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Objective: To examine the association between the Medicare pressure ulcer quality indicator (the development of new or worsened pressure ulcers) and rehabilitation outcomes among Medicare patients seen in an inpatient rehabilitation facility (IRF)., Design: Retrospective descriptive study., Setting: IRFs subscribed to the Uniform Data System for Medical Rehabilitation., Participants: Nearly 500,000 IRF Medicare patients who were discharged between January 2013 and September 2014 were examined., Interventions: Not applicable., Main Outcome Measures: Functional independence, functional change (gain), and discharge destination., Results: The pressure ulcer quality indicator was associated with poorer rehabilitation outcomes; patients were less likely to achieve functional independence (odds ratio [OR], .47; 95% confidence interval [CI], .44-.51), were less likely to be discharged to a community setting (OR, .88; 95% CI, .82-.95), and made less functional gain during their IRF stay (a difference of 6 FIM points)., Conclusions: These results support that the pressure ulcer quality indicator is associated with lower quality of rehabilitation outcomes; however, given that those patients with a new or worsened pressure injury still made functional gains and most were discharged to the community, the risk of pressure injury development should not preclude the admission of these cases to an IRF., (Published by Elsevier Inc.)

Objective: To examine trajectories of functional recovery after rehabilitation for traumatic brain injury (TBI)., Design: Prospective study., Setting: Inpatient rehabilitation hospitals in the Uniform Data System for Medical Rehabilitation., Participants: A subset of individuals receiving inpatient rehabilitation services for TBI from 2002 to 2010 who also had postdischarge measurement of functional independence (N=16,583)., Interventions: Inpatient rehabilitation., Main Outcomes Measures: Admission, discharge, and follow-up data were obtained from the Uniform Data System for Medical Rehabilitation. We used latent class mixture models to examine recovery trajectories for both cognitive and motor functioning as measured by the FIM instrument., Results: Latent class models identified 3 trajectories (low, medium, high) for both cognitive and motor FIM subscales. Factors associated with membership in the low cognition trajectory group included younger age, male sex, racial/ethnic minority, Medicare or Medicaid (vs commercial or other insurance), comorbid conditions, and greater duration from injury date to rehabilitation admission date. Factors associated with membership in the low motor trajectory group included older age, racial/ethnic minority, Medicare or Medicaid coverage, comorbid conditions, open head injury, and greater duration to admission., Conclusions: Standard approaches to assessing recovery patterns after TBI obscure differences between subgroups with trajectories that differ from the overall mean. Select demographic and clinical characteristics can help classify patients with TBI into distinct functional recovery trajectories, which can enhance both patient-centered care and quality improvement efforts., (Copyright © 2017. Published by Elsevier Inc.)

