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Background. Structural integrity of the ipsilesional corticospinal tract (CST) is important for upper limb motor recovery after stroke. However, additional neuromechanisms associated with motor function poststroke are less well understood, especially regarding the lower limb. Objective. To investigate the neural basis of upper/lower limb motor deficits poststroke by correlating measures of motor function with diffusion tensor imaging-derived indices of white matter integrity (fractional anisotropy (FA), mean diffusivity (MD)) in primary and secondary motor tracts/structures. Methods. Forty-three individuals with chronic stroke (time poststroke, 64.4 ± 58.8 months) underwent a comprehensive motor assessment and MRI scanning. Correlation and multiple regression analyses were performed to examine relationships between FA/MD in a priori motor tracts/structures and motor function. Results. FA in the ipsilesional CST and red nucleus (RN) was positively correlated with motor function of both the affected upper and lower limb ( r = 0.36 ‐ 0.55 , p ≤ 0.01 ), while only ipsilesional RN FA was associated with gait speed ( r = 0.50 ). Ipsilesional CST FA explained 37.3% of the variance in grip strength ( p < 0.001 ) and 31.5% of the variance in Arm Motricity Index ( p = 0.004 ). Measures of MD were not predictors of motor performance. Conclusions. Microstructural integrity of the ipsilesional CST is associated with both upper and lower limb motor function poststroke, but appears less important for gait speed. Integrity of the ipsilesional RN was also associated with motor performance, suggesting increased contributions from secondary motor areas may play a role in supporting chronic motor function and could become a target for interventions.

Objective The purpose of this study was to describe the process and cost of delivering a physical therapist–guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline. Methods Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant. Results A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the “value proposition” of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved. Conclusions The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a “blue print” for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine. Impact As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study’s experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.

BACKGROUND AND PURPOSE: Persons with stroke have increased risk for recurrent stroke and other health conditions. Group exercise programs like cardiac rehabilitation might reduce this risk. These programs commonly use the six-minute walk to measure aerobic capacity. However, failure to assess balance or fall risk may compromise safety for persons with stroke. The study aim was to determine the association between the six-minute walk test and fall risk in persons with stroke. METHODS: Cross-sectional analysis measured the association between the six-minute walk test and fall risk in 66 persons with stroke with a mean age of 66 years (SD 12) and median stroke chronicity of 60.9 months (range 6.0–272.1). The six-minute walk test alone and combined with potential co-variates were evaluated using logistic regression. The best fit model was used in Receiver Operating Characteristic analysis. Likelihood ratios and post-test probabilities were calculated. RESULTS: Lower six-minute walk test distance was associated with increased fall risk in logistic regression (p=0.002). The area under the curve for the univariate six-minute walk test model (best fit) was 0.701 (p=0.006). The cutoff for increased fall risk was six-minute walk test < 331.65 meters. The post-test probability of fall risk increased to 74.3% from a pre-test probability of 59.1%. DISCUSSION: The moderate association between fall risk and six-minute walk test suggests that in addition to assessing capacity, the six-minute walk test provides insight into fall risk/balance confidence. CONCLUSION: Using the six-minute walk test cutoff to screen fall risk in community exercise programs may enhance safety for persons with stroke without additional testing required.

