Vera A. Gonzales

Comparison of the Community Integration Questionnaire, the Craig Handicap Assessment and Reporting Technique, and the Disability Rating Scale in traumatic brain injury.

Objective:To examine the concurrent validity of the Community Integration Questionnaire (CIQ) in assessing outcomes in traumatic brain injury (TBI) by comparing it with two widely used and well-validated measurements of rehabilitation outcome. Design:A retrospective relational study of the concurrent validity of the CIQ, Craig Handicap Assessment and Reporting Technique (CHART), and Disability Rating Scale (DRS). Setting:A postacute rehabilitation facility. Participants:Seventy patients with a medical diagnosis of TBI admitted between April 1996 and October 1998 participated in the study. Results:CIQ and CHART provide ratings that are similar in several areas to those provided by the DRS. Correlation (r) among total scores and subscales for all three instruments ranged from 0.021 to 0.671 (P < .01). Correlation between CIQ and CHART is stronger than that between CIQ and DRS or between CHART and DRS, and the correlation between CHART and DRS is stronger than that between CIQ and DRS. Conclusion:The CIQ appears to be the most appropriate instrument in quantifying rehabilitation outcome in patients with TBI at the participatory (handicap) level. The findings of this study can help clinicians gain a greater understanding of the nature, redundancy, and gaps among functional outcome measures. Monitoring outcomes can also help clinicians better understand the effectiveness of interventions.

Satisfaction with medical rehabilitation in patients with cerebrovascular impairment

Ottenbacher KJ, Gonzales VA, Smith PM, Illig SB, Fiedler RC, Granger CV: Satisfaction with medical rehabilitation in patients with cerebrovascular impairment. Am J Phys Med Rehabil 2001;80:876–884. ObjectiveOverall satisfaction has important social and economic implications for patients who have received inpatient medical rehabilitation. We conducted this study to examine the overall satisfaction level at 3- to 6-mo follow-up for inpatients with cerebrovascular impairments discharged from medical rehabilitation. DesignThe study was retrospective using information from a national database representative of medical rehabilitation patients across the United States. Information submitted in 1997 and 1998 to the Uniform Data System for Medical Rehabilitation by 177 hospital and rehabilitation facilities from 40 states was examined. The final sample included 8,900 patient records. The main outcome measure was the level of satisfaction with medical rehabilitation at 80–180 days postdischarge follow-up. ResultsA logistic regression model including ten independent variables was used to predict satisfied vs. dissatisfied at follow-up. Three statistically significant variables were included in the final model and correctly classified 95.1% of the patients. Higher FIM™ instrument discharge scores were associated with increased satisfaction. Further analysis of the FIM instrument subscales indicated that higher ratings in transfers, social cognition, and locomotion were significantly associated with increased satisfaction. ConclusionWe identified several functional variables associated with increased satisfaction after medical rehabilitation in persons with stroke. The ability to objectively assess patient satisfaction is important as consumer-based outcome measures are integrated in accreditation and healthcare evaluation.

Disparity in health services and outcomes for persons with hip fracture and lower extremity joint replacement.

Objective. Examine disparity in health services and outcomes for adults with a hip fracture or lower extremity joint replacement. Materials and methods. This study examined 28,522 patient records including 12,328 (mean age 76.6 years) with hip fracture and 16,194 (mean age 71.8 years) with joint replacement. Results. Non-Hispanic white and black patients were significantly (P <0.05) more likely to be discharged home alone and responsible for their own care than were Asian or Hispanic patients. Sixty-four percent of Hispanic patients received inpatient rehabilitation after hip fracture and 36% after hip or knee arthroplasty. In contrast, 58% of non-Hispanic white persons, 67% of black persons, and 56% of Asian persons received inpatient medical rehabilitation after hip or knee joint replacement. Conclusion. Disparity in outcomes appeared to be related to family structure and social support.

Satisfaction With Medical Rehabilitation in Patients With Orthopedic Impairment

OBJECTIVE To examine patient satisfaction after orthopedic impairment at 80 to 180 days after inpatient rehabilitation. DESIGN Retrospective design examining records from facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDSmr). SETTING Information submitted to UDSmr from 1997 to 1998 by 177 hospital and rehabilitation facilities from 40 states. PARTICIPANTS The sample (N=7781) was 72.63% female and 88.60% non-Hispanic white, with a mean age +/- standard deviation of 73.07+/-11.81 years, and average length of stay (LOS) of 13.84+/-10.48 days. INTERVENTION Usual rehabilitation care. Main outcome measures Level of satisfaction 80 to 180 days after discharge as well as motor, cognitive, and subscale ratings for the FIM trade mark instrument. Predictor variables included gender, age, English language, marital status, discharge setting, LOS, rehospitalization, FIM gain, and primary payer. RESULTS A logistic regression model was used to predict patient satisfaction at follow-up. Five statistically significant (P<.05) variables were found and correctly classified 94.9% of the patients. Discharge motor FIM rating, rehospitalization, age, patients primary language, and discharge setting were associated with increased satisfaction. Discharge motor FIM ratings were significantly associated with increased satisfaction in patients with joint replacements and lower-extremity fractures. CONCLUSION unctional and demographic variables were identified as predictors of satisfaction in patients with orthopedic impairments.