Objectives: To identify the types of cancer patients admitted to inpatient medical rehabilitation and to describe their rehabilitation outcomes., Design: Retrospective cohort study., Setting: U.S. inpatient rehabilitation facilities (IRFs)., Participants: Adult patients (N=27,952) with a malignant cancer diagnosis admitted to an IRF with a cancer-related impairment between October 2010 and September 2012 were identified from the Uniform Data System for Medical Rehabilitation database., Interventions: Not applicable., Main Outcome Measures: Demographic, medical, and rehabilitation characteristics for patients with various cancer tumor types were summarized using data collected from the Inpatient Rehabilitation Facility-Patient Assessment Instrument. Rehabilitation outcomes included the percentage of patients discharged to the community and acute care settings, and functional change from admission to discharge. Functional status was measured using the FIM instrument., Results: Cancer patients constituted about 2.4% of the total IRF patient population. Cancer types included brain and nervous system (52.9%), digestive (12.0%), bone and joint (8.7%), blood and lymphatic (7.6%), respiratory (7.1%), and other (11.7%). Overall, 72% were discharged to a community setting, and 16.5% were discharged back to acute care. Patients with blood and lymphatic cancers had the highest frequency of discharge back to acute care (28%). On average, all cancer patient groups made significant functional gains during their IRF stay (mean FIM total change ± SD, 23.5±16.2)., Conclusions: In a database representing approximately 70% of all U.S. patients in IRFs, we found that patients with a variety of cancer types are admitted to inpatient rehabilitation. Most cancer patients admitted to IRFs were discharged to a community setting and, on average, improved their function. Future research is warranted to understand the referral patterns of admission to postacute care rehabilitation and to identify factors that are associated with rehabilitation benefit in order to inform the establishment of appropriate care protocols., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation., Design: Retrospective cohort design., Setting: Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States., Participants: Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007., Interventions: Not applicable., Main Outcome Measures: Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS)., Results: Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days., Conclusions: Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The National Center for Medical Rehabilitation Research recently celebrated its 20th Anniversary. The celebration included a symposium highlighting advances in rehabilitation science over the past 2 decades. The anniversary also reminds us of the challenges that remain in order to strengthen the foundation of disability and rehabilitation research. These challenges have been described in 3 reports published by the Institute of Medicine (IOM) in 1991, 1997, and 2007. Three areas of concern appear across the IOM reports. These include (1) the lack of a comprehensive disability monitoring program, (2) the need for better integration and coordination of federally supported disability research, and (3) funding levels that are inconsistent with the current and projected impacts of disability on individuals, families, and communities. In this commentary we examine the lack of progress in addressing the recommendations contained in the IOM reports. We conclude that renewed efforts by consumers, clinicians, educators, researchers, administrators, and policy makers are needed to achieve the promise of rehabilitation and disability science identified 20 years ago., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the ability of patient functional status to differentiate between community and institutional discharges after rehabilitation for stroke., Design: Retrospective cross-sectional design., Setting: Inpatient rehabilitation facilities contributing to the Uniform Data System for Medical Rehabilitation., Participants: Patients (N=157,066) receiving inpatient rehabilitation for stroke from 2006 and 2007., Interventions: Not applicable., Main Outcome Measure: Discharge FIM rating and discharge setting (community vs institutional)., Results: Approximately 71% of the sample was discharged to the community. Receiver operating characteristic curve analyses revealed that FIM total performed as well as or better than FIM motor and FIM cognition subscales in differentiating discharge settings. Area under the curve for FIM total was .85, indicating very good ability to identify persons discharged to the community. A FIM total rating of 78 was identified as the optimal cut point for distinguishing between positive (community) and negative (institution) tests. This cut point yielded balanced sensitivity and specificity (both=.77)., Conclusions: Discharge planning is complex, involving many factors. Identifying a functional threshold for classifying discharge settings can provide important information to assist in this process. Additional research is needed to determine if the risks and benefits of classification errors justify shifting the cut point to weight either sensitivity or specificity of FIM ratings., (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Graham JE, Radice-Neumann DM, Reistetter TA, Hammond FM, Dijkers M, Granger CV. Influence of sex and age on inpatient rehabilitation outcomes among older adults with traumatic brain injury., Objective: To assess the influence of sex and age on inpatient rehabilitation outcomes in a large national sample of older adults with traumatic brain injury (TBI)., Design: Prospective case series., Setting: Eight hundred forty-eight inpatient rehabilitation facilities that subscribe to the Uniform Data System for Medical Rehabilitation., Participants: Patients (n=18,413) age 65 years and older admitted for inpatient rehabilitation after TBI from 2005 through 2007., Interventions: None., Main Outcome Measures: Rehabilitation length of stay, discharge FIM motor and cognitive ratings, discharge setting, and scheduled home health services at discharge., Results: Mean age +/- SD of the sample was 79+/-7 years, and 47% were women. In multivariable models, higher age was associated with shorter lengths of stay (P<.001), lower discharge FIM motor and cognitive ratings (P<.001), and greater odds of home health services at discharge (P<.001). Women demonstrated shorter lengths of stay (P=.006) and greater odds of being scheduled for home health services at discharge (P<.001) than men. The sex-by-age interaction term was not significant in any outcome model. Sex differences and trends were consistent across the entire age range of the sample., Conclusions: Sex and age patterns in rehabilitation outcomes among older adults with TBI varied by outcome. The current findings related to rehabilitation length of stay may be helpful for facility-level resource planning. Additional studies are warranted to identify the factors associated with returning to home and to assess the long-term benefits of combined inpatient rehabilitation and home health services for older adults with TBI., (Copyright (c) 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the extent to which diabetes codes that increase reimbursement (tier comorbidities) under the prospective payment system are related to length of stay and functional outcomes in stroke rehabilitation., Design: Secondary data analysis., Setting: Inpatient rehabilitation facilities (N=864) across the United States., Participants: Patients (N=135,097) who received medical rehabilitation for stroke in 2002-2003., Intervention: None., Main Outcome Measures: Length of stay, FIM instrument, and discharge setting. Diabetes status was assigned to 1 of 3 categories: tier (increases reimbursement), nontier (no reimbursement effect), and no diabetes., Results: Mean +/- standard deviation age of the sample was 70.4+/-13.4 years, and 31% had diabetes (6% tier, 25% nontier). Diabetes status by age demonstrated significant (P<.05) interaction effects, which lead to the following age-specific findings. In younger stroke patients (60y), tier diabetes was associated with shorter lengths of stay compared with both groups, lower FIM discharge scores compared with both groups, and lower odds of discharge home relative to the no-diabetes group. In older stroke patients (80y), tier diabetes was associated with longer lengths of stay compared with both groups and with higher FIM discharge scores compared with the nontier group., Conclusions: The diabetes-related conditions identified as tier comorbidities under the prospective payment system are significant predictors of stroke rehabilitation outcomes, but these relationships are moderated by patient age.

Objective: To compare the functional outcomes and discharge location of older adults admitted to inpatient rehabilitation for debility, hip fracture, and myopathy., Design: Retrospective cohort study from 2002 to 2003 with information from the Uniform Data System for Medical Rehabilitation (UDSMR)., Setting: United States inpatient rehabilitation facilities subscribing to the UDSMR., Participants: Patients 65 years or older (N=84.701) with primary diagnoses of debility (n=14,835), hip fracture (n=68,915), and myopathy (n=951)., Interventions: Not applicable., Main Outcome Measures: Change in functional status, including efficiency (change in functional status divided by length of stay in days) and discharge setting., Results: The efficiency of the patients with debility (1.7+/-2.1) was significantly lower than that of the patients with hip fracture (1.9+/-1.6; P<.001), but not different from the patients with myopathy (1.6+/-1.4; P=.3). Significantly more patients with debility (68%) were discharged home than the hip fracture and myopathy groups (66% and 65%, respectively; P<.001)., Conclusions: Although statistical differences exist, the functional recovery and rate of discharge home of older adult patients admitted to inpatient rehabilitation with a primary debility diagnosis are essentially the same clinically as those of patients with a diagnosis of either hip fracture or myopathy. Given these findings, and given that hip fracture and myopathy are approved medical conditions according to the Centers for Medicare and Medicaid Services 75% rule, the medical condition debility warrants consideration for inclusion as a qualifying medical diagnosis under this rule. However, further research is needed to develop relatively objective criteria for the debility diagnosis, and to identify those patients with debility who are most likely to benefit from inpatient rehabilitation.

Objective: To describe changes in inpatient rehabilitation facility (IRF) outcomes due to the program interruption definitional change, from 30 days to 3 days, in 2002., Design: Secondary data analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database., Setting: Four hundred eleven IRFs that submitted data to the UDSMR database in each of the years 1998 through 2003., Participants: Patient assessment data for 772,584 Medicare fee-for-service beneficiaries., Interventions: None., Main Outcome Measures: The number of IRF patient discharges, percent of IRF patients discharged to the community, percent of IRF patients discharged to acute care, percent of IRF patients with program interruptions, percent of IRF inpatient deaths, and average IRF length of stay (LOS)., Results: IRF outcomes appeared to change because of the program interruption redefinition, with changes varying by impairment group. The largest changes due to the redefinition occurred for patients with traumatic spinal cord injury, including the largest percentage increase in patients (5.16%), the largest decrease in program interruptions (5.14%), the largest increase in acute care discharges (5.04%), and the largest mean decrease in LOS (1.27d). Community discharge showed the largest decrease for patients with Guillain-Barré syndrome (4.03%)., Conclusion: The change in the definition of program interruptions creates the appearance of changes in IRF performance and is important to consider when comparing the preprospective payment system (PPS) and PPS assessment data.