Beginning in 2019, home health agencies' rates of potentially preventable hospital readmissions over the 30 days following discharge will be publicly reported.Our primary objective was to determine the association between patients' functional status at discharge from home health care and 30-day potentially preventable readmissions. A secondary objective was to identify the most common conditions resulting in potentially preventable readmissions.This was a retrospective cohort study.A total of 1,510,297 Medicare fee-for-service beneficiaries discharged from home health care in 2013-2015. Average age was 75.9 (SD, 10.9) years, 60.0% were female, and 84.2% non-Hispanic white.Thirty-day potentially preventable readmissions following home health discharge. Functional status measures included mobility, self-care, and impaired cognition.The overall rate of 30-day potentially preventable readmissions was 2.6% (N=39,452), which accounted for 40% of all 30-day readmissions. After adjusting for sociodemographic and clinical characteristics, the odds ratios for the most dependent score quartile versus the most independent was 1.58 [95% confidence interval (CI), 1.53-1.63] for mobility and 1.65 (95% CI, 1.59-1.69) for self-care. The odds ratios for impaired versus intact cognition was 1.21 (95% CI, 1.18-1.24). The 5 most common conditions resulting in a potentially preventable readmission were congestive heart failure (23.6%), septicemia (16.7%), bacterial pneumonia (9.8%), chronic obstructive pulmonary disease (9.4%), and renal failure (7.5%).Functional limitations at discharge from home health are associated with increased risk for potentially preventable readmissions. Future research is needed to determine whether improving functional independence decreases the risk for potentially preventable readmissions following home health care.

BACKGROUND In an effort to improve quality and reduce costs, reimbursement for total knee arthroplasty (TKA) and total hip arthroplasty (THA) in the United States is being based on the value of care provided, with adjustments for some qualifying comorbidities, including diabetes in its most severe form and excluding many diabetes codes. The aims of this study were to examine the effects of diabetes on elective TKA or THA complications and readmission risks among Medicare beneficiaries. METHODS Complication (n = 521,230) and readmission (n = 515,691) data were extracted from Medicare files in 2013 and 2014. Diabetes status (no diabetes, controlled-uncomplicated diabetes, controlled-complicated diabetes, and uncontrolled diabetes) was identified with ICD-9 (International Classification of Diseases, 9th Revision) codes. TKA or THA complications and readmission odds based on diabetes status were estimated using logistic regression and adjusted for sociodemographic and clinical characteristics, including comorbidities. RESULTS Compared with no diabetes, the odds ratio (OR) of TKA complications was significantly higher for uncontrolled diabetes (1.29, 95% confidence interval [CI] = 1.06 to 1.57). The OR of THA complications was significantly higher for controlled-complicated diabetes (1.45, 95% CI = 1.17 to 1.80). The OR of readmission was significantly higher for all diabetes groups (1.21 to 1.48 for TKA, 1.20 to 1.70 for THA). CONCLUSIONS Readmission odds were higher in all diabetes categories. The uncontrolled-diabetes group had the greatest TKA readmission and complication odds. The controlled-complicated diabetes group had the greatest THA readmission and complication odds. The findings suggest that including diabetes and associated systemic complications in cost adjustments in alternative payment models for arthroplasty should be considered. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Although risk-stratifying patients with acute lower back pain is a promising approach for improving long-term outcomes, efforts to implement stratified care in the US healthcare system have had limited success. The objectives of this process evaluation were to 1) examine variation in two essential processes, risk stratification of patients with low back pain and referral of high-risk patients to psychologically informed physical therapy and 2) identify barriers and facilitators related to the risk stratification and referral processes. Methods We used a sequential mixed methods study design to evaluate implementation of stratified care at 33 primary care clinics (17 intervention, 16 control) participating in a larger pragmatic trial. We used electronic health record data to calculate: 1) clinic-level risk stratification rates (proportion of patients with back pain seen in the clinic over the study period who completed risk stratification questionnaires), 2) rates of risk stratification across different points in the clinical workflow (front desk, rooming, and time with clinician), and 3) rates of referral of high-risk patients to psychologically informed physical therapy among intervention clinics. We purposively sampled 13 clinics for onsite observations, which occurred in month 24 of the 26-month study. Results The overall risk stratification rate across the 33 clinics was 37.8% (range: 14.7–64.7%). Rates were highest when patients were identified as having back pain by front desk staff (overall: 91.9%, range: 80.6–100%). Rates decreased as the patient moved further into the visit (rooming, 29.3% [range: 0–83.3%]; and time with clinician, 11.3% [range: 0–49.3%]. The overall rate of referrals of high-risk patients to psychologically informed physical therapy across the 17 intervention clinics was 42.1% (range: 8.3–70.8%). Barriers included staffs’ knowledge and beliefs about the intervention, patients’ needs, technology issues, lack of physician engagement, and lack of time. Adaptability of the processes was a facilitator. Conclusions Adherence to key stratified care processes varied across primary care clinics and across points in the workflow. The observed variation suggests room for improvement. Future research is needed to build on this work and more rigorously test strategies for implementing stratified care for patients with low back pain in the US healthcare system. Trial registration Trial registration: ClinicalTrials.gov (NCT02647658). Registered January 6, 2016