Effect of functional gain on satisfaction with medical rehabilitation after stroke.

Tooth LR, Ottenbacher KJ, Smith PM, Illig SB, Linn RT, Gonzales VA, Granger CV: Effect of functional gain on satisfaction with medical rehabilitation after stroke. Am J Phys Med Rehabil 2003;82:692–699. Objective To examine the association between gain in motor and cognitive functional status with patient satisfaction 3–6 mo after rehabilitation discharge. Design Patient satisfaction and changes in functional status were examined in 18,375 patients with stroke who received inpatient medical rehabilitation. Information was obtained from 144 hospitals and rehabilitation facilities contributing records to the Uniform Data System for Medical Rehabilitation and the National Follow-up Services. Results Data analysis revealed significant (P < 0.05) differences in satisfaction responses based on whether information was collected from patient self-report or from a family member proxy, and the two subsets were analyzed separately. Logistic regression revealed the following significant predictors of satisfaction for data collected from stroke patients: cognitive and motor gain, rehospitalization, who the patient was living with at follow-up, age, and follow-up therapy. In the patient-reported data subset, compared with patients who showed improved cognitive or motor functional status, those with no change, respectively, had a 31% and 33% reduced risk of dissatisfaction. In addition, rehospitalized patients had a higher risk of dissatisfaction. For the proxy reported data subset, significant influences on satisfaction were health maintenance, rehospitalization, stroke type, ethnicity, cognitive FIM™ gain, length of stay, and follow-up therapy. Conclusions Ratings of satisfaction with rehabilitation services were affected by change in functional status and whether the information was collected from patient rating or proxy response.

Prediction of follow-up living setting in patients with lower limb joint replacement.

Ottenbacher KJ, Smith PM, Illig SB, Fiedler RC, Gonzales VA, Granger CV: Prediction of follow-up living setting in patients with lower limb joint replacement. Am J Phys Med Rehabil 2002;81:471–477. Objective The living setting to which older adults are discharged from medical rehabilitation has important social and economic implications. This study was undertaken to develop statistical models to predict living setting after medical rehabilitation in persons with lower limb joint replacement. Design Information submitted from 1994 through 1998 to the Uniform Data System for Medical Rehabilitation was examined. Hip replacement was experienced by 42% of the patients, 51% experienced a knee replacement, and 7% received some combination or other lower limb procedure. Results Persons with hip replacements were slightly older than persons with knee replacements and had a longer length of stay. Logistic regression was used to develop a predictive model based on 60% of the cases. The model included five statistically significant predictor variables. Conclusion Cognitive and basic motor function associated with activities of daily living, age, length of stay, and marital status were important variables in predicting if older adults would be living at home 80–180 days after rehabilitation for lower limb joint replacement.

Measures of central tendency in rehabilitation research: What do they mean?

Gonzales VA, Ottenbacher KJ: Measures of central tendency in rehabilitation research: what do they mean? Am J Phys Med Rehabil 2001;80:141–146.Measures of central tendency including the mean, median, and mode are commonly reported in rehabilitation research. It is believed that the relationship among the mean, median, and mode changes in a specific way when the distribution being analyzed is skewed. A number of widely used textbooks were reviewed to determine how the relationship among the mean, median, and mode is presented in the health sciences and rehabilitation literature. We report a potential misinterpretation of the relationship between measures of central tendency that was identified in several research and statistical textbooks on the subject of rehabilitation. The misinterpretation involves measures of central tendency derived from skewed unimodal sample distributions. The reviewed textbooks state or imply that in asymmetrical distributions, the median is always located between the mode and mean. An example is presented illustrating the fallacy of this assumption. The mean and median will always be to the right of the mode in a positively skewed unimodal distribution and to the left of the mode in a negatively skewed distribution; the order of the mean and median is impossible to predict or generalize. The assumption that the median always falls between the mode and mean in the calculation of coefficients of skewness has implications for the interpretation of exploratory and confirmatory data analysis in rehabilitation research.