Susan Stark

Operationalizing the International Classification of Functioning, Disability and Health in Clinical Settings

Functional status may be a better indicator of health care needs and outcomes than diagnosis. Appropriate use of the International Classification of Functioning, Disability and Health (ICF) in health service settings can provide a standardized way for clinicians to communicate complex clinical assessments to other professionals, administrators, and payers. The American Psychological Association is working with the World Health Organization to develop a Procedural Manual and Guide for a Standardized Application of the ICF for use by multidisciplinary health professionals. The Procedural Manual includes operational definitions of concepts, examples of each code, and assessment information relevant to each qualifier. The purpose of the Procedural Manual is to provide health professionals with the guidance necessary for reliable, valid, and clinically useful classification. This article discusses a range of issues and problems in the application of individual ICF codes in the context of health care and offers some potential solutions.

A subjective measure of environmental facilitators and barriers to participation for people with mobility limitations

Purpose. The aim of this paper is to describe the development and psychometric properties of a self-report survey of environmental facilitators and barriers to participation by people with mobility impairments. Method. A measure called the Facilitators And Barriers Survey of environmental influences on participation among people with lower limb Mobility impairments and limitations (FABS/M) was developed using items based on focus groups to ensure content validity. Discriminant validity was assessed on 604 individuals who completed the FABS/M once. Internal consistency and test-retest reliabilities were based on 371 individuals who completed two surveys. Results. The FABS/M includes 61 questions, 133 items and six domains including the type of primary mobility device; built features of homes; built and natural features in the community; community destination access; community facilities access; community support network. Environmental items are scored for the frequency of encounter and the magnitude of influence on their participation. The internal consistencies and the test-retest reliabilities of the domains of the FABS/M ranged from low to moderate. The discriminant validity of domains differed for device and diagnostic groups. Conclusion. The FABS/M joins the MQE and the CHIEF as another subjective measure for use in assessing environmental features important for understanding participation. The FABS can be used to assess the influence of environmental interventions at the individual and community levels of analysis. The type of primary mobility device that is used can be related to reported environmental barriers. Community-based improvements in built features, access to destinations, access to facilities and augmented support networks can be tracked through the reports of people with mobility impairments.

Environmental Barriers and Supports to Everyday Participation: A Qualitative Insider Perspective From People With Disabilities

OBJECTIVE To describe environmental factors that influence participation of people with disabilities. DESIGN Constant comparative, qualitative analyses of transcripts from 36 focus groups across 5 research projects. SETTING Home, community, work, and social participation settings. PARTICIPANTS Community-dwelling people (N=201) with diverse disabilities (primarily spinal cord injury, traumatic brain injury, and stroke) from 8 states. INTERVENTIONS None. MAIN OUTCOME MEASURES Environmental barriers and supports to participation. RESULTS We developed a conceptual framework to describe how environmental factors influence the participation of people with disabilities, highlighting 8 domains of environmental facilitators and barriers (built, natural, assistive technology, transportation, information and technology access, social support and attitudes, systems and policies, economics) and a transactional model showing the influence of environmental factors on participation at the micro (individual), mesa (community), and macro (societal) levels. Focus group data validated some International Classification of Functioning, Disability and Health environmental categories while also bringing unique factors (eg, information and technology access, economic quality of life) to the fore. Data were used to construct items to enable people with disabilities to assess the impact of environmental factors on everyday participation from their firsthand experience. CONCLUSIONS Participants with disabilities voiced the need to evaluate the impact of the environment on their participation at the immediate, community, and societal levels. The results have implications for assessing environmental facilitators and barriers to participation within rehabilitation and community settings, evaluating outcomes of environmental interventions, and effecting system and policy changes to target environmental barriers that may result in societal participation disparities versus opportunities.

Removing Environmental Barriers in the Homes of Older Adults with Disabilities Improves Occupational Performance

The current study examines the effectiveness of an occupational therapy home modification intervention program by examining differences in self-reported occupational performance before and after intervention in a population of community-dwelling older adults with disabilities. An occupational therapy intervention was provided in the homes of 16 older adults with functional limitations. The intervention included changing the existing space by the provision of adaptive equipment and making architectural modifications (including major remodeling) to the home. No remediative treatment was provided. The Canadian Occupational Performance Measure was used to measure satisfaction and performance in daily activities in the home before and after home modification intervention. Overall, the mean scores on the satisfaction and performance subscales indicated an improvement in performance and satisfaction with occupational performance. The average number of barriers in each home was 4.7. An average of only 2.5 barriers were solved during the intervention. The removal of environmental barriers from the homes of older adults who have functional limitations can significantly improve their occupational performance and their satisfaction with their ability to perform everyday activities.