Objective The objective of this study was to determine the feasibility of a rehabilitation approach focusing on cardiovascular, strength, and gait training intensity in the inpatient rehabilitation setting after a new onset of stroke. We additionally aimed to determine the efficacy of this intensity-based program on rehabilitation outcomes compared with usual care. Design Participants were pseudo-randomized to an intensity-based program focusing on gait, cardiovascular, and strength training or to usual care. Outcomes included FIM, 10-meter walk, 2-minute walk, timed Up and Go test, 5-time sit-to-stand test, and Tinetti balance assessment. Intervention The intervention consisted of 6 20-minute sessions per week dedicated to intensity of activity: 2 each for walking, cardiovascular training, and strength training. Participants Patients (N=49) with new onset stroke admitted to inpatient rehabilitation over the course of 1 year. Setting Four inpatient rehabilitation facilities with comprehensive neurologic rehabilitation teams. Results Thirty-five individuals (16 intervention, 19 controls) completed all testing. Subject compliance to the intensity intervention demonstrated completion of approximately half the prescribed sessions. All outcomes improved significantly from admission to discharge, and a significant interaction between treatment group and time was observed for the 2-minute walk and the Tinetti balance assessment. The 2-minute walk, Tinetti balance assessment, 10-meter walk, and FIM demonstrated between-group effect sizes greater than 0.60 in favor of the intervention group. Conclusions The intensity-based protocol was safe, and several measures demonstrated efficacy when compared with usual care. Results may have been limited by poor program compliance, showing a need to identify and ameliorate obstacles to integration of comprehensive intensity-based programs addressing endurance, strength, and gait training. Applying physiological principles of exercise to acute stroke rehabilitation demonstrates great promise for improving independent physical function.

Objective The purpose of this study was to determine the association between mobility, self-care, cognition, and caregiver support and 30-day potentially preventable readmissions (PPR) for individuals with dementia. Design This retrospective study derived data from 100% national Centers for Medicare and Medicaid Services data files from July 1, 2013, through June 1, 2015. Participants Criteria from the Home Health Claims-Based Rehospitalization Measure and the Potentially Preventable 30-Day Post Discharge Readmission Measure for the Home Health Quality Reporting Program were used to identify a cohort of 118,171 Medicare beneficiaries. Main Outcome Measure The 30-day PPR rates with associated 95% CIs were calculated for each patient characteristic. Multilevel logistic regression was used to study the relationship between mobility, self-care, caregiver support, and cognition domains and 30-day PPR during home health, adjusting for patient demographics and clinical characteristics. Results The overall rate of 30-day PPR was 7.6%. In the fully adjusted models, patients who were most dependent in mobility (odds ratio [OR], 1.59; 95% CI, 1.47-1.71) and self-care (OR, 1.73; 95% CI, 1.61-1.87) had higher odds for 30-day PPR. Patients with unmet caregiving needs had 1.11 (95% CI, 1.05-1.17) higher odds for 30-day PPR than patients whose caregiving needs were met. Patients with cognitive impairment had 1.23 (95% CI, 1.16-1.30) higher odds of readmission than those with minimal to no cognitive impairment. Conclusions Decreased independence in mobility and self-care tasks, unmet caregiver needs, and impaired cognitive processing at admission to home health are associated with risk of 30-day PPR during home health for individuals with dementia. Our findings indicate that deficits in mobility and self-care tasks have the greatest effect on the risk for PPR.

