Kendon J. Conrad

The foot function index: A measure of foot pain and disability

A Foot Function Index (FFI) was developed to measure the impact of foot pathology on function in terms of pain, disability and activity restriction. The FFI is a self-administered index consisting of 23 items divided into 3 sub-scales. Both total and sub-scale scores are produced. The FFI was examined for test-retest reliability, internal consistency, and construct and criterion validity. A total of 87 patients with rheumatoid arthritis were used in the study. Test-retest reliability of the FFI total and sub-scale scores ranged from 0.87 to 0.69. Internal consistency ranged from 0.96 to 0.73. With the exception of two items, factor analysis supported the construct validity of the total index and the sub-scales. Strong correlation between the FFI total and sub-scale scores and clinical measures of foot pathology supported the criterion validity of the index. The FFI should prove useful for both clinical and research purposes.

Psychometric Evaluation of the 12-Item Short-Form Health Survey (SF-12) in Osteoarthritis and Rheumatoid Arthritis Clinical Trials

BACKGROUND The psychometric properties of the 12-Item Short-Form Health Survey (SF-12), a subset of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), have been tested in the general population and certain disease states. OBJECTIVE The purpose of this study was to evaluate the psychometric properties of the SF-12 as a generic measure of health-related quality of life (HRQoL) in osteoarthritis (OA) and rheumatoid arthritis (RA) patient populations in clinical trials. METHODS Data were aggregated from 5 clinical trials evaluating the efficacy of non-steroidal anti-inflammatory drugs in OA (n = 651) and RA (n = 693) patients. Patient assessments in these trials were made using the SF-36 and commonly used clinical measures of OA and RA at baseline and after up to 6 weeks of treatment. For the items of the SF-36 contained in the SF-12, the item missing rate, computability of scores, floor and ceiling effects, factor structure, and item-component correlations were evaluated. Clinical variables and correlations of physical component summary (PCS-12) and mental component summary (MCS-12) scores of the SF-12 with the corresponding SF-36 component summary scores (PCS-36 and MCS-36) were also examined. Analyses were conducted separately for OA and RA patients. RESULTS A low individual SF-12 item missing rate (0.29% to 2.30%) and a high percentage score computability (90.9%-94.3%) were observed at baseline. No floor or ceiling effects at baseline were observed. The scree plot confirmed the 2-factor structure of the SF-12 items. Items belonging to the physical component correlated more strongly with the PCS-12 than with the MCS-12; similarly, items belonging to the mental component correlated more strongly with the MCS-12 than with the PCS-12. The correlations between the PCS-12 and PCS-36 and between the MCS-12 and MCS-36 ranged from 0.92 to 0.96 (P < 0.001) at baseline and at week 2, 4, or 6. Significant correlations ranging from -0.09 to -0.58 (P < 0.05) were observed between the SF-12 scores and clinical variables. CONCLUSION The SF-12 appears to be a psychometrically sound tool for the assessment of HRQoL in OA and RA patients.

Reliability and validity of a modified Colorado Symptom Index in a national homeless sample.

This study examined the reliability and construct validity of a modified version of the Colorado Symptom Index (MCSI), a brief, self-report measure of psychological symptomatology, in a study of interventions to prevent homelessness. Eight projects in a national, cooperative study collected new data at baseline, 6, and 12 months using a set of common measures as well as site-specific instruments. The pooled sample consisted of 1,381 persons in treatment for mental illness or substance abuse (or both), of which 84% had a history of homelessness. The analyses employed classical and Rasch methods to examine the MCSIs content validity, internal consistency and item quality, test/retest reliability, dimensionality, appropriateness for the sample, construct validity, and responsiveness to change. This 14-item scale was found to be a reliable and valid measure of psychological symptoms in this sample. Its content was consistent with other symptom measures, its high internal consistency and test-retest coefficients supported its reliability, its relationships to other measures indicated that it had good construct validity, and it was responsive to change. We conclude that the MCSI performed similarly to longer, more widely used measures of psychological symptomatology and could be useful in other studies targeting homeless adults with severe mental illness, substance use disorders, or both.

International conference on objective measurement: applications of Rasch analysis in health care.