Unlabelled: Ethnic differences in discharge destination among older patients with traumatic brain injury., Objective: To estimate the association between ethnicity and discharge destination in older patients with traumatic brain injury (TBI)., Design: A retrospective analysis., Setting: Nationally representative sample of older patients from the Uniform Data System for Medical Rehabilitation in 2002 and 2003., Participants: Patients (N=9240) aged 65 years or older who received inpatient rehabilitation services for TBI., Interventions: Not applicable., Main Outcome Measures: Discharge destination (home, assisted living facility, institution) and ethnicity (white, black, Hispanic)., Results: Multinomial logit models showed that older Hispanics (odds ratio [OR]=2.24; 95% confidence interval [CI], 1.66-3.02) and older blacks (OR=2; 95% CI, 1.55-2.59) with TBI were significantly more likely to be discharged home than older whites with TBI, after adjusting for relevant risk factors. Older blacks were also 78% less likely (OR=.22; 95% CI, .08-.60) to be discharged to an assisted living facility than whites after adjusting for relevant risk factors., Conclusions: Our findings indicate that older minority patients with TBI were significantly more likely to be discharged home than white patients with TBI. Studies are needed to investigate underlying factors associated with this ethnic difference.

Objective: To develop a measure of home and community participation related to the World Health Organization's International Classification of Functioning, Disability and Health., Design: Cross-sectional analysis of survey data., Setting: Nine medical inpatient rehabilitation facilities from 6 states., Participants: A total of 594 patients of mixed impairment type admitted for inpatient rehabilitation in 2002. Mean age was 74.0 years and 61.4% were women., Interventions: Not applicable., Main Outcome Measures: Reliability and validity of the participation instrument., Results: A 20-item instrument of home and community participation was developed (PAR-PRO). The instrument showed good internal consistency and good Rasch person and item fit statistics. Four subfactors were identified beyond the unidimensional construct of participation including domestic management, socialization, physical vigor, and generative activities. The PAR-PRO total participation score correlated inversely with age (r=-.31, P<.001) but did not differ by sex., Conclusions: The 20-item PAR-PRO instrument of home and community participation displayed good psychometric characteristics. The instrument shows promise as a broad measure of home and community involvement for persons with disabilities. Further work is needed to support its application for people without disability.

Objective: To describe functional capability at admission and discharge of children with traumatic brain injury (TBI) in rehabilitation settings., Design: Descriptive analysis., Setting: Inpatient pediatric rehabilitation hospitals in the United States., Participants: Children (N=3815) in 56 pediatric inpatient rehabilitation facilities who were discharged during 1999 to 2001., Interventions: Not applicable., Main Outcome Measures: Admission and discharge WeeFIM scores., Results: Admission and discharge WeeFIM scores correlated positively with age at admission, time from injury to rehabilitation admission, and length of stay (LOS). Higher admission WeeFIM scores correlated with shorter LOS, shorter time from injury to admission to rehabilitation, and higher discharge WeeFIM scores., Conclusions: Children with TBI demonstrated significant improvement in functional measures during rehabilitation. Discharge function and LOS correlated with admission severity, with children who had higher functional status and shorter time between injury and rehabilitation care having higher discharge function and shorter LOS.

Objective: To develop prognostic indexes with which to establish the likelihood of individuals achieving specific grades of physical independence by the conclusion of inpatient rehabilitation., Design: Logistic regression with prospective validation., Setting: Five hundred sixty inpatient rehabilitation facilities., Participants: Records of 218,290 adults discharged in 1995 were used to establish the grades and the indexes predicting those grades. There were 259,806 1997 discharges included in the validation., Interventions: Not applicable., Main Outcome Measures: Six physical independence grades reflecting the most likely profiles of performance across the 13 motor FIM items., Results: After severity adjustment, patients 65 years of age or younger, compared with those 84 years of age or older, had odds ratios of reaching higher grades ranging from 1.5 (95% confidence interval [CI], 1.4-1.7) to 7.5 (95% CI, 4.3-13.1). Admission to rehabilitation within 2 weeks of disability was associated with more favorable prognoses. Areas under the receiver operating characteristic curve ranged from.80 to.94 for the indexes, with minimal shrinkage on prospective validation., Conclusion: The models have sufficient reliability to establish from admission information the likelihood that a patient will achieve a specific grade of physical independence by the time of discharge from rehabilitation. The capacity to quantify prognosis has clinical, policy, and research applications.

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, patient's 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.

Objective: To identify demographic, medical, and functional factors associated with transfer of stroke patients to acute hospital services and/or mortality during stroke rehabilitation., Design: Two case-control studies in which logistic regression was used to control for clinical traits associated with differences in likelihood., Setting: A total of 542 US inpatient and rehabilitation units., Participants: A total of 64,471 patients discharged during 1995., Interventions: Not applicable., Main Outcome Measures: Transfer to an acute hospital service and death., Results: There were 5847 (9.1%) acute hospital transfers and 320 (0.5%) deaths. Greater disability at admission was associated with higher odds of both acute hospitalization and mortality. Cardiopulmonary arrest, chest pain, gastrointestinal problems, bleeding disorders, hypercoagulable states, and acute renal difficulties increased the relative odds of acute hospitalization from 3.1 (95% confidence interval [CI], 2.3-4.2) to 12.7 (95% CI, 9.2-17.6). The likelihood of mortality for patients 85 years of age or older was more than 2-fold (2.5; 95% CI, 1.7-3.6) that of patients 65 years of age or younger for blacks, it was nearly 2-fold (1.7; 95% CI, 1.3-2.3) compared with whites, after adjusting for clinical differences., Conclusion: Higher likelihoods of mortality among older patients versus younger, black patients versus white, and patients with more rather than less disability at admission suggest the need for greater vigilance in monitoring medical status.

