Manual Ability Measure (MAM-16): a preliminary report on a new patient-centred and task-oriented outcome measure of hand function.

The purpose of this study was to develop an easy-to-use and psychometrically sound outcome instrument that is task-oriented and patient-centred. One hundred fifteen patients with a variety of hand impairments completed a rating scale of perceived manual ability (i.e., the Manual Ability Measure). The first 70 patients also completed two other questionnaires about physical health and psychological well-being. Rasch Analyses were conducted to transform the ordinal ratings into linear measures; Rasch statistics were used to evaluate its measurement properties at both scale and item levels. Eighty-three original items were reduced to 16 common tasks; Rasch reliabilities were good; the easy-to-difficult item hierarchy makes sense clinically. Moderate correlations were found between manual ability, physical function and general sense of well-being. The results of this preliminary study suggest that the MAM is a promising outcome measure that has adequate psychometric properties and can be used to complement other objective clinical measurements.

Results of stroke rehabilitation in Thailand.

OBJECTIVE: The purpose of this study is to identify predictors of functional outcome after acute to sub-acute stroke rehabilitation using raw FIM score and results of stroke rehabilitation in Thailand. DESIGN: Descriptive and multivariate analysis was performed on data collected prospectively from 50 patients who were on stroke rehabilitation at Thai Red Cross Rehabilitation Center from October 1, 2000 to September 30, 2001. Six independent variables were obtained from patients' medical records. RESULTS: The total FIM scores at the time of discharge and total FIM scores gain are strongly correlated with the total FIM scores at the time of admission to the hospital and correlated negatively with age using multiple linear regression analysis, significant at p < 0.05. The equation for all cases were: (discharge total FIM scores) = 82.856 + 0.708 x (admission total FIM scores) - 0.408 x (age) and (total FIM scores gain) = 82.85 - 0.292 x (admission total FIM scores) - 0.408 x (age). The models explained 76.48% of variation for total FIM scores at the time of discharge and 45.66% of variation for total FIM scores gain. The total FIM scores at the time of admission and age were the best predictors of the total FIM score at the time of discharge and the total FIM scores gain. However, the nature of stroke, gender, onset to admission interval (OAI), and length of rehabilitation stay (LOS) were not statistically significantly correlated with the total FIM scores at the time of discharge and the total FIM scores gain. CONCLUSIONS: Because the total FIM score at the time of discharge and the total FIM scores gain are highly correlated with the total FIM scores at the time of admission and age, we can inform the patient and their family about the possibility of recovery, and assess the amount and quality of care needed at home or placement after discharge.

Multiple sclerosis characteristics in African American patients in the New York State Multiple Sclerosis Consortium.

The objective of this study was to determine the clinical characteristics of multiple sclerosis (MS) in African American (AA) patients in the New York State Multiple Sclerosis Consortium (NYSMSC) patient registry. The NYSMSC is a group of 18 MS centers throughout New York State organized to prospectively assess clinical characteristics of MS patients. AAs comprise 6% (329) of the total NYSMSC registrants (5602). Demographics, disease course, therapy, and socioeconomic status were compared in AA registrants versus nonAfrican Americans (NAA). There was an increased female preponderance and a significantly younger age at diagnosis in the AA group. AA patients were more likely to have greater disability with increased disease duration. No differences were seen in types of MS and use of disease modifying therapies. Our findings suggest a racial influence in MS. Further genetic studies that consider race differences are warranted to elucidate mechanisms of disease susceptibility.

Comparison of logistic regression and neural networks to predict rehospitalization in patients with stroke.

CONTEXT: Rehospitalization following inpatient medical rehabilitation has important health and economic implications for patients who have experienced a stroke. OBJECTIVE: Compare logistic regression and neural networks in predicting rehospitalization at 3-6-month follow-up for patients with stroke discharged from medical rehabilitation. DESIGN: The study was retrospective using information from a national database representative of medical rehabilitation patients across the US. SETTING: Information submitted to the Uniform Data System for Medical Rehabilitation from 1997 and 1998 by 167 hospital and rehabilitation facilities from 40 states was examined. PARTICIPANTS: 9584 patient records were included in the sample. The mean age was 70.74 years (SD = 12.87). The sample included 51.6% females and was 77.6% non-Hispanic White with an average length of stay of 21.47 days (SD = 15.47). MAIN OUTCOME MEASURES: Hospital readmission from 80 to 180 days following discharge. RESULTS: Statistically significant variables (P <.05) in the logistic model included sphincter control, self-care ability, age, marital status, ethnicity and length of stay. Area under the ROC curves were 0.68 and 0.74 for logistic regression and neural network analysis, respectively. The Hosmer-Lemeshow goodness-of-fit chi-square was 11.32 (df = 8, P = 0.22) for neural network analysis and 16.33 (df = 8, P = 0.11) for logistic regression. Calibration curves indicated a slightly better fit for the neural network model. CONCLUSION: There was no statistically significant or practical advantage in predicting hospital readmission using neural network analysis in comparison to logistic regression for persons who experienced a stroke and received medical rehabilitation during the period of the study.