The International Conference on Objective Measurement (ICOM): Focus on Health Care was held in Chicago, Illinois, on October 19 and 20, 2001. Sponsored by the Department of Veterans Affairs Health Services Research and Development Service (VA HSR&D), the Agency for Healthcare Research and Quality (AHRQ), the National Cancer Institute (NCI), and the Institute for Objective Measurement, it was an important event in measurement and health care. In terms of its size, it was one of the largest gatherings to date of psychometricians and health care clinicians, with over 100 presentations focusing on health care. Specifically, of the 117 papers accepted for ICOM, 104 used Rasch measurement models, 8 employed 2and 3-parameter item response theory (IRT) models, and 5 used methods based on classic test theory (CTT). ICOM brought together some of the top theoreticians in Rasch measurement, such as Ben Wright, David Andrich, John Michael Linacre, and Mark Wilson, with a large group of over 200 health care researchers and clinicians from around the world. The meeting was largely a sharing of works in progress since most of the participants presented their work in concurrent sessions focusing on 4 themes: fundamentals of measurement, methodology, policy, and clinical research. This demonstration of the worldwide use of Rasch analysis is revolutionary when many researchers still think of measurement in the CTT framework. The advances that have been made in outcomes assessment principally using CTT have been discussed in a prior supplement to Medical Care. The Preface to the 2000 supplement chronicles the history of prior health measurement conferences and the major role that AHRQ, the Kaiser Foundation, and the Institute of Medicine have played as sponsors. It was also AHRQ funding that supported the ICOM conference itself, with supplemental support from NCI and in-kind support from VA HSR&D and the Institute for Objective Measurement. The bulk of the support for this supplement came from VA HSR&D with additional funding from NCI and the Institute for Objective Measurement. For a historical perspective on measurement in health services research, McHorney has written a review of health measurement leading up to and including the use of IRT in computerized-adaptive testing. Thanks to the contributions of a range of disciplines, an array of measures of health status and health outcomes have been developed to evaluate whether health care is achieving its mission of reducing morbidity, pain, and disability, as well as improving health-related quality of life. The methods reflected in this supplement are intended to build on the breakthroughs achieved by the “outcomes revolution” in putting patients’ judgments at the center of health care improvement.

Theoretical model and Rasch analysis to develop a revised Foot Function Index.

Background: The Foot Function Index (FFI) is a widely used self-reported measure of health-related foot function. Several areas have been identified for potential improvement, and this study responds to such criticisms. The objectives of this study were to: (1) develop a theoretical model of foot functioning, (2) develop a revised FFI (FFI-R), and (3) field-test the FFI-R. Methods: A literature review was conducted to develop the theoretical model. The FFI-R items were developed from the original 23 FFI items, and more items were added as a result of the literature review. A focus group discussion with clinicians and pilot interviews with patients resulted in a final draft of the FFI-R. This draft consisted of four subscales and comprised 68 items with a six-point response scale. The FFI-R was field tested on 92 patients in the podiatry clinic of a Veterans Administration Hospital in the Midwest. Psychometric analyses were conducted with modern item response theory (IRT) methods. Results: A theoretical model of foot functioning was developed. The FFI-R response scale was revised from six to five categories since confusion was found between categories 4 and 5. Rasch analyses indicated a person reliability of 0.96 and item reliability of 0.93. The subscale reliability of pain and stiffness, psychosocial, and disability were all >0.80; the exception was assistive devices (>0.50). Construct validity of FFI-R was supported based on the correlation of 50-ft walk time with an FFI-R total of 0.306, p = 0.018, N = 59. Rasch analyses indicated several items with poor fit statistics and a short form with 34 items was developed. Conclusion: The FFI was revised, and new items were added to compose the FFI-R. The chief theoretical change was adding a psychosocial scale. Both long and short forms had very good psychometric properties.

Impacts of foot orthoses on pain and disability in rheumatoid arthritics

Rheumatoid arthritis (RA) frequently causes foot pain and swelling that affect ambulation. Pharmaceutical management of pain and disability is standard in clinical practice. The use of functional posted foot orthoses, as an adjunct to pharmaceutical treatment, is a promising treatment for managing foot pain and disability in RA. Its effectiveness, however, has not been rigorously evaluated. We performed a double-blind clinical trial using foot orthoses vs. placebo orthoses in the management of the rheumatoid arthritic foot, while subjects continued customary treatment. On the basis of findings of no effect on disability and pain measures, this study indicates no benefit of functional posted foot orthoses over placebos.

