Chih Ying Li

Equating activities of daily living outcome measures: the Functional Independence Measure and the Korean version of Modified Barthel Index

Abstract Purpose: To create a crosswalk between the Functional Independence Measure (FIM) motor items and the Korean version of the Modified Barthel Index (K-MBI). Method: Korean community-dwelling adult patients (n = 276) completed the FIM and K-MBI on the same day in outpatient rehabilitation hospitals. We used a single group design with the Rasch common person equating and conducted a factor analysis of the co-calibrated item pool using the two measures. Rasch analysis was used to investigate the psychometrics of the equated test items in the identified factor structure(s). The correlation between FIM raw scores and converted K-MBI scores was examined. Results: Three measurement constructs were identified: self-care, mobility, involuntary movement. The equated test items in the three constructs demonstrated good person separation reliability (r = 0.94–0.96) and good internal consistency (Cronbach’s alpha =0.93–0.97). The three crosswalks between the FIM raw scores and converted K-MBI scores demonstrated good correlations (r = 0.91–0.93, all p < 0.0001). Conclusions: The Rasch equating method successfully created three crosswalks between the FIM motor items and K-MBI, with the equated test items demonstrating good psychometrics. The crosswalks would address the incomparable scoring systems between the FIM motor items and K-MBI. Implications for Rehabilitation The three crosswalk tables (scoring tables) would allow clinicians to compare or translate a patient’s motor scores between the FIM and K-MBI. The crosswalk tables would allow health-care administrators to track patients’ functional status across various rehabilitation facilities that exclusively use the FIM or K-MBI.

The Development of a Scoring System for the Kinetic House-Tree-Person Drawing Test

Objective/Background The Kinetic House-Tree-Person Test (KHTPT) is already in widespread use amongst psychiatric occupational therapists in Taiwan, but the psychometric attributes of the test are somewhat limited. The primary aims of this study are to develop a quantitative scoring system for the KHTPT and carry out an assessment of its psychometric attributes. Methods Based on the test manual and the related literature, we identified 35 drawing characteristics relating to anxiety and depression, and we recruited 323 participants from two universities in northern Taiwan to participate in our study. These participants, who had a mean age of 20.1 years (SD = 3.0), were instructed to draw a KHTPT picture, and were then asked to complete related questionnaires. The data were subsequently analysed using WINSTEPS (Beavertown, Oregon: Winsteps.com) and SPSS (SPSS Inc., Chicago). Results The results revealed that all of the items of the scoring system provided a good fit with the Rasch measurement model, with the Cronbachs alpha for the scale being .94. The Spearman correlation coefficients of the Rasch-transformed KHTPT scores with the Beck Anxiety Inventory, the Beck Depression Inventory-II, the Beck Hopelessness Scale, and the National Taiwan University Hospital Symptom Checklist were all found to be small, albeit with statistical significance (Spearman correlation coefficients, r = .140–-.226). Conclusion This study demonstrates our proposed KHTPT scoring system has eminently acceptable construct validity and internal consistency. We suggest that future studies should include patients with psychiatric disorders at varying degrees of severity or functional level to examine the applicability and predictive validity of our proposed scoring system.

Linking Existing Instruments to Develop an Activity of Daily Living Item Bank

This study examined dimensionality and item-level psychometric properties of an item bank measuring activities of daily living (ADL) across inpatient rehabilitation facilities and community living centers. Common person equating method was used in the retrospective veterans data set. This study examined dimensionality, model fit, local independence, and monotonicity using factor analyses and fit statistics, principal component analysis (PCA), and differential item functioning (DIF) using Rasch analysis. Following the elimination of invalid data, 371 veterans who completed both the Functional Independence Measure (FIM) and minimum data set (MDS) within 6 days were retained. The FIM-MDS item bank demonstrated good internal consistency (Cronbach’s α = .98) and met three rating scale diagnostic criteria and three of the four model fit statistics (comparative fit index/Tucker–Lewis index = 0.98, root mean square error of approximation = 0.14, and standardized root mean residual = 0.07). PCA of Rasch residuals showed the item bank explained 94.2% variance. The item bank covered the range of θ from −1.50 to 1.26 (item), −3.57 to 4.21 (person) with person strata of 6.3. The findings indicated the ADL physical function item bank constructed from FIM and MDS measured a single latent trait with overall acceptable item-level psychometric properties, suggesting that it is an appropriate source for developing efficient test forms such as short forms and computerized adaptive tests.