Objective: To develop a staging system for functional independence across the activities of daily living (ADLs), sphincter-management, mobility, and executive-function domains (ASME) for the FIM instrument that is consistent with the International Classification of Functioning, Disability and Health., Design: National data were used to define the stages. We searched for the most likely configurations of item scores that increased ability to perform component activities in each domain by approximately 1 level per item per stage., Setting: Inpatient rehabilitation facilities., Participants: Data from 218,290 people discharged from 560 US inpatient rehabilitation facilities in 1995., Interventions: Not applicable., Main Outcome Measures: Activity profiles formed from FIM scores., Results: Seven stages were defined separately for each ASME domain. Stages approximate the average amount of effort expended by the patient when performing the component activities included in a domain, beginning with less than 25% of effort at the lowest total assistance (stage 1) and ending with 100% effort at the highest complete independence (stage 7). Consistent with developmental principles, independence is achieved at lower stages in the most fundamental activities of eating, transfers, and communication. Recovery of independence in the more difficult activities of bathing, stair climbing, and problem solving does not occur until the higher stages are reached. The degree of independence is described with a shorthand abbreviation of the domains followed by the stage the patient has reached in each domain. For example, ASME 5,1,6,7 indicates need for supervision in the ADLs (A-5), total assistance in sphincter management (S-1), modified independence in mobility (M-6), and complete independence in executive functions (E-7)., Conclusions: ASME stages serve as a common language and shorthand for expressing the functional consequences of illness and injury, while complementing information about impairment and diagnosis, thereby facilitating communication, assessment, and goal setting in terms that are meaningful to patients and their care givers., (Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objectives: To establish construct and predictive validity of the activities of daily living, sphincter-management, mobility, and executive-function (ASME) staging system of functional independence and to describe potential applications., Design: National data were used to validate the stages. Sensitivity to functional change was addressed by comparing patients' stages at discharge to their stages at admission. Construct validity was assessed by examining stage distribution differences among groups of patients classified by impairment category. Predictive validity was determined by the degree to which high stages at admission predict discharge to the community and low stages at admission predict serious morbidity or mortality., Setting: Inpatient rehabilitation facilities., Participants: Data from 231,686 individuals discharged from 560 US inpatient rehabilitation facilities in 1995., Interventions: Not applicable., Main Outcome Measures: Stage at rehabilitation discharge, community discharge, acute hospital discharge, or death while in rehabilitation., Results: More than 90% of patients were discharged at a higher stage in at least 1 domain while not declining in any other domain. The odds (95% confidence interval) of community discharge for patients admitted at the highest compared with the lowest stage varied from 2.1 (1.9-2.2) to 3.1 (2.9-3.2), depending on the domain. The odds of acute hospitalization or death were reduced at the highest stages, compared with the lowest, by a factor ranging from .33 (.22-.49) to .65 (.61-.69)., Conclusions: The ASME stages appear valid and sensitive to change. Functional Independence Staging (FIS) has relevance in establishing prognoses and in selecting among therapeutic modalities. FIS will facilitate the identification of meaningful functional goals and interpretable clinical trial endpoints. One of its most important applications could be in the establishment of outcome indicators for quality monitoring under the prospective payment system., (Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objectives: To document patient, program characteristics, and therapy service provision in subacute rehabilitation across 3 types of facilities that provide subacute rehabilitation, to examine the determinants of therapy intensity, and to evaluate the contribution of rehabilitation services to functional gains., Design: A retrospective study linking administrative billing data and patients' functional assessment records., Setting: Twenty facilities part of the Uniform Data System for Medical Rehabilitation (UDSMR) subacute database, Participants: A total of 1976 billing records of patients with stroke, orthopedic, and debility impairments, discharged in 1996 and 1997, were retrieved and linked with the FIM trade mark instrument ratings from UDSMR subacute database., Interventions: Not applicable., Main Outcomes Measures: Total therapy intensity and Rasch-transformed FIM domain gains (ie, gains in self-care, mobility, cognition)., Results: Therapy intensity was mostly determined by impairment and facility type, although variances explained by the predictors were small. Patients in all 3 impairment groups made functional gains; gains were related weakly, although significantly, to therapy intensity and rehabilitation duration after controlling for other variables., Conclusions: The provision of rehabilitation therapies varied across facilities. Skilled nursing facilities with subacute rehabilitation units tended to provide more therapies than subacute units in acute or rehabilitation hospitals., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: To examine living setting at 3- to 6-month follow-up for inpatients with functional impairments discharged from medical rehabilitation., Design: Retrospective performed by using information from the Uniform Data System for Medical Rehabilitation (UDSMR) representing medical rehabilitation patients across the United States., Setting: National survey data., Participants: Information submitted in 1997 and 1998 to the UDSMR by 167 facilities from 40 states was examined. A total of 9587 patient records were included in the final sample. The mean age +/- standard deviation was 70.2+/-12.4 years. The sample included 51.6% women and was comprised of 77.5% non-Hispanic white patients, with an average length of stay of 22.3+/-4.6 days., Interventions: Not applicable., Main Outcome Measure: Living setting (home vs not at home) at 3- to 6-month follow-up., Results: A discriminant function training model including 8 statistically significant variables correctly classified 85.1% of the patients (n=8149). The total FIM instrument score, patient age, function-related group, and marital status were found to be useful classification variables. Wilks lambda for the model was.924 (chi(2)=1031.49, P<.000). The area under the receiver operating characteristics curve was.85., Conclusion: The association among functional abilities, demographic characteristics, and follow-up living setting in patients with stroke is complex. Functional variables can be used to help predict follow-up living setting. These variables change based on patient severity level., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: To develop classification models for risk of hospital readmission 80 to 180 days after discharge based the demographic and functional characteristics of persons discharged from acute inpatient rehabilitation after stroke., Design: Retrospective, using information from US facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDS(MR))., Setting: Information submitted to the UDS(MR) from 1994 through 1996 by 167 hospital and rehabilitation facilities from 40 states was examined., Participants: A total of 15,992 records of patients (mean age +/- standard deviation, 70.97 +/- 12.19yr) with a diagnosis of stroke were included in the final sample. The sample included 52.7% women and was 80% non-Hispanic white with an average length of stay (LOS) of 25.31 +/- 14.72 days., Interventions: Not applicable., Main Outcome Measures: Six subscales of the FIM instrument (self-care, sphincter control, transfers, locomotion, communication, social cognition), total FIM, and other predictor variables for regression analysis (gender, age, ethnicity, marital status, prehospital living setting, LOS, primary payer source, level of function-related group)., Results: A logistic regression model included the following statistically significant variables (p <.05): ethnicity, sphincter control, self-care ability, gender, and LOS. The greatest variability occurred among men. Exactly 18.1% of non-Hispanic white men and 17.9% of African-American men were rehospitalized. In contrast, only 10.1% of Hispanic men and 11.4% of Asian men were rehospitalized. The odds of rehospitalization were lowest for Hispanic men., Conclusion: As prospective payment systems are introduced for postacute care, it is important that the relationship among functional abilities, demographic characteristics, and incidence of hospital readmission following medical rehabilitation be examined., (Copyright 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: To examine the utility of the WeeFIM instrument ("WeeFIM") in detecting changes in the functional status of children with disability., Design: Prospective longitudinal design with correlation and responsiveness analysis., Setting: Three facilities providing services to children with developmental disabilities in western New York State., Participants: Two hundred five children (72 girls, 133 boys) with identified medical disabilities receiving special services were administered the WeeFIM. Subjects ranged in age from 11 to 87 months and came from diverse socioeconomic and ethnic backgrounds. Scores for 174 children were available for 3 administrations performed over a 1-year period., Main Outcome Measures: The responsiveness of the WeeFIM instrument was examined using 5 statistical procedures: Reliability Change Index, Proportional Change Index, effect size, standardized response means, and paired t tests., Results: All 5 indexes of responsiveness indicated statistically significant (p < .05) or reliable changes over time. The transfer subscale of the WeeFIM showed a skewed distribution that affected the results for some responsiveness indexes. The advantage, limitations, and assumptions of the responsiveness indexes are described and graphic examples of change over time are presented to validate the responsiveness of the WeeFIM instrument., Conclusion: The WeeFIM instrument showed the ability to document change in functional abilities over a 1-year period in children with chronic disabilities.

