Poonam Pardasaney

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.

Effect of a Home-Based Exercise Program on Functional Recovery Following Rehabilitation After Hip Fracture: A Randomized Clinical Trial

IMPORTANCE For many older people, long-term functional limitations persist after a hip fracture. The efficacy of a home exercise program with minimal supervision after formal hip fracture rehabilitation ends has not been established. OBJECTIVE To determine whether a home exercise program with minimal contact with a physical therapist improved function after formal hip fracture rehabilitation ended. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted from September 2008 to October 2012 in the homes of 232 functionally limited older adults who had completed traditional rehabilitation after a hip fracture. INTERVENTIONS The intervention group (n = 120) received functionally oriented exercises (such as standing from a chair, climbing a step) taught by a physical therapist and performed independently by the participants in their homes for 6 months. The attention control group (n = 112) received in-home and telephone-based cardiovascular nutrition education. MAIN OUTCOMES AND MEASURES Physical function assessed at baseline, 6 months (ie, at completion of the intervention), and 9 months by blinded assessors. The primary outcome was change in function at 6 months measured by the Short Physical Performance Battery (SPPB; range 0-12, higher score indicates better function) and the Activity Measure for Post-Acute Care (AM-PAC) mobility and daily activity (range, 23-85 and 9-101, higher score indicates better function). RESULTS Among the 232 randomized patients, 195 were followed up at 6 months and included in the primary analysis. The intervention group (n=100) showed significant improvement relative to the control group (n=95) in functional mobility (mean SPPB scores for intervention group: 6.2 [SD, 2.7] at baseline, 7.2 [SD, 3] at 6 months; control group: 6.0 [SD, 2.8] at baseline, 6.2 [SD, 3] at 6 months; and between-group differences: 0.8 [95% CI, 0.4 to 1.2], P < .001; mean AM-PAC mobility scores for intervention group: 56.2 [SD, 7.3] at baseline, 58.1 [SD, 7.9] at 6 months; control group: 56 [SD, 7.1] at baseline, 56.6 [SD, 8.1] at 6 months; and between-group difference, 1.3 [95% CI, 0.2 to 2.4], P = .03; and mean AM-PAC daily activity scores for intervention group: 57.4 [SD, 13.7] at baseline, 61.3 [SD, 15.7] at 6 months; control group: 58.2 [SD, 15.2] at baseline, 58.6 [SD, 15.3] at 6 months; and between-group difference, 3.5 [95% CI, 0.9 to 6.0], P = .03). In multiple imputation analyses, between-group differences remained significant for SPPB and AM-PAC daily activity, but not for mobility. Significant between-group differences persisted at 9 months for all functional measures with and without imputation. CONCLUSIONS AND RELEVANCE Among patients who had completed standard rehabilitation after hip fracture, the use of a home-based functionally oriented exercise program resulted in modest improvement in physical function at 6 months after randomization. The clinical importance of these findings remains to be determined. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00592813.

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 Veterans 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 Veterans 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.

Development of a Risk-adjustment Model for the Inpatient Rehabilitation Facility Discharge Self-care Functional Status Quality Measure

Background: Functional status measures are important patient-centered indicators of inpatient rehabilitation facility (IRF) quality of care. We developed a risk-adjusted self-care functional status measure for the IRF Quality Reporting Program. This paper describes the development and performance of the measure’s risk-adjustment model. Methods: Our sample included IRF Medicare fee-for-service patients from the Centers for Medicare & Medicaid Services’ 2008–2010 Post-Acute Care Payment Reform Demonstration. Data sources included the Continuity Assessment Record and Evaluation Item Set, IRF-Patient Assessment Instrument, and Medicare claims. Self-care scores were based on 7 Continuity Assessment Record and Evaluation items. The model was developed using discharge self-care score as the dependent variable, and generalized linear modeling with generalized estimation equation to account for patient characteristics and clustering within IRFs. Patient demographics, clinical characteristics at IRF admission, and clinical characteristics related to the recent hospitalization were tested as risk adjusters. Results: A total of 4769 patient stays from 38 IRFs were included. Approximately 57% of the sample was female; 38.4%, 75–84 years; and 31.0%, 65–74 years. The final model, containing 77 risk adjusters, explained 53.7% of variance in discharge self-care scores (P<0.0001). Admission self-care function was the strongest predictor, followed by admission cognitive function and IRF primary diagnosis group. The range of expected and observed scores overlapped very well, with little bias across the range of predicted self-care functioning. Conclusions: Our risk-adjustment model demonstrated strong validity for predicting discharge self-care scores. Although the model needs validation with national data, it represents an important first step in evaluation of IRF functional outcomes.

Refinements of the Medicare Outpatient Therapy Annual Expenditure Limit Policy

Background A Medicare beneficiarys annual outpatient therapy expenditures that exceed congressionally established caps are subject to extra documentation and review requirements. In 2011, these caps were

Computer-Adaptive Balance Testing Improves Discrimination Between Community-Dwelling Elderly Fallers and Nonfallers

1,870 for physical therapy and speech-language pathology combined and

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

1,870 for occupational therapy separately. Objective This article considers the distributional effects of replacing current cap policy with equal caps by therapy discipline (physical therapy, occupational therapy, and speech-language pathology) or a single combined cap, and risk adjusting the physical therapy cap using beneficiary characteristics and functional status. Methods Alternative therapy cap policies are simulated with 100% Medicare claims for 2011 therapy users (N=4.9 million). A risk-adjusted cap for annual physical therapy expenditures is calculated from a quantile regression estimated on a sample of physical therapy users with diagnoses and clinician assessments of functional ability merged to their claims (n=4,210). Results Equal discipline-specific caps of

Assessing Quality of Care: Variation in Discharge to Community Rates in Post-Acute Care Settings

1,710 each for physical therapy, occupational therapy, and speech-language pathology result in the same aggregate Medicare expenditures above the caps as 2011 cap policy. A single combined-disciplines cap of

Assessing discharge to community outcomes in post-acute care settings

2,485 also results in the same aggregate expenditures above the cap. Risk adjustment varies the physical therapy cap by as much as 5 to 1 across beneficiaries and equalizes the probability of exceeding the physical therapy cap across diagnosis and functional status groups. Limitations One limitation of the study was the assumption of no behavioral response on the part of beneficiaries or providers to a change in cap policy. Additionally, analysis of risk adjusting the therapy caps was limited by sample size. Conclusions Equal discipline-specific caps for physical therapy, occupational therapy, and speech-language pathology are more equitable to high users of both physical therapy and speech-language pathology than current cap policy. Separating the physical therapy and speech-language pathology caps is a change that policy makers could consider. Risk adjustment of the therapy caps is a first step in incorporating beneficiary need for services into Medicare outpatient therapy payment policy.