Background Relying solely on null hypothesis significance testing to investigate rehabilitation interventions may result in researchers erroneously concluding the presence of a treatment effect. Objective We sought to quantify the strength of evidence in favour of rehabilitation treatment effects by calculating Bayes factors (BF10s) for significant findings. Additionally, we sought to examine associations between BF10s, P-values, and Cohen's d effect sizes. Methods We searched the Cochrane Database of Systematic Reviews for meta-analyses with “rehabilitation” as a keyword that evaluated a rehabilitation intervention. We extracted means, standard deviations, and sample sizes for treatment and comparison groups from individual findings within 175 meta-analyses. Investigators independently classified the interventions according to the Rehabilitation Treatment Specification System. We calculated t-statistics, P-values, effect sizes, and BF10s for each finding. We isolated statistically significant findings (P ≤ 0.05); applied evidential categories to BF10s, P-values, and effect sizes; and examined relationships descriptively. Results We analysed 1935 rehabilitation findings. Across intervention types, 25% of significant findings offered only anecdotal evidence in favour of a treatment effect; only 48% indicated strong evidence. This pattern persisted within intervention types and when conducting robustness analyses. Smaller P-values and larger effect sizes were associated with stronger evidence in favour of a treatment effect. However, a notable portion of findings with P-value 0.01 to 0.05 (63%) or a large effect size (18%) offered anecdotal evidence in favour of an effect. Conclusions For a substantial portion of statistically significant rehabilitation findings, the data neither support nor refute the presence of a treatment effect. This was the case among a notable portion of large treatment effects and for most findings with P-value > 0.01. Rehabilitation evidence would be improved by researchers adopting more conservative levels of significance, complementing the use of null hypothesis significance testing with Bayesian techniques and reporting effect sizes.

This cohort study examines the differences between 2 Centers for Medicare & Medicaid Services measures for 30-day rehospitalization after discharge from postacute inpatient rehabilitation., Key Points Question Can Centers for Medicare & Medicaid Services Quality Reporting Program measures detect variation in 30-day hospital readmission rates after postacute inpatient rehabilitation among US inpatient rehabilitation facilities (IRFs)? Findings In this cohort study of 454 378 Medicare fee-for-service beneficiaries discharged from 1162 IRFs submitting claims, risk-standardized potentially preventable readmission rates ranged from 4.3% to 7.3%. Application of the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation resulted in risk-standardized readmission rates above or below the national mean for less than 1% of 1162 Medicare-eligible IRFs. Meaning These findings suggest that the current readmission measure does not distinguish high- and low-performing facilities, and therefore it should not be implemented as part of the IRF quality reporting program., Importance The Improving Medicare Post-Acute Care Transformation Act of 2014 mandated a quality measure of potentially preventable 30-day hospital readmission for inpatient rehabilitation facilities (IRFs). Examining IRF performance nationally may help inform health care quality initiatives for Medicare beneficiaries. Objective To examine variation in Centers for Medicare & Medicaid Services Quality Reporting Program measures for US facility-level risk-adjusted all-cause and potentially preventable hospital readmission rates after inpatient rehabilitation. Design, Setting, and Participants This cohort study of Medicare claims data included 454 378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. Data were analyzed March 23, 2018, through June 24, 2019. Main Outcomes and Measures All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities and the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation. Specifications from the Centers for Medicare & Medicaid Services were followed to identify the cohort, define outcomes, and calculate risk-standardized facility-level rates. Results Among a cohort of 454 378 patients, the mean (SD) age was 76.2 (10.6) years and 263 546 (58.0%) were women. The all-cause readmission rate was 12.3% (95% CI, 12.2%-12.4%), and the potentially preventable readmission rate was 5.3% (95% CI, 5.3%-5.4%). Across 1162 included IRFs, risk-standardized all-cause readmission rates ranged from 10.1% (95% CI, 8.9%-11.6%) to 15.9% (95% CI, 13.6-18.6%) and potentially preventable readmission rates ranged from 4.3% (95% CI, 3.7%-5.4%) to 7.3% (95% CI, 5.7%-8.3%). Using the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities, 16 IRFs (1.4%) had 95% CIs above the national mean rate, 1137 IRFs (97.9%) had 95% CIs containing the national mean rate, and 9 IRFs (0.8%) had 95% CIs below the national mean rate. Using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation, 8 IRFs (0.7%) had 95% CIs above the national mean rate, 1153 IRFs (99.2%) had 95% CIs containing the national mean rate, and 1 IRF (0.1%) had a 95% CI below the national mean rate. Conclusions and Relevance This cohort study found that readmission rates were lower when using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation and further reduced discrimination between facilities compared with the recently discontinued All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities. This finding may indicate there is a lack of room for improvement in readmission rates. Given the rationale of the Centers for Medicare & Medicaid Services for removing measures that fail to discriminate quality performance, this suggests that the current readmission measure should not be implemented as part of the Inpatient Rehabilitation Quality Reporting Program.