Characteristics of persons rehospitalized after stroke rehabilitation.

OBJECTIVE: To develop classification models for risk of hospital readmission 80 to 180 days after discharge based the demographic and functional characteristics of persons discharged from acute inpatient rehabilitation after stroke. DESIGN: Retrospective, using information from US facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDS(MR)). SETTING: Information submitted to the UDS(MR) from 1994 through 1996 by 167 hospital and rehabilitation facilities from 40 states was examined. PARTICIPANTS: A total of 15,992 records of patients (mean age +/- standard deviation, 70.97 +/- 12.19yr) with a diagnosis of stroke were included in the final sample. The sample included 52.7% women and was 80% non-Hispanic white with an average length of stay (LOS) of 25.31 +/- 14.72 days. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six subscales of the FIM instrument (self-care, sphincter control, transfers, locomotion, communication, social cognition), total FIM, and other predictor variables for regression analysis (gender, age, ethnicity, marital status, prehospital living setting, LOS, primary payer source, level of function-related group). RESULTS: A logistic regression model included the following statistically significant variables (p <.05): ethnicity, sphincter control, self-care ability, gender, and LOS. The greatest variability occurred among men. Exactly 18.1% of non-Hispanic white men and 17.9% of African-American men were rehospitalized. In contrast, only 10.1% of Hispanic men and 11.4% of Asian men were rehospitalized. The odds of rehospitalization were lowest for Hispanic men. CONCLUSION: As prospective payment systems are introduced for postacute care, it is important that the relationship among functional abilities, demographic characteristics, and incidence of hospital readmission following medical rehabilitation be examined.

Applications of functional assessment to musculoskeletal disability evaluation.

A review of the history of the disability determination for LBP suggests that the early focus upon disability as a direct "effect" of impairment has given way to an updated approach acknowledging the multitude of factors, many of which are subjective, that contribute to an individual's future return to work and disability status. In addition to the evaluation of the underlying impairment and pathology, physicians performing disability evaluations for LBP will be best served when they can assess the individual's functional status, and incorporate that information into their decision regarding the individual's current limitations and prognosis. As discussed above, many of the factors contributing to the evaluation of functional status, including pain, physical functioning, and affective status, are necessarily subjective. Nonetheless, the rehabilitation literature suggests that inclusion of this information into the disability determination using a patient-centered approach may provide the factors that are most potent with respect to patient prognosis and eventual return to work.

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system.

BACKGROUND: Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system. OBJECTIVE: The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences. DESIGN: This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system. SUBJECTS: The study included 55,438 stroke patients. MEASURES: Study measures were LOS, functional status at discharge, and community discharge. RESULTS: The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05). CONCLUSIONS: While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.

Satisfaction with medical rehabilitation in patients with cerebrovascular impairment.

OBJECTIVE: Overall satisfaction has important social and economic implications for patients who have received inpatient medical rehabilitation. We conducted this study to examine the overall satisfaction level at 3- to 6-mo follow-up for inpatients with cerebrovascular impairments discharged from medical rehabilitation. DESIGN: The study was retrospective using information from a national database representative of medical rehabilitation patients across the United States. Information submitted in 1997 and 1998 to the Uniform Data System for Medical Rehabilitation by 177 hospital and rehabilitation facilities from 40 states was examined. The final sample included 8,900 patient records. The main outcome measure was the level of satisfaction with medical rehabilitation at 80-180 days postdischarge follow-up. RESULTS: A logistic regression model including ten independent variables was used to predict satisfied vs. dissatisfied at follow-up. Three statistically significant variables were included in the final model and correctly classified 95.1% of the patients. Higher FIM instrument discharge scores were associated with increased satisfaction. Further analysis of the FIM instrument subscales indicated that higher ratings in transfers, social cognition, and locomotion were significantly associated with increased satisfaction. CONCLUSION: We identified several functional variables associated with increased satisfaction after medical rehabilitation in persons with stroke. The ability to objectively assess patient satisfaction is important as consumer-based outcome measures are integrated in accreditation and healthcare evaluation.

Neuropsychological effects of interferon beta-1a in relapsing multiple sclerosis. Multiple Sclerosis Collaborative Research Group.

Cognitive dysfunction is common in multiple sclerosis (MS), yet few studies have examined effects of treatment on neuropsychological (NP) performance. To evaluate the effects of interferon beta-1a (IFNbeta-1a, 30 microg administered intramuscularly once weekly [Avonex]) on cognitive function, a Comprehensive NP Battery was administered at baseline and week 104 to relapsing MS patients in the phase III study, 166 of whom completed both assessments. A Brief NP Battery was also administered at 6-month intervals. The primary NP outcome measure was 2-year change on the Comprehensive NP Battery, grouped into domains of information processing and learning/memory (set A), visuospatial abilities and problem solving (set B), and verbal abilities and attention span (set C). NP effects were most pronounced in cognitive domains vulnerable to MS: IFNbeta-1a had a significant beneficial effect on the set A composite, with a favorable trend evident on set B. Secondary outcome analyses revealed significant between-group differences in slopes for Brief NP Battery performance and time to sustained deterioration in a Paced Auditory Serial Addition Test processing rate, favoring the IFNbeta-1a group. These results support and extend previous observations of significant beneficial effects of IFNbeta-1a for relapsing MS.