Objective: To develop an index that weights diagnostic information (International Classification of Diseases, 9th revision, Clinical Modification, or ICD-9-CM codes) by the extent to which it is expected to affect functional status and inpatient rehabilitation length of stay (LOS)., Design: Eleven nationally prominent physiatrists assigned ICD-9-CM codes to ordinal categories by expected effect on functional recovery. A resulting functional diagnostic complexity index score was calculated for each patient by combining the ranked values of each ICD-9-CM code in the discharge record. Analyses were stratified across the 20 rehabilitation impairment categories (RICs) of the Functional Independence Measure-Function Related Groups., Data: Patients (182,254) discharged from 465 inpatient rehabilitation units in larger hospitals and free-standing rehabilitation hospitals in 1995., Results: High degrees of diagnostic complexity were associated with low levels of functional independence at admission within each of 20 RICs (Spearman R = .06 to .25). Depending on RIC, patients in the highest (compared with the lowest) complexity category had up to a 35% increase in rehabilitation LOS after accounting for the primary medical reason for rehabilitation and severity of disabilities at admission., Conclusion: This prototype index of medical complexity offers a promising approach for analyzing the cumulative effects of diagnoses on patients' initial functional status and rehabilitation LOS.

Objective: This study evaluated the validity of the Functional Independence Measure (FIM instrument) in predicting (1) the number of minutes of daily assistance provided, (2) the cost of durable goods currently used, and (3) the number of paid helper hours provided daily to persons with spinal cord injury living in the community., Design: A cross-sectional study., Subjects: One hundred nine persons with spinal cord injury who were a median 6 years postdischarge from initial medical rehabilitation., Results: A significant inverse linear relationship was observed between FIM scores and the square root values of the three cost-related measures. The FIM-18 and the FIM motor scores were the best single predictors of the square root of minutes of assistance (paid and/or unpaid) per day, explaining 85% of variance. The FIM motor measure was the best single predictor of square root of cost of durable goods, explaining 29% of variance. The Self-Care, FIM motor, and FIM-18 scores equally predicted square root of hours of paid help per day, explaining 58% of variance., Conclusion: The findings indicate FIM-related scores predict the amount of assistance needed and certain costs for persons with spinal cord injury disability.

Objective: To present the Features-Resource Trade-Off Game (Features Game) as a new method for comparing preferences for alternative outcomes among different groups of people., Design: The Features Game is illustrated by comparing preferences for recovery among the 18 functional status items making up the Functional Independence Measure. Methods involved trading levels of independence (resources) across the different items (features)., Setting: Ten community-dwelling consumers with physical disabilities and 10 rehabilitation clinicians participated in four separate expert panels-two in Houston and two in Philadelphia., Main Outcome Measures: Five sets of hierarchical stages defined by the four separate panels specifying the profiles of function believed to most foster independent living., Results: Cognitive and communication skills were selected preferentially over the recovery of physical tasks by all panels, but, in comparison to clinicians, consumers were more willing to accept mild deficits in cognitive skills as trade for realizing earlier recovery of physical abilities., Conclusion: The overwhelming choice of cognitive and communication abilities over physical abilities suggests a need to enhance therapeutic efforts in those areas. More subtle differences in consumer and clinician preferences emphasize the importance of establishing consumer-oriented goals.

Objective: To determine typical outcome "benchmarks" for 18 functional tasks in patients undergoing stroke rehabilitation. The benchmarks are intended to serve as points of reference to which the outcomes of patients with similar impairments and degrees of disability can be compared., Subjects: Records from 26,339 stroke patients discharged from 252 inpatient facilities across the United States that submitted 1992 data to the Uniform Data System for Medical Rehabilitation., Methods: Stroke impairment was detailed as the presence or absence of hemiparesis resulting from stroke and the side(s) of involvement. Within each of five stroke impairment categories, patients were further classified by the Functional Independence Measure-Function-Related Groups (FIM-FRGs) into nine syndromes by degree of disability (admission motor and cognitive FIM scores) and by age. Outcomes were determined for each stroke syndrome at patients' discharge from medical rehabilitation., Main Outcome Measures: Patients' median performance levels on each of the 18 items making up the FIM, length of stay, and community discharge rates., Results: The majority of patients whose admission motor FIM scores were above 37 were able to eat, groom, dress the upper body, and manage bladder and bowel functions independently by discharge. In addition to these tasks, most of those whose motor FIM scores were above 55 were able to dress the lower body, bathe, and transfer onto a chair/bed or toilet. The majority of patients whose initial motor FIM scores were above 62 points and whose cognitive FIM scores were above 30 gained independence in most tasks, including stair climbing and tub transfers. Community discharge rates ranged from 51.6% for the group of patients with the most severe disabilities to 99.2% for the group with the least severe disabilities., Conclusion: The clinician can apply these benchmarks to guideline development and quality improvement, and in establishing patient goals.