Objectives To describe the trajectories in the first year after individuals are admitted to long-term care nursing homes. Design Retrospective cohort study. Setting US long-term care facilities. Participants Medicare fee-for-service beneficiaries newly admitted to long-term care nursing homes from July 1, 2012, to December 31, 2013 (N=535,202). Measurements Demographic characteristics were from Medicare data. Individual trajectories were conducted using the Minimum Data Set for determining long-term care stays and community discharge, and Medicare Provider and Analysis Reviews claims data for determining hospitalizations, skilled nursing facility stays, inpatient rehabilitation, long-term acute hospital and psychiatric hospital stays. Results The median length of stay in a long-term care nursing home over the 1 year following admission was 127 [interquartile range (IQR): 24, 356] days. The median length of stay in any institution was 158 (IQR: 38, 365). Residents experienced a mean of 2.1 ± 2.8 (standard deviation) transitions over the first year. The community discharge rate was 36.5% over the 1-year follow-up, with 20.8% discharged within 30 days and 31.2% discharged within 100 days. The mortality rate over the first year of nursing home residence was 35.0%, with 16.3% deaths within 100 days. At 12 months post long-term care admission, 36.9% of the cohort were in long-term care, 23.4% were in community, 4.7% were in acute care hospitals or other institutions, and 35.0% had died. Conclusion After a high initial community discharge rate, the majority of patients newly admitted to long-term care experienced multiple transitions while remaining institutionalized until death or the end of 1-year follow-up.

Live Long Walk Strong is a rehabilitation program that produces large clinically meaningful improvements in mobility when implemented as an outpatient program for older adults. We adapted Live Long Walk Strong for the post-acute nursing home setting within the Veterans Health Administration as a clinical demonstration project. The adapted version includes novel elements and bridges the inpatient stay and three months post-discharge. The inpatient phase focuses on maximizing functional recovery and includes activities focused on timing and coordination of gait, leg strength and power, and trunk muscle endurance. The care transition and virtual (telehealth) post-discharge phase focuses on case management and engagement in physical activity programs. Coaching and behavior change are a consistent focus throughout the program. To date, 13 Veterans (mean age 67.9, SD 11.7 years) have completed the inpatient phase, and of those Veterans, six have completed the entire program, five are still active, one was lost to follow-up, and one was rehospitalized. The program demonstrates feasibility, 91% of all inpatient sessions and 81% of all post-discharge sessions were completed. Regarding preliminary efficacy, 83% of Veterans who completed the program exceeded the minimal detectable change score (4 points) on the Activity Measure for Post-Acute Care (AM-PAC) Mobility scale from program enrollment to completion (mean change 6.5, SD 6.9 points). Based on findings from this clinical demonstration project, the program is feasible. However, future research is needed to further examine the program’s impact on mobility and other outcomes important to older Veterans receiving post-acute nursing home care.