Development of a measure of receptivity of the physical environment

Purpose. New models of disability identify the importance of measuring the influence of the environment (environmental barriers) on the performance of persons with disabilities. The objective of this paper is to present a new measure of the receptivity of the physical environment for persons with mobility impairments and to offer preliminary information about its psychometric properties. Methods. The measure, The Community Health Environment Checklist (CHEC), was developed and validated in a community setting with a group of persons with mobility impairments. Sixty-three destinations (buildings, recreational areas or facilities) were assessed using the CHEC. Results. Using Cronbachs alpha, the CHEC was found to have an internal consistency reliability of 0.95. The content validity of the CHEC was assured by the development procedure. Conclusion. The CHEC offers a brief, easily administered measure of receptivity of the physical environment for persons with mobility impairments that is psychometrically sound.

Systematic review of falls in older adults with cancer.

OBJECTIVES Older adults frequently experience falls, at great cost to themselves and society. Older adults with cancer may be at greater risk for falls and have unique risk factors. MATERIALS AND METHODS We undertook a systematic review of the available medical literature to examine the current evidence regarding factors associated with falls in older adults with cancer. PubMed, Embase, CINAHL, CENTRAL, DARE, Cochrane Database of Systematic Reviews and clinical trials.gov were searched using standardized terms for concepts of oncology/cancer, people 60 and older, screening, falls and diagnosis. Eligible studies included cohort or case-control studies or clinical trials in which all patients, or a subgroup of patients, had a diagnosis of cancer and in which falls were either the primary or secondary outcome. RESULTS We identified 31 studies that met our inclusion criteria. Several studies suggest that falls are more common in older adults with a diagnosis of cancer than those without. Among the 11 studies that explored factors associated with outpatient falls, some risk factors for falls established in the general population were also associated with falls in older adults with cancer, including dependence in activities of daily living and prior falls. Other factors associated with falls in a general population, such as age, polypharmacy and opioid use, were not predictive of falls among oncology populations. Falls among older adults with cancer in the inpatient setting were associated with established risk factors for falls in people without cancer, but also with factors unique to an oncology population, such as brain metastases. CONCLUSIONS Falls in older adults with cancer are more common than in the general population, and are associated with risk factors unique to people with cancer. Further study is needed to establish methods of screening older adults with cancer for fall risk and ultimately implement interventions to reduce their risk of falls. Identifying which older adults with cancer are at greater risk for falls is a requisite step to ultimately intervene and prevent falls in this vulnerable population.

Anticipating relocation: concerns about moving among NORC residents.

Summary Most older adults prefer to live at home as long as possible, requiring supports and services to help them age in place. This study examines the relocation concerns of a group of older adults in a suburban naturally-occurring retirement community (NORC). Twenty-six percent of the 324 residents interviewed expressed concern about having to move in the next few years. Residents who were worried differed from those who did not worry on a number of demographic and biopsychosocial characteristics. Overall, residents present a profile of vulnerability that calls for preemptive action to help them stay in their homes. A NORC is an ideal setting in which to provide supportive services.

Predicting geriatric falls following an episode of emergency department care: a systematic review.

BACKGROUND Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. OBJECTIVES This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factors accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. METHODS A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. RESULTS A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. CONCLUSIONS This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk.

Creating Disability in the Home: The role of environmental barriers in the United States

One thousand persons with disabilities were sampled to discover the types of barriers they encountered in their home while carrying out their daily activities. A 43 percent response rate was obtained. The open-ended questions were submitted to a process of analytic coding and suggested 27 different categories of barriers existed in the homes of persons who have disabilities. The findings have implications for rehabilitation practice. Performance of daily activities is greatly diminished by the presence of architectural barriers. Environmental supports can greatly improve performance in daily tasks. These findings are discussed in light of disability policy and implications for improving performance of persons who have disability.

Physician and Nurse Acceptance of Technicians to Screen for Geriatric Syndromes in the Emergency Department

Introduction The objective of this study was to evaluate emergency medicine physician and nurse acceptance of nonnurse, nonphysician screening for geriatric syndromes. Methods This was a single-center emergency department (ED) survey of physicians and nurses after an 8-month project. Geriatric technicians were paid medical student research assistants evaluating consenting ED patients older than 65 years for cognitive dysfunction, fall risk, or functional decline. The primary objective of this anonymous survey was to evaluate ED nurse and physician perceptions about the geriatric screener feasibility and barriers to implementation. In addition, as a secondary objective, respondents reported ongoing geriatric screening efforts independent of the research screeners. Results The survey was completed by 72% of physicians and 33% of nurses. Most nurses and physicians identified geriatric technicians as beneficial to patients without impeding ED throughput. Fewer than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluated for fall risk significantly more often than physicians, but no other significant differences were noted in ongoing screening efforts. Conclusion Dedicated geriatric technicians are perceived by nurses and physicians as beneficial to patients with the potential to improve patient safety and clinical outcomes. Most nurses and physicians are not currently screening for any geriatric syndromes.