Medicare Outpatient Physical Therapy Expenditures Vary by Diagnosis and Functional Mobility.

BACKGROUND: Clinical characteristics driving variations in Medicare outpatient physical therapy expenditures are inadequately understood. OBJECTIVE: The objectives of this study were to examine variations in annual outpatient physical therapy expenditures of Medicare fee-for-service beneficiaries by primary diagnosis and baseline functional mobility, and to assess whether case mix groups based on primary diagnosis and functional mobility scores would be useful for expenditure differentiation. DESIGN: This was an observational, longitudinal study. METHODS: Volunteer providers in community settings participated in data collection with Continuity Assessment Record and Evaluation-Community (CARE-C) assessments for Medicare fee-for-service beneficiaries. Annual outpatient physical therapy expenditures were calculated using allowed charges on Medicare claims; primary diagnosis and baseline functional mobility were obtained from CARE-C assessments. Whether annual expenditures varied significantly across primary diagnosis groups and within diagnosis groups by functional mobility was examined. RESULTS: Data for 4210 patients (mean [SD] age = 72.9 [9.9] years; 64.6% women) from 127 providers were included. Mean expenditures differed significantly across 12 primary diagnosis groups created from CARE-C clinician-reported diagnoses (F = 12.73; df = 11). Twenty-five pairwise differences in 66 pairwise diagnosis group comparisons were statistically significant. Within 8 diagnosis groups, expenditures were significantly higher for low-mobility subgroups than for high-mobility subgroups; borderline significance was achieved for 1 diagnosis group. LIMITATIONS: The small convenience sample limited the statistical power and the generalizability of the results. CONCLUSIONS: Significant variations in physical therapy expenditures based on primary diagnosis and baseline functional mobility support the use of these variables in predicting outpatient physical therapy expenditures. Although Medicare's annual therapy spending cap was repealed effective January 2018, the data from this study provide an initial foundation to inform any future policy efforts, such as targeted medical review, risk-adjusted therapy payments, or case mix groups as potential payment alternatives. Additional research with larger samples is needed to further develop and test case mix groups and improve generalizability to the national population. Refined case mix groups could also help providers prognosticate physical therapy expenditures based on patient profiles.

Measuring Inpatient Rehabilitation Facility Quality of Care: Discharge Self-Care Functional Status Quality Measure.

OBJECTIVE: To describe the calculation and psychometric properties of the discharge self-care functional status quality measure implemented in the Centers for Medicare & Medicaid Services' (CMS) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program on October 1, 2016. DESIGN: Medicare fee-for-service (FFS) patients from 38 IRFs that participated in the CMS Post-Acute Care Payment Reform Demonstration were included in this cohort study. Data came from the Continuity Assessment Record and Evaluation Item Set, IRF-Patient Assessment Instrument, and Medicare claims. For each patient, we calculated an expected discharge self-care score, risk-adjusted for demographic and baseline clinical characteristics. The performance score of each IRF equaled the percentage of patient stays where the observed discharge self-care score met or exceeded the expected score. We assessed the measure's discriminatory ability across IRFs and reliability. SETTING: IRFs. PARTICIPANTS: Medicare FFS patients aged ≥21 years (N=4769). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Facility-level discharge self-care quality measure performance score. RESULTS: A total of 4769 patient stays were included; 57% of stays were in women, and 12.1% were in patients aged <65 years. Stroke was the most common diagnosis (21.8%). The mean±SD performance score was 55.1%±16.6% (range, 25.8%-100%). About 54% of IRFs had scores significantly different from the percentage of stays that met or exceeded the expected discharge self-care score in the overall demonstration sample. The quality measure showed strong reliability, with intraclass correlation coefficients of .91. CONCLUSIONS: The discharge self-care quality measure showed strong discriminatory ability and reliability, representing an important initial step in evaluation of IRF self-care outcomes. A wide range in performance scores suggested a gap in quality of care across IRFs. Future work should include testing the measure with nationwide data from all IRFs.

Computer-adaptive balance testing improves discrimination between community-dwelling elderly fallers and nonfallers.