Background Relying solely on null hypothesis significance testing (NHST) to investigate rehabilitation interventions may result in researchers erroneously concluding the absence of a treatment effect. Objective We aimed to distinguish between truly null treatment effects and data that are insensitive to detecting treatment effects by calculating Bayes factors (BF01s) for non-significant findings in the rehabilitation literature. Additionally, to examine associations between BF01, sample size, and observed P-values. Method We searched the Cochrane Database of Systematic Reviews for meta-analyses with “rehabilitation” as a keyword that clearly evaluated a rehabilitation intervention. We extracted means, standard deviations, and sample sizes for treatment and comparison groups for individual findings within 175 meta-analyses. Two independent investigators classified the interventions into 4 categories using the Rehabilitation Treatment Specification System. We calculated t-statistics and associated P-values for each finding in order to extract non-significant results (P > 0.05). We calculated BF01s for 5790 non-significant results and classified BF01s based on the strength of evidence in favour of the null hypothesis (i.e., anecdotal, moderate, and strong) across and within intervention types. We examined correlations between BF01, sample size, and P-values across and within intervention types. Results Across all intervention types, most (71.9%) findings were deemed anecdotal, and this pattern remained within distinct intervention types (58.4–76.0%). Larger sample sizes tended to be associated with greater strength in favour of the null hypothesis, both across and within intervention types. Larger P-values were not associated with greater strength in favour of the null hypothesis; this finding was present both across and within intervention types. Conclusion Our findings indicate that most non-significant rehabilitation findings are unable to distinguish between the true absence of a treatment effect and data that are merely insensitive to detecting a treatment effect. Findings also suggest that rehabilitation researchers may improve the strength of their statistical conclusions by increasing sample size and that Bayes factors may offer unique benefits relative to P-values.

Advances in neuroimaging have enabled the mapping of white matter connections across the entire brain, allowing for a more thorough examination of the extent of white matter disconnection after stroke. To assess how cortical disconnection contributes to motor impairments, we examined the relationship between structural brain connectivity and upper and lower extremity motor function in individuals with chronic stroke. Forty-three participants [mean age: 59.7 (±11.2) years; time poststroke: 64.4 (±58.8) months] underwent clinical motor assessments and MRI scanning. Nonparametric correlation analyses were performed to examine the relationship between structural connectivity amid a subsection of the motor network and upper/lower extremity motor function. Standard multiple linear regression analyses were performed to examine the relationship between cortical necrosis and disconnection of three main cortical areas of motor control [primary motor cortex (M1), premotor cortex (PMC), and supplementary motor area (SMA)] and motor function. Anatomical connectivity between ipsilesional M1/SMA and the (1) cerebral peduncle, (2) thalamus, and (3) red nucleus were significantly correlated with upper and lower extremity motor performance (P ≤ 0.003). M1-M1 interhemispheric connectivity was also significantly correlated with gross manual dexterity of the affected upper extremity (P = 0.001). Regression models with M1 lesion load and M1 disconnection (adjusted for time poststroke) explained a significant amount of variance in upper extremity motor performance (R2 = 0.36-0.46) and gait speed (R2 = 0.46), with M1 disconnection an independent predictor of motor performance. Cortical disconnection, especially of ipsilesional M1, could significantly contribute to variability seen in locomotor and upper extremity motor function and recovery in chronic stroke. Hum Brain Mapp 39:120-132, 2018. © 2017 Wiley Periodicals, Inc.