Objective: To determine if diagnostic information provided in the form of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes improves rehabilitation length of stay (LOS) prediction when used in combination with the Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system., Design: Various models characterizing diagnostic information using ICD-9-CM codes were created that included individual ICD-9-CM codes and groupings of those codes by organ or etiology involved. Each method was evaluated using linear regression with the natural logarithm of LOS as the dependent variable. Separate validation data sets were held back to quantify the incremental effect of diagnosis when combined with the FIM-FRG classification system., Setting: Records from 252 rehabilitation facilities and hospital units across the nation., Patients: Analyses were undertaken using 82,646 records from patients discharged in 1992., Results: The addition of ICD-9-CM diagnostic information to the FIM-FRG classification system increased the variance explained by a maximum of 1.9%, from 31.5% to 33.4%., Conclusions: Refinement of the FIM-FRGs to include ICD-9-CM diagnoses does not appear warranted on the basis of the small increase in the percentage of explained variance in LOS. We believe the lack of improved prediction with the addition of ICD-9-CM codes relates primarily to incomplete coding practices and to the effect of patients' diagnoses being absorbed in variables as already expressed by the FIM-FRG system. Although ICD-9-CM codes, overall, did not greatly improve LOS prediction, they appeared to have some impact in certain impairment categories.

Objective: To examine the extent to which outcomes from traumatic brain injury differ as a function of time and can be predicted at discharge from inpatient rehabilitation., Design: Survey method employing cross-sectional analyses., Setting: An inpatient brain injury rehabilitation unit in a large midwestern academic medical center., Subjects: Ninety-five adults with traumatic brain injuries, 6 months to 5 years after inpatient rehabilitation, stratified by time postdischarge., Main Outcome Measures: Functional Independence Measure (FIM), Sickness Impact Profile (SIP), Medical Outcomes Survey SF-36, Community Integration Questionnaire (CIQ), Craig Handicap Assessment and Reporting Technique (CHART), Brief Symptom Inventory (BSI), Satisfaction With Life Scale (SWLS), and indices of current psychosocial functioning., Results: Substance abuse, need for supervision, life satisfaction, and selected subscales of the CIQ and CHART differed over the period 6 months to 5 years after discharge. Approximately 75% of the variance in current FIM scores, and 40% to 50% of CHART, CIQ, and SIP total scores, could be predicted at time of discharge., Conclusions: Outcomes over the first 5 years after discharge were dynamic, with most change being improvement, at least after the first 2 years. Important aspects of outcome could not be predicted based on premorbid characteristics, injury severity, and initial functional abilities.

Objective: To evaluate the range, distribution, and unidimensionality of the items included in Version Five of the Functional Independence Measure (FIM) Mastery Test, a 54-item written examination used to determine FIM rating proficiency by professionals who administer the instrument., Study Design: Rasch analysis of the test results of 6,645 clinicians who took the FIM Mastery Test in 1996., Results: Overall, clinicians performed well on the test. When the mean item difficulty was centered at 50, and the test scores were calibrated to range from 0 to 100 logits, the mean person ability level was 77 logits. Fit statistics indicated that the test was unidimensional, measuring a common theme. While the item separation index value was 17, 22 items were not efficient in determining the clinicians' ability levels. Analysis of the logit values by the correct response showed that descriptions of Total Assistance (Level 1) and Complete Independence (Level 7) were easiest for clinicians to score correctly., Conclusion: The examination measures the common theme of FIM knowledge in a consistent manner. Further, the results suggest that the FIM Mastery Test may be shortened, perhaps by eliminating one of the three case studies, and improved by adding more challenging questions. In addition, FIM training should focus on distinguishing among levels 2 through 6, since clinicians had more difficulty identifying these levels.

Objective: Examination of the interrater agreement and stability of ratings obtained using the Functional Independence Measure for Children (WeeFIM) in a sample of children with developmental disabilities., Design: A relational design was used in which two sets of WeeFIM scores were collected under four conditions: same rater-short interval; same rater-long interval; different rater-short interval; and different rater-long interval., Setting: WeeFIM scores were collected in outpatient developmental rehabilitation centers, school programs, and the children's homes., Participants: Data were collected for 205 children ranging in age from 11 to 87 months. All children had a medical diagnosis of disability and were receiving habilitative-educational intervention or follow-along services including neurodevelopmental surveillance., Instrument: The WeeFIM instrument examines basic daily living and functional skills in children from birth to 7 years of age. The WeeFIM is modeled after the Functional Independence Measure (FIM) for adults and includes 18 items in the following subscales: self-care, sphincter control, transfers, locomotion, communication, and social cognition., Results: Kappa values for items ranged from .44 to .82. Intraclass correlation coefficients (ICC) for the six subscales ranged from .73 to .98. Total WeeFIM ICC values were greater than .95 for all analyses., Conclusions: The WeeFIM ratings for the 205 children with developmental disabilities participating in this investigation were consistent across raters and time.