OBJECTIVES: To build an item response theory-based computer adaptive test (CAT) for balance from 3 traditional, fixed-form balance measures: Berg Balance Scale (BBS), Performance-Oriented Mobility Assessment (POMA), and dynamic gait index (DGI); and to examine whether the CAT's psychometric performance exceeded that of individual measures. DESIGN: Secondary analysis combining 2 existing datasets. SETTING: Community based. PARTICIPANTS: Community-dwelling older adults (N=187) who were aged ≥65 years (mean age, 75.2±6.8y, 69% women). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The BBS, POMA, and DGI items were compiled into an initial 38-item bank. The Rasch partial credit model was used for final item bank calibration. CAT simulations were conducted to identify the ideal CAT. CAT score accuracy, reliability, floor and ceiling effects, and validity were examined. Floor and ceiling effects and validity of the CAT and individual measures were compared. RESULTS: A 23-item bank met model expectations. A 10-item CAT was selected, showing a very strong association with full item bank scores (r=.97) and good overall reliability (.78). Reliability was better in low- to midbalance ranges as a result of better item targeting to balance ability when compared with the highest balance ranges. No floor effect was noted. The CAT ceiling effect (11.2%) was significantly lower than the POMA (40.1%) and DGI (40.3%) ceiling effects (P<.001 per comparison). The CAT outperformed individual measures, being the only test to discriminate between fallers and nonfallers (P=.007), and being the strongest predictor of self-reported function. CONCLUSIONS: The balance CAT showed excellent accuracy, good overall reliability, and excellent validity compared with individual measures, being the only measure to discriminate between fallers and nonfallers. Prospective examination, particularly in low-functioning older adults and clinical populations with balance deficits, is recommended. Development of an improved CAT based on an expanded item bank containing higher difficulty items is also recommended.

Conceptual limitations of balance measures for community-dwelling older adults.

BACKGROUND: Psychometric limitations of balance measures for community-dwelling elderly may be related to gaps in task and environmental representation. OBJECTIVE: The purposes of this study were: (1) to conduct item-level content analysis of balance measures for community-dwelling elderly people based on task and environmental factors and (2) to develop profiles of individual measures summarizing their task and environment representation. DESIGN: A systematic content analysis was conducted. METHODS: A literature search was conducted to identify balance measures. Item-level content analysis was based on 7 criteria related to task and environment: (1) task role, (2) environmental variation, (3) object interaction, (4) obstacle negotiation, (5) external forces, (6) dual-tasking, and (7) moving people or objects in the environment. RESULTS: Twenty-six measures, containing 167 items, were identified. Task role was fairly evenly distributed, with the majority of items examining gait tasks (32.3%), followed by dynamic body stability (29.9%) and static body stability (25.1%). The majority of items involved no environmental variation (58.1%), followed by variation of support surfaces (20.4%), visual conditions (13.2%), and both support and visual conditions (8.4%). Limited task role variability was seen within measures, with 73.1% of measures examining only one task role. Environmental variation was present in 65.3% of measures, primarily during static body stability tasks. Few measures involved object interaction (23.1%), obstacle negotiation (38.5%), external forces (11.5%), dual-tasking (7.7%), or moving people or objects (0%). LIMITATIONS: The classification framework was not externally validated. CONCLUSIONS: Existing measures focus on single-task assessment in static environments, underrepresenting postural control demands in daily-life situations involving dynamic changing environments, person-environment interactions, and multitasking. New items better reflecting postural control demands in daily-life situations are needed for more ecologically valid balance assessment. Individual balance measure profiles provided can help identify the most appropriate measure for a given purpose.

Development of the computer-adaptive version of the Late-Life Function and Disability Instrument.