Objective To examine the effect of home- and community-based physical activity interventions on physical functioning among cancer survivors based on the most prevalent physical function measures, randomized trials were reviewed. Data Sources Five electronic databases—Medline Ovid, PubMed, CINAHL, Web of Science, and PsycINFO—were searched from inception to March 2016 for relevant articles. Study Selection Search terms included community-based interventions, physical functioning, and cancer survivors. A reference librarian trained in systematic reviews conducted the final search. Data Extraction Four reviewers evaluated eligibility and 2 reviewers evaluated methodological quality. Data were abstracted from studies that used the most prevalent physical function measurement tools—Medical Outcomes Study 36-Item Short-Form Health Survey, Late-Life Function and Disability Instrument, European Organisation for the Research and Treatment of Cancer Quality-of-Life Questionnaire, and 6-minute walk test. Random- or fixed-effects models were conducted to obtain overall effect size per physical function measure. Data Synthesis Fourteen studies met inclusion criteria and were used to compute standardized mean differences using the inverse variance statistical method. The median sample size was 83 participants. Most of the studies (n=7) were conducted among breast cancer survivors. The interventions produced short-term positive effects on physical functioning, with overall effect sizes ranging from small (.17; 95% confidence interval [CI], .07–.27) to medium (.45; 95% CI, .23–.67). Community-based interventions that met in groups and used behavioral change strategies produced the largest effect sizes. Conclusions Home and community-based physical activity interventions may be a potential tool to combat functional deterioration among aging cancer survivors. More studies are needed among other cancer types using clinically relevant objective functional measures (eg, gait speed) to accelerate translation into the community and clinical practice.

Objective To examine the effects of facility-level acute–postacute continuity on probability of community discharge and 30-day rehospitalization following inpatient rehabilitation. Data Sources We used national Medicare enrollment, claims, and assessment data to study 541,097 patients discharged from 1,156 inpatient rehabilitation facilities (IRFs) in 2010–2011. Study Design We calculated facility-level continuity as the percentages of an IRF's patients admitted from each contributing acute care hospital. Patients were categorized into three groups: low continuity ( 75 percent from same hospital). The multivariable models included an interaction term to examine the potential moderating effects of facility type (freestanding facility vs. hospital-based rehabilitation unit) on the relationships between facility-level continuity and our two outcomes: community discharge and 30-day rehospitalization. Principal Findings Medicare beneficiaries in hospital-based rehabilitation units were more likely to be referred from a high-contributing hospital compared to those in freestanding facilities. However, the association between higher acute–postacute continuity and desirable outcomes is significantly better in freestanding rehabilitation facilities than in hospital-based units. Conclusions Improving continuity is a key premise of health care reform. We found that both observed referral patterns and continuity-related benefits differed markedly by facility type. These findings provide a starting point for health systems establishing or strengthening acute–postacute relationships to improve patient outcomes in this new era of shared accountability and public quality reporting programs.

Objectives Hospitalization in community-dwelling elderly is often accompanied by functional loss, increasing the risk for continued functional decline and future institutionalization. The primary objective of our study was to examine the hospital-level variation in rates of new institutionalizations among Medicare beneficiaries. Design Retrospective cohort study. Setting Hospitals and nursing homes. Participants Medicare fee-for-service beneficiaries discharged from 4,469 hospitals in 2013 (N = 4,824,040). Measurements New institutionalization, defined as new long term care nursing home residence (not skilled nursing facility) of at least 90 days duration within 6 months of hospital discharge. Results The overall observed rate of new institutionalizations was 3.6% (N = 173,998). Older age, white race, Medicaid eligibility, longer hospitalization, and having a skilled nursing facility stay over the 6 months before hospitalization were associated with higher adjusted odds. Observed rates ranged from 0.9% to 5.9% across states. The variation in rates attributable to the hospital after adjusting for case-mix and state was 5.1%. Odds were higher for patients treated in smaller (OR = 1.36, 95% CI: 1.27–1.45, ≤50 vs >500 beds), government owned (OR = 1.15, 95% CI: 1.09–1.21 compared to for-profit), limited medical school affiliation (OR = 1.13, 95% CI: 1.07–1.19 compared to major) hospitals and lower for patients treated in urban hospitals (OR = 0.79, 95% CI: 0.76–0.82 compared to rural). Higher Summary Star ratings (OR = 0.75, 95% CI: 0.67–0.93, five vs one stars) and Overall Hospital Rating (OR = 0.62, 95% CI: 0.57–0.67, ratings of 9–10 vs 0) were associated with lower odds of institutionalization. Conclusion Hospitalization may be a critical period for preventing future institutionalization among elderly patients. The variation in rates across hospitals and its association with hospital quality ratings suggest some of these institutionalizations are avoidable and may represent targets for care improvement.