Dimensionality and Item-Difficulty Hierarchy of the Lower Extremity Fugl-Meyer Assessment in Individuals With Subacute and Chronic Stroke

OBJECTIVE To investigate the dimensionality and item-difficulty hierarchy of the Fugl-Meyer Assessment of the lower extremity (FMA-LE). DESIGN Secondary analyses of data pooled from 4 existing datasets: a phase III randomized controlled trial investigating the effectiveness of body weight support and a treadmill for rehabilitation of walking poststroke, and 3 cross-sectional studies investigating the link between impaired motor performance poststroke and walking. SETTING University research centers and rehabilitation centers. PARTICIPANTS A pooled sample of individuals with a stroke (N=535, men=313; mean age ± SD, 61.91±12.42y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Confirmatory factor analyses (CFA) and Rasch residual principal component analysis (PCA) investigated the dimensionality of the FMA-LE. The Rasch analysis rating scale model investigated item-difficulty hierarchy of the FMA-LE. RESULTS The CFA showed adequate fit of a 3-factor model, with 2 out of 3 indices (CFA=.95; Tucker-Lewis Index=.94; root mean square error of approximation=.124) showing good model fit. Rasch PCA showed that removal of the reflex and coordination items explained 90.8% of variance in the data, suggesting that the abnormal synergy items contributed to the measurement of a unidimensional construct. However, rating scale model results revealed deviations in the item-difficulty hierarchy of the unidimensional abnormal synergy items from the originally proposed stepwise sequence of motor recovery. CONCLUSIONS Our findings suggest that the FMA-LE might represent a multidimensional construct, challenging the use of a total score of the FMA-LE to predict lower extremity motor recovery. Removal of the misfit items resulted in creation of a unidimensional scale composed of the abnormal synergy items. However, this unidimensional scale deviates from the originally proposed hierarchical ordering.

Factor structure and item level psychometrics of the Social Problem Solving Inventory – Revised: Short Form in traumatic brain injury

Social problem-solving deficits characterise individuals with traumatic brain injury (TBI), and poor social problem solving interferes with daily functioning and productive lifestyles. Therefore, it is of vital importance to use the appropriate instrument to identify deficits in social problem solving for individuals with TBI. This study investigates factor structure and item-level psychometrics of the Social Problem Solving Inventory – Revised: Short Form (SPSI-R:S), for adults with moderate and severe TBI. Secondary analysis of 90 adults with moderate and severe TBI who completed the SPSI-R:S was performed. An exploratory factor analysis (EFA), principal components analysis (PCA) and Rasch analysis examined the factor structure and item-level psychometrics of the SPSI-R:S. The EFA showed three dominant factors, with positively worded items represented as the most definite factor. The other two factors are negative problem-solving orientation and skills; and negative problem-solving emotion. Rasch analyses confirmed the three factors are each unidimensional constructs. It was concluded that the total score interpretability of the SPSI-R:S may be challenging due to the multidimensional structure of the total measure. Instead, we propose using three separate SPSI-R:S subscores to measure social problem solving for the TBI population.

A Psychometric Study of the Kinetic-House-Tree-Person Scoring System for People with Psychiatric Disorders in Taiwan

Objective/Background The Kinetic-House-Tree-Person (KHTP) drawing test is widely used by psychiatric occupational therapists in Taiwan; however, very little support has been provided through studies examining its psychometric properties. The aim of the study is to validate a scoring system for the KHTP on a group of people with psychiatric disorders. Methods A total of 66 individuals with psychiatric disorders were recruited for this study along with 53 college students as a comparative group. Each participant completed the KHTP test. Half of the individuals with psychiatric disorders (33 people) completed the KHTP again following a 2-week period. The KHTP scoring system contains 54 items representing drawing characteristics. Two independent raters determined the score of the drawings, with the validity and reliability of the KHTP scoring system being subsequently examined by the Rasch and traditional analysis. Results The results reveal both validity and unidimensionality of the KHTP scoring system, demonstrating acceptable test—retest reliability. The intraclass correlation coefficient of the scoring systems inter-rater reliability was .76, with significant statistical differences found between the KHTP scores of college students and individuals with psychiatric disorders. Conclusion The KHTP scoring system has acceptable construct validity, inter-rater reliability, and test—retest reliability. Because drawing tests have the advantage of expressing nonverbal characteristics, the scoring system should prove to be very useful for those who are unwilling or unable to communicate verbally. This study therefore provides valuable information for clinical application, particularly for the psychiatric rehabilitation professions.

Impact of Multiple Chronic Conditions on Activity Limitations Among Older Mexican-American Care Recipients

Introduction Older Mexican Americans are living longer with multiple chronic conditions (MCCs). This has placed greater demands on caregivers to assist with basic activities of daily living (ADL) or instrumental activities of daily living (IADL). To understand the needs of older Mexican-American care recipients, we examined the impact of MCC on ADL and IADL limitations. Methods We analyzed data from 485 Mexican American care-receiving/caregiving dyads. Selected MCCs in the analysis were diabetes, hypertension, stroke, heart disease, arthritis, emphysema/chronic obstructive pulmonary disease, cognitive impairment, depression, and cancer. Care recipients were dichotomized as having 3 or more conditions or as having 2 or fewer conditions. Three comorbidity clusters were established on the basis of the most prevalent health conditions among participants with comorbid arthritis and hypertension. These clusters included arthritis and hypertension plus: diabetes (cluster 1), cognitive impairment (cluster 2), and heart disease (cluster 3). Results Care recipients with 3 or more chronic conditions (n = 314) had higher odds of having mobility limitations (OR = 1.98; 95% CI, 1.34–2.94), self-care limitations (OR = 2.53; 95% CI, 1.70–3.81), >3 ADL limitations (OR = 2.00; 95% CI, 1.28–3.17), and >3 IADL limitations (OR = 1.88; 95% CI, 1.26–2.81). All clusters had increased odds of ADL and severe ADL limitations. Of care recipients in cluster 2, those with arthritis, hypertension, and cognitive impairment had significantly higher odds of mobility limitations (OR = 2.33; 95% CI, 1.05–5.24) than those with just arthritis and hypertension. Conclusion MCCs were associated with more ADL and IADL limitations among care recipients, especially for those with hypertension and arthritis plus diabetes, cognitive impairment, or heart disease. These findings can assist in developing programs to meet the needs of older Mexican-American care recipients.