Length of stay and hospital readmission for persons with disabilities.

OBJECTIVES: Length of stay (LOS) and hospital readmission for persons receiving medical rehabilitation were examined. METHODS: A total of 96,473 patient records (1994-1998) were analyzed. Mean age of patients was 68.97 years; 61% were female and 83% were non-Hispanic White. RESULTS: A decrease in LOS of 6.07 days (SD = 3.23) and increase in hospital readmission were found across all impairment groups (P < .001). Readmission increases ranged from 6.7% for amputations to 1.4% for orthopedic conditions. LOS was longer (2.1 days) for readmitted patients (P < .01). Age was not a significant predictor of rehospitalization. CONCLUSIONS: Understanding variables associated with rehospitalization is important as prospective payment systems are introduced for postacute care.

The WeeFIM instrument: its utility in detecting change in children with developmental disabilities.

OBJECTIVE: To examine the utility of the WeeFIM instrument ("WeeFIM") in detecting changes in the functional status of children with disability. DESIGN: Prospective longitudinal design with correlation and responsiveness analysis. SETTING: Three facilities providing services to children with developmental disabilities in western New York State. PARTICIPANTS: Two hundred five children (72 girls, 133 boys) with identified medical disabilities receiving special services were administered the WeeFIM. Subjects ranged in age from 11 to 87 months and came from diverse socioeconomic and ethnic backgrounds. Scores for 174 children were available for 3 administrations performed over a 1-year period. MAIN OUTCOME MEASURES: The responsiveness of the WeeFIM instrument was examined using 5 statistical procedures: Reliability Change Index, Proportional Change Index, effect size, standardized response means, and paired t tests. RESULTS: All 5 indexes of responsiveness indicated statistically significant (p < .05) or reliable changes over time. The transfer subscale of the WeeFIM showed a skewed distribution that affected the results for some responsiveness indexes. The advantage, limitations, and assumptions of the responsiveness indexes are described and graphic examples of change over time are presented to validate the responsiveness of the WeeFIM instrument. CONCLUSION: The WeeFIM instrument showed the ability to document change in functional abilities over a 1-year period in children with chronic disabilities.

A functional diagnostic complexity index for rehabilitation medicine: measuring the influence of many diagnoses on functional independence and resource use.

OBJECTIVE: To develop an index that weights diagnostic information (International Classification of Diseases, 9th revision, Clinical Modification, or ICD-9-CM codes) by the extent to which it is expected to affect functional status and inpatient rehabilitation length of stay (LOS). DESIGN: Eleven nationally prominent physiatrists assigned ICD-9-CM codes to ordinal categories by expected effect on functional recovery. A resulting functional diagnostic complexity index score was calculated for each patient by combining the ranked values of each ICD-9-CM code in the discharge record. Analyses were stratified across the 20 rehabilitation impairment categories (RICs) of the Functional Independence Measure-Function Related Groups. DATA: Patients (182,254) discharged from 465 inpatient rehabilitation units in larger hospitals and free-standing rehabilitation hospitals in 1995. RESULTS: High degrees of diagnostic complexity were associated with low levels of functional independence at admission within each of 20 RICs (Spearman R = .06 to .25). Depending on RIC, patients in the highest (compared with the lowest) complexity category had up to a 35% increase in rehabilitation LOS after accounting for the primary medical reason for rehabilitation and severity of disabilities at admission. CONCLUSION: This prototype index of medical complexity offers a promising approach for analyzing the cumulative effects of diagnoses on patients' initial functional status and rehabilitation LOS.

Functional assessment and care of children with neurodevelopmental disabilities.

OBJECTIVES: To determine the relationship between pediatric assessment scores and ratings by parents and teachers regarding the amount of assistance required to complete basic activities of daily living; and to examine the relationship among scores for three commonly used pediatric assessments. DESIGN: Prospective correlational study. 205 children with developmental disabilities. The children ranged in age from 11 to 87 mo and included 72 females and 133 males of diverse socioeconomic and ethnic backgrounds. The children were evaluated by using the Battelle Developmental Inventory Screening Test, Vineland Adaptive Behavior Scales, Functional Independence Measure for Children (WeeFIM instrument), and the Amount of Assistance Questionnaire. RESULTS: The test-retest reliability coefficients for items on the Amount of Assistance Questionnaire were found to range from 0.82 to 0.97. Correlations among subscale scores and amount of assistance ratings were highest for the WeeFIM instrument and Battelle Developmental Inventory Screening Test. The highest correlation was between WeeFIM total rating and total amount of assistance rating (r = 0.91). CONCLUSION: Total WeeFIM instrument ratings and severity of disability were the best predictors of amount of assistance ratings provided by parents and teachers.