A Randomized Trial of Veterans Administration Home Care for Severely Disabled Veterans

This randomized study screened hospital admissions to all wards except Psychiatry and Spinal Cord Injured during a 3-year period to identify 233 severely disabled patients (2 impairments on the Katz Index of ADL) and caregivers who were willing to participate in a pretest-multiple posttest trial of the Hines VA Hospital-based Home Care (HBHC) Program. Patient functional status, morale, and satisfaction with care were measured at baseline, 1 month and 6 months post discharge. Caregiver satisfaction and morale were assessed at the same time periods. All health care services used by both groups were tracked over the 6-month period and converted to cost. Findings include improved 1-month satisfaction with care (p = 0.04) and improved 6-month cognitive functioning (p = 0.04) among HBHC patients and improved 1-month (p = 0.04) and 6-month satisfaction with care (p < 0.01) among their caregivers. A nonsignificant 10% decrease in net cost of care, was found in the treatment group, largely due to lower use of private sector hospital care.

The Development of a Conceptual Model for Understanding Elder Self-neglect

PURPOSE Elder self-neglect (ESN) represents half or more of all cases reported to adult protective services. ESN directly affects older adults and also their families, neighbors, and the larger communities around them. ESN has public health implications and is associated with higher than expected mortality rates, hospitalizations, long-term care placements, and localized environmental and safety hazards. This article describes results from a study using concept mapping to create a conceptual model of ESN. DESIGN AND METHODS Two brainstorming sessions were convened with senior services program supervisors, geriatricians, local policy analysts and program planners, elder law practitioners, and university-based researchers (n = 20), and a list of 73 ESN indicators was generated. Using Concept Systems software, the 20 original panelists and an additional 30 practitioners, including case managers and supervisors from local agencies, social workers specializing in working with older adults, and elder abuse investigators, sorted the 73 items and rated them along the dimension of importance for the concept of self-neglect. RESULTS Using hierarchical cluster analysis and multidimensional scaling, a conceptual map with 7 clusters was produced. Clusters with the highest importance ratings were Physical Living Conditions and Mental Health. Clusters were highly interrelated, with the exception of the Physical Living Conditions cluster. IMPLICATIONS This research presents a conceptualization of ESN, identifies the constituent domains, and proposes a conceptual model based on the importance for assessing symptoms and indicators. Findings may help focus programmatic and research efforts, leading to the development of measures that open the field for further research and theory generation.

Case Managed Residential Care for Homeless Addicted Veterans Results of a True Experiment

OBJECTIVES The effectiveness of case-managed residential care (CMRC) in reducing substance abuse, increasing employment, decreasing homelessness, and improving health was examined. METHODS A five-year prospective experiment included 358 homeless addicted male veterans 3, 6, and 9 months during their enrollment and at 12, 18, and 24 months after the completion of the experimental case-managed residential care program. The customary control condition was a 21-day hospital program with referral to community services. RESULTS The experimental group averaged 3.4 months in transitional residential care with ongoing and follow-up case management for a total of up to 1 year of treatment. The experimental group showed significant improvement compared with the control group on the Medical, Alcohol, Employment, and Housing measures during the 2-year period. An examination of the time trends indicated that these group differences tended to occur during the treatment year, however, and to diminish during the follow-up year. CONCLUSIONS Within groups, significant improvements were observed with time from baseline to all posttests on the four major outcomes. We learned, however, that veterans had access to and used significant amounts of services even without the special case-managed residential care program. This partially may account for improvements in the control group and may have muted the differences between groups.

Can foot orthoses prevent hallux valgus deformity in rheumatoid arthritis? A randomized clinical trial.

Hallux valgus deformity is the most commonly observed forefoot deformity in patients with rheumatoid arthritis. This 5-year, double-blind, randomized clinical trial compared treatment orthoses with placebo orthoses for the prevention of hallux valgus deformity in the rheumatoid arthritic foot.One hundred and two subjects with active rheumatoid arthritis and with foot pain and minimal radiographic changes of the feet participated in the study. They were recruited from five arthritis clinics in the Chicago metropolitan area that are affiliated with or are teaching clinics of area medical schools. Patients were followed for 3 years.Eighty-one subjects completed the study. In a logistic regression analysis, the treatment group was 73% less likely to develop hallux valgus deformity compared with the control group (adjusted odds ratio 0.27, 95% confidence interval 0.078, 0.916 p = .04). These findings suggest that foot orthoses can prevent or slow the progression of hallux valgus deformity.