Development and Validation of the Activities of Daily Living Short Form for Community-Dwelling Korean Stroke Survivors

This study developed and validated a short form (SF) using activities of daily living (ADL) outcome measures from the Korea National Health and Nutrition Examination Survey (KNHANES) that can minimize survey administration burden for clinicians. This study utilized secondary data from the 2005 KNHANES with 422 community-dwelling stroke survivors. The KNHANES data were collected from April to June 2005 in South Korea. We created a 7-item SF from the 17 ADL questions in the survey using item response theory (IRT) methodologies. The precision and validity of the SF were compared to the full questionnaire of ADL items and the EuroQol-5D total score. Among the 17 ADL questions, 14 questions demonstrated unidimensional construct validity. Using IRT methodologies, a set of 7 items were selected from the full bank. The 7-item SF demonstrated good psychometric properties: high correlation with the full bank (r = .975, p < .001), good internal consistency (Cronbach’s α = .93), and a high correlation with the EuroQol-5D total score (r = .678, p < .001). These findings indicate that a well-developed SF can precisely measure ADL performance capacity for stroke survivors compared to the full item bank, which is expected to reduce the administration burden of the KNHANES.

Effects of Age and Sex on Hospital Readmission in Traumatic Brain Injury

OBJECTIVE To investigate the effects of age and sex on 30-, 60-, and 90-day hospital readmission after acute hospital discharge for individuals with traumatic brain injury (TBI). DESIGN Retrospective cohort study. SETTING Acute hospitals and postacute discharge settings. PARTICIPANTS Individuals (N=52,877) with Diagnosis Related Group codes of TBI, who were divided into 4 age groups: 18 to 40, 41 to 65, 66 to 75, and ≥76 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All-cause hospital readmission. RESULTS Sex differences in 30-, 60-, and 90-day hospital readmission were found among all age groups (P<.05 for all). The largest sex differences in hospital readmission were in the 2 oldest groups (66-75 and ≥76y). For both sexes, the oldest group (≥76y) had the highest adjusted 90-day readmission risk (eg, 90-d readmission: odds ratio, 2.32 [95% confidence interval, 2.01-2.69] for men; odds ratio, 1.96 [95% confidence interval, 1.59-2.43] for women). Among those readmitted within 90 days, the youngest group (18-40y) had the highest cumulative readmission percentage (35% for both sexes) within the first week of hospital discharge. CONCLUSIONS Age and sex were significantly associated with hospital readmission during the first 90 days postdischarge in our TBI sample. Specifically, those aged 66 to 75 or ≥76 years had the highest readmission risk over 90 days for both sexes. The findings suggest that clinicians should consider age and sex in discharge planning and for the entire episode of care for the population with TBI.

Physical Activity and the Risk of Depression in Community-Dwelling Korean Adults With a History of Stroke.

Background Physical activity (PA) is believed to improve mental health, including depression. However, whether recommended PA levels have a similar impact in individuals with poststroke depression is unclear. Objective The aim of this study was to apply a quasi‐experimental propensity score (PS) matching control for covariate differences and compare the effects of PA on reducing depression risk among people with stroke. Design A cross‐sectional design was used for this study. Methods Health‐related information for community‐dwelling adults (N=4,555) who reported having had a stroke was extracted from the 2013 Korean Community Health Survey data set. The survey participants were asked a series of questions about depression, recommended PA levels (moderate and vigorous intensity), and chronic conditions. A multivariable regression model, inverse probability weighting adjustment, and Greedy algorithms with 1:1 matching and covariate adjustment were used to estimate the effects of PA on risk of depression. The dependent variable was diagnosis of depression, and the primary independent variable was PA. Baseline covariates were 10 demographic and 9 chronic condition variables. Results Without PS methods, there were significant differences in baseline covariates (16 out of 19) between people who performed PA and those who did not perform PA. After applying 1:1 matching, the number of patients in each group comparing the effect of PA numbered 1,970, and 13 covariates did not differ significantly between the 2 groups. Physical activity reduced the risk of poststroke depression by 36.1% to 42.4% (odds ratio=0.639‐0.376) across the 3 methods. Limitations Unaccounted‐for covariates, including stroke severity, predepression status, and history of depression treatments, may have biased the results. Conclusions The findings suggest that recommended PA levels have protective relationships with the risk of poststroke depression.