BACKGROUND: Having psychometrically strong disability measures that minimize response burden is important in assessing of older adults. METHODS: Using the original 48 items from the Late-Life Function and Disability Instrument and newly developed items, a 158-item Activity Limitation and a 62-item Participation Restriction item pool were developed. The item pools were administered to a convenience sample of 520 community-dwelling adults 60 years or older. Confirmatory factor analysis and item response theory were employed to identify content structure, calibrate items, and build the computer-adaptive testings (CATs). We evaluated real-data simulations of 10-item CAT subscales. We collected data from 102 older adults to validate the 10-item CATs against the Veteran's Short Form-36 and assessed test-retest reliability in a subsample of 57 subjects. RESULTS: Confirmatory factor analysis revealed a bifactor structure, and multi-dimensional item response theory was used to calibrate an overall Activity Limitation Scale (141 items) and an overall Participation Restriction Scale (55 items). Fit statistics were acceptable (Activity Limitation: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.03; Participation Restriction: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.05). Correlation of 10-item CATs with full item banks were substantial (Activity Limitation: r = .90; Participation Restriction: r = .95). Test-retest reliability estimates were high (Activity Limitation: r = .85; Participation Restriction r = .80). Strength and pattern of correlations with Veteran's Short Form-36 subscales were as hypothesized. Each CAT, on average, took 3.56 minutes to administer. CONCLUSIONS: The Late-Life Function and Disability Instrument CATs demonstrated strong reliability, validity, accuracy, and precision. The Late-Life Function and Disability Instrument CAT can achieve psychometrically sound disability assessment in older persons while reducing respondent burden. Further research is needed to assess their ability to measure change in older adults.

Sensitivity to change and responsiveness of four balance measures for community-dwelling older adults.

BACKGROUND: Impaired balance has a significant negative impact on mobility, functional independence, and fall risk in older adults. Although several, well-respected balance measures are currently in use, there is limited evidence regarding the most appropriate measure to assess change in community-dwelling older adults. OBJECTIVE: The aim of this study was to compare floor and ceiling effects, sensitivity to change, and responsiveness across the following balance measures in community-dwelling elderly people with functional limitations: Berg Balance Scale (BBS), Performance-Oriented Mobility Assessment total scale (POMA-T), POMA balance subscale (POMA-B), and Dynamic Gait Index (DGI). DESIGN: Retrospective data from a 16-week exercise trial were used. Secondary analyses were conducted on the total sample and by subgroups of baseline functional limitation or baseline balance scores. METHODS: Participants were 111 community-dwelling older adults 65 years of age or older, with functional limitations. Sensitivity to change was assessed using effect size, standardized response mean, and paired t tests. Responsiveness was assessed using minimally important difference (MID) estimates. RESULTS: No floor effects were noted. Ceiling effects were observed on all measures, including in people with moderate to severe functional limitations. The POMA-T, POMA-B, and DGI showed significantly larger ceiling effects compared with the BBS. All measures had low sensitivity to change in total sample analyses. Subgroup analyses revealed significantly better sensitivity to change in people with lower compared with higher baseline balance scores. Although both the total sample and lower baseline balance subgroups showed statistically significant improvement from baseline to 16 weeks on all measures, only the lower balance subgroup showed change scores that consistently exceeded corresponding MID estimates. LIMITATIONS: This study was limited to comparing 4 measures of balance, and anchor-based methods for assessing MID could not be reported. CONCLUSIONS: Important limitations, including ceiling effects and relatively low sensitivity to change and responsiveness, were noted across all balance measures, highlighting their limited utility across the full spectrum of the community-dwelling elderly population. New, more challenging measures are needed for better discrimination of balance ability in community-dwelling elderly people at higher functional levels.

Advantage of limb salvage over amputation for proximal lower extremity tumors.

UNLABELLED: Although function after lower extremity amputation and limb salvage has been compared, no study has assessed individual functional variables by surgical level. Our aim was to determine whether risks of long-term psychologic and physical limitations were associated with amputation or limb salvage at four levels: below-knee, above-knee, hip, and pelvis. We included 408 patients with sarcomas and postoperative followup of 2 years or greater who had completed a quality-of-life self-report questionnaire. The mean length of followup was 8.91 +/- 5.15 years (range, 2-27 years). Relative risk analysis was done on 12 dichotomous general health, psychologic, and physical function variables. At the below-knee level, outcomes were similar after both procedures. At the above-knee level, amputation was associated with increased risk of limp (RR = 1.6), walking aid use (RR = 2.1), anxiety (RR = 2.4), and inability to drive (RR = 3), and decreased risk of muscle weakness (RR = 0.57). At the hip and pelvic levels, outcomes were descriptively compared because of the small number of amputations. At these higher levels, limitations were more common after amputation. The difference in results between the below-knee and above-knee levels supports the importance of distinguishing surgical levels. Limb salvage offers a functional advantage at proximal tumor locations. LEVEL OF EVIDENCE: Therapeutic study, Level III (retrospective, comparative study). See the Guidelines for Authors for a complete description of levels of evidence.