Objective: To determine which factors related to departments of physical medicine and rehabilitation (PM&R) might contribute to the academic productivity of members of the teaching staff of those departments, and to develop an instrument that measures them., Design: Prospective, inception cohort., Setting: University medical center, academic PM&R departments., Participants: PM&R academic departments., Intervention: Over a 6-year period, seven PM&R departments volunteered to use this instrument to measure academic productivity at 2-year intervals. Rasch analysis was applied to the generated data., Main Outcome Measure: Measurable items that were included in questions of the scale fell into six categories: research funding and/or experience; scholarly productivity; equipment and facilities; quality of the training program for resident physicians; continuing education efforts in research methodologies and professional organizational participation; and departmental leadership. Rasch analysis was applied to evaluate a new outcome instrument to measure academic productivity in PM&R departments., Results: Twenty-eight of the original 42 questions survived the Rasch analysis and were retained. Questions were dropped either because they did not fit the Rasch analysis (4 of 42 questions) or because application of the Rasch analysis demonstrated that they were inappropriately or outstandingly easy (10 of 42 were inappropriately or outstandingly easy)., Conclusion: This shortened instrument of 28 questions fits the Rasch analysis, has questions that evently range from easy to very difficult, and addresses six measurable categories that are correlates of PM&R departmental influences on the academic productivity of the PM&R teaching staff.

Objective: To develop a patient classification system that groups patients achieving similar functional outcome scores by discharge from medical rehabilitation., Design: Patient groups were developed using a recursive partitioning algorithm and clinical input. Results were validated in a separate set of patient records., Setting: Two hundred fifty-two free-standing rehabilitation hospitals and distinct part units that participate in the Uniform Data System for Medical Rehabilitation., Patients: The 84,492 rehabilitation inpatients discharged in 1992 were grouped into 20 impairment categories., Main Outcome Measure: Discharge score on the motor subscale of the Functional Independence Measure (FIM)., Results: In the Discharge Motor FIM-Function Related Groups (DMF-FRGs) system, patients are first classified into one of 20 impairment categories and then into FRGs by their admission motor FIM scores. Some FRGs are also subdivided on the basis of admission cognitive FIM scores and age. The entire system consists of 139 patient groups that explain 63% of the variation in motor FIM discharge scores in the validation data set. Nontraumatic brain injury and joint replacement DMF-FRGs are provided as examples., Conclusion: Clinicians can use the DMF-FRGs to identify groups of patients whose motor FIM scores at discharge are below, within, or above nationally established ranges of values for the purpose of outcomes management, guideline development, and quality improvement. The DMF-FRGs can also be considered in the design of an outcome-based payment system for medical rehabilitation.

Objective: Replicate and extend studies of the construct validity of the Functional Independence Measure (FIM) for persons with traumatic brain injury (TBI)., Design: A cross-sectional study of admissions to acute rehabilitation evaluated 6 months to 5 years after discharge., Setting: An inpatient brain injury rehabilitation unit in a large, academic medical center., Subjects: Ninety-five patients with primary diagnosis of TBI stratified by time postdischarge., Main Outcome Measures: Prediction of (1) average daily minutes of assistance and (2) supervision required in comparison to the Sickness Impact Profile (SIP) and SF-36., Results: The FIM was highly predictive of minutes of assistance (83% accuracy), supervision (82% accuracy), and the need for either type of assistance (78% accuracy). Prediction was only minimally improved by measures of neurobehavioral impairment. The accuracy of the FIM was superior to the SIP and SF-36., Conclusions: Results provided substantial support for the validity of the FIM as a measure of functional independence for persons with TBI. The importance of supervision as a type of assistance required after TBI was evident, with the FIM highly predictive of this need, as well.

Objective: The reliability of the Functional Independence Measure (FIMSM) for adults was examined using procedures of meta-analysis., Data Sources: Eleven published studies reporting estimates of reliability for the FIM were located using computer searches of Index Medicus, Psychological Abstracts, the Functional Assessment Information Service, and citation tracking., Study Selection: Studies were identified and coded based on type of reliability (interrater, test-retest, or equivalence), method of data analysis, size of sample, and training or experience of raters., Data Extraction: Information from the articles was coded by two independent raters. Interrater reliability for coding all elements included in the analysis ranged from .89 to 1.00., Data Synthesis: The 11 investigations included a total of 1,568 patients and produced 221 reliability coefficients. The majority of the reliability values (81%) were from interrater reliability studies, and the intraclass correlation coefficient (ICC) was the most commonly used statistical procedure to compute reliability. The reported reliability values were converted to a common correlation metric and aggregated across the 11 studies. The results revealed a median interrater reliability for the total FIM of .95 and median test-retest and equivalence reliability values of .95 and .92, respectively. The median reliability values for the six FIM subscales ranged from .95 for Self-Care to .78 for Social Cognition. For the individual FIM items, median reliability values varied from .90 for Toilet Transfer to .61 for Comprehension. Median and mean reliability coefficients for FIM motor items were generally higher than for items in the cognitive or communication subscales., Conclusions: Based on the 11 studies examined in this review the FIM demonstrated acceptable reliability across a wide variety of settings, raters, and patients.

Objective: The analysis presented here evaluated the psychometric properties of the Functional Independence Measure (FIM) as a summated rating scale within context of the 20 impairment categories of the FIM-Function Related Group (FIM-FRG) system., Design: This study involved a cross-sectional analysis of patient records, utilizing factor analysis and techniques of multitrait scaling to verify the summative properties of the motor and cognitive dimensions of the FIM and to study the statistical properties of admission FIM scores., Patients: Included were a total of 93.829 patients discharged from 252 freestanding rehabilitation hospitals and units during calendar year 1992. Cases were excluded that had missing or out-of-range values or atypical lengths of stay. These criteria were developed previously in conjunction with an expert clinical panel and confirmed through statistical analyses., Results: Factor analyses supported the motor and cognitive dimensions across all 20 impairment categories. The resulting subscales exceeded minimum criteria for item internal consistency in 96.9% of tests and item discriminant validity in 100% of tests. Reliability coefficients for each impairment category for both subscales ranged from .86 to .97. There were no major ceiling effects, but patients in certain impairment categories were unable to climb stairs at admission., Conclusion: The psychometric properties of the summated FIM compare favorably to most standardized health measures used in medical practice. Findings provide support for the motor and cognitive subscales as used in the FIM-FRGs. As a unidimensional scale, the FIM quantifies care burden. Split into the motor and cognitive (as used in the FIM-FRGs) it distinguishes physical disabilities from those arising from communication or cognitive difficulties.

