensatory strategies for mobility, but several other factors also influence the ways that women adapt to mobility limitations.

The impact of diabetes on patient outcomes after ankle fracture.

BACKGROUND: Ankle fracture is one of the most common injuries treated by orthopaedic surgeons, and the presence of diabetes complicates treatment and recovery from this injury. Although a higher prevalence of adverse postoperative events has been found in small series of diabetic patients with an ankle fracture, we are not aware of any large national series with specific documentation of the outcomes following ankle fracture in patients with diabetes. METHODS: We analyzed data from the Nationwide Inpatient Sample database for the years 1988 through 2000. Information regarding the hospitalizations of 160,598 adult patients with an ankle fracture who underwent subsequent surgical procedures was extracted from the database. Multiple linear and logistic regression models were used to ascertain whether patients with diabetes mellitus were more likely than patients without diabetes mellitus to die while in the hospital, to have in-hospital postoperative complications, to stay longer in the hospital, to have a higher incidence of non-routine discharge, and to have a higher total cost associated with the hospital stay. RESULTS: Significant increases in in-hospital mortality, the rate of in-hospital postoperative complications, the length of hospital stay, the rate of non-routine discharge, and the total charges were found in the diabetic patient group (p < 0.001). Specifically, we found that diabetic patients across all levels of fracture severity (closed unimalleolar, closed bimalleolar or trimalleolar, and dislocated or open fractures) stayed in the hospital for about one additional day (mean, 4.7 compared with 3.6 days) and incurred more than dollar 2000 in increased charges (mean, dollar 12,898 compared with dollar 10,794). CONCLUSIONS: This nationally representative study of inpatients in the United States provides evidence that diabetic patients with an operatively treated ankle fracture are likely to have worse results than non-diabetic patients with regard to postoperative complications, mortality, rate of non-routine discharge, length of hospital stay, and total hospital charges.