The purpose was to examine the inter-rater agreement and test-retest stability of the Functional Independence Measure (FIM) and the Instrumental Activities of Daily Living Scale (IADL) from the Multidimensional Functional Assessment of Older Adults. These two instruments were administered to 20 older persons living in the community. Two experienced raters administered the assessment instruments over either a short (7-10 days) or long (4 to 6 week) interval. The intraclass correlation (ICC) was used to analyze the data. ICC values were computed for agreement between and within raters and across short and long intervals. ICC values for inter-rater agreement and stability ranged from 0.90 to 0.99. The relation between scores on the FIM and IADL scale was also examined. The analysis produced an r value of 0.85, suggesting a positive statistical relationship among the items assessed. The high ICC values indicate that the Functional Independence Measure Instrument and IADL scale of the Multidimensional Functional Assessment of Older Adults provide consistent information across two experienced raters and over time when used with a sample of elderly persons residing in the community.

The Functional Independence Measure-Function Related Groups (FIM-FRGs) were developed to classify medical rehabilitation inpatients into homogeneous groups based on length of stay (LOS). Patients are first grouped into clinically relevant rehabilitation impairment categories, then by functional status, as expressed by the FIM, and in certain cases by patient age. The statistical approach used to form the final groupings was a recursive partitioning algorithm applied to the FIM scores and patient age within impairment category. This analysis compares four FIM-FRG classification schemes developed from four scale sets that combine FIM items differently: (1) use of the 18 FIM items as separate variables, (2) the combination of FIM items into six clinical subscales, (3) the combination of the six clinical subscales into motor and cognitive subscales, and (4) the combination of all FIM items into a single scale. The FIM-FRG schemes explain similar amounts of variance in the logarithm of LOS and contain approximately equal numbers of FRGs. The motor and cognitive subscale scheme is recommended for use in payment, however, this scheme and the other schemes have additional uses. Each FRG scheme provides different insight into the clinical relationship between disability and LOS.

The Functional Independence Measure (FIM) records the severity of disability of rehabilitation patients. The necessarily curvilinear relationship between the finite range of recorded FIM raw scores and the conceptually infinite range of additive disability measures is resolved through Rasch analysis. The analysis of admission and discharge FIM ratings of 14,799 patients shows that the 18 FIM items define two statistically and clinically different indicators. Thirteen items define disability in motor functions. Five items define disability in cognitive functions. Additive measures for each indicator have the same characteristics at admission and discharge, so that these measures can be used to assess change in patient status.

The purpose of this study was to investigate disability in persons after stroke by using combinations of functional assessment item, subscale, domain, and full-scale scores, to predict (1) the burden of care measured in minutes of assistance provided per day by another person in the home, and (2) the subject's level of satisfaction with life in general. The Functional Independence Measure (FIM) and the Sickness Impact Profile (SIP) each contributed to prediction of the subject's physical care needs. A change in total FIM score of one point (range, 61 to 126) was equivalent to an average of 2.19 minutes of help from another person per day and a change in one point in the SIP physical dysfunction (SIPPHYS) score (range, 4.0% to 57.4%) was equivalent to an average of 3.32 minutes. Along with the Brief Symptom Inventory and a measure of visual ability, the FIM contributed to predicting the patient's general satisfaction as well. The burden of care and subjective satisfaction with life in general are important standards by which functional assessment instruments may be compared to reflect, in pragmatic terms, the impact of disability on the lives of individuals and on the human and economic resources of the community.

The purpose of this study was to investigate disability in persons with multiple sclerosis (MS) by using combinations of functional assessment scales and subscales to predict (1) the burden of care measured in minutes of assistance provided per day by another person in the home, and (2) the subject's level of satisfaction with life in general. The Functional Independence Measure (FIM), Incapacity Status Scale, Environmental Status Scale, and the Barthel Index had high intercorrelations with each other. Although each was predictive of the MS subject's physical care needs, the FIM was the most useful. A change in total FIM score of one point was equivalent to an average of 3.38 minutes of help from another person per day. With the Brief Symptom Inventory and the Environmental Status Scale, the FIM contributed to predicting the patient's general satisfaction as well. We propose that burden of care and subjective satisfaction with life be the standards by which functional assessment instruments are compared to reflect, in pragmatic terms, the impact of disability on the lives of individuals and on the human and economic resources of the community.

This study describes development of a functional assessment instrument used to screen ambulatory care patients who have difficulty performing daily activities. Sample selection occurred in 2 stages. In the first stage, an interdisciplinary team used clinical selection criteria in order to screen patients into 2 groups: group 1, those likely to have functional limitations; and group 2, those not likely to have functional limitations. Using clinical selection criteria for a 3-week period in an ambulatory primary care setting, it was found that 20% of the outpatients seen fell into group 1. In the second stage, a randomly selected subsample of 194 persons was used, with 97 in group 1, and 97 in group 2. The Functional Assessment Screening Questionnaire (FASQ) was tested using this second sample. The FASQ was found to discriminate between the 2 groups, with those in group 1 having a significantly greater number of functional difficulties than those in group 2. An analysis was conducted to investigate which diagnostic problems were more likely to be associated with patients reporting functional limitations. Fourteen diagnostic patient problems found to be significantly more limiting than for the total sample were identified. The factor structure of the FASQ was examined and a format for clinically integrating the FASQ factors was offered.

In view of current emphasis on evaluation of benefits derived from rehabilitation programs, it is important that there be easily replicated measures for demonstrating the efficiency and effectiveness of services provided, as well as for transmitting information on patient functional status when transferring service responsibilities from one agency or facility to another. The authors used the PULSES profile and the Barthel index to measure severity of disability and to monitor rehabilitation progress in a heterogeneous sample of 307 severely disabled persons in 10 comprehensive medical rehabilitation centers, geographically selected. Gains in functional independence were registered for up to 2 years after admission. Cutting points of PULSES score totals or Barthel score totals distinguished the degree of severity of disability. The 2 scoring modalities appear valid, reliable, and sensitive for describing functional abilities and change over a period of time. They can be applied both to medical records and direct observations, and staff of medical facilities can readily be trained in their use.