BACKGROUND: Falls and their consequences are significant concerns for older adults, caregivers, and health care providers. Identification of fall risk is crucial for appropriate referral to preventive interventions. Falls are multifactorial; no single measure is an accurate diagnostic tool. There is limited information on which history question, self-report measure, or performance-based measure, or combination of measures, best predicts future falls. Purpose: First, to evaluate the predictive ability of history questions, self-report measures, and performance-based measures for assessing fall risk of community-dwelling older adults by calculating and comparing posttest probability (PoTP) values for individual test/measures. Second, to evaluate usefulness of cumulative PoTP for measures in combination. Data Sources: To be included, a study must have used fall status as an outcome or classification variable, have a sample size of at least 30 ambulatory community-living older adults (>=65 years), and track falls occurrence for a minimum of 6 months. Studies in acute or long-term care settings, as well as those including participants with significant cognitive or neuromuscular conditions related to increased fall risk, were excluded. Searches of Medline/PubMED and Cumulative Index of Nursing and Allied Health (CINAHL) from January 1990 through September 2013 identified 2294 abstracts concerned with fall risk assessment in community-dwelling older adults. Study Selection: Because the number of prospective studies of fall risk assessment was limited, retrospective studies that classified participants (faller/nonfallers) were also included. Ninety-five full-text articles met inclusion criteria; 59 contained necessary data for calculation of PoTP. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) was used to assess each study's methodological quality. Data Extraction: Study design and QUADAS score determined the level of evidence. Data for calculation of sensitivity (Sn), specificity (Sp), likelihood ratios (LR), and PoTP values were available for 21 of 46 measures used as search terms. An additional 73 history questions, self-report measures, and performance-based measures were used in included articles; PoTP values could be calculated for 35. Data Synthesis: Evidence tables including PoTP values were constructed for 15 history questions, 15 self-report measures, and 26 performance-based measures. Recommendations for clinical practice were based on consensus. Limitations: Variations in study quality, procedures, and statistical analyses challenged data extraction, interpretation, and synthesis. There was insufficient data for calculation of PoTP values for 63 of 119 tests. Conclusions: No single test/measure demonstrated strong PoTP values. Five history questions, 2 self-report measures, and 5 performance-based measures may have clinical usefulness in assessing risk of falling on the basis of cumulative PoTP. Berg Balance Scale score (=12 seconds), and 5 times sit-to-stand times (>=12) seconds are currently the most evidence-supported functional measures to determine individual risk of future falls. Shortfalls identified during review will direct researchers to address knowledge gaps. Copyright (C) 2016 the Section on Geriatrics of the American Physical Therapy Association Language: en

Background Clinicians and researchers have used bathroom scales, balance performance monitors with feedback, postural scale analysis, and force platforms to evaluate weight bearing asymmetry (WBA). Now video game consoles offer a novel alternative for assessing this construct. By using specialized software, the Nintendo Wii Fit balance board can provide reliable measurements of WBA in healthy, young adults. However, reliability of measurements obtained using only the factory settings to assess WBA in older adults and individuals with stroke has not been established. Purpose To determine whether measurements of WBA obtained using the Nintendo Wii Fit balance board and default settings are reliable in older adults and individuals with stroke. Methods Weight bearing asymmetry was assessed using the Nintendo Wii Fit balance board in 2 groups of participants-individuals older than 65 years (n = 41) and individuals with stroke (n = 41). Participants were given a standardized set of instructions and were not provided auditory or visual feedback. Two trials were performed. Intraclass correlation coefficients (ICC), standard error of measure (SEM), and minimal detectable change (MDC) scores were determined for each group. Results The ICC for the older adults sample was 0.59 (0.35-0.76) with SEM95 = 6.2% and MDC95 = 8.8%. The ICC for the sample including individuals with stroke was 0.60 (0.47-0.70) with SEM95 = 9.6% and MDC95 = 13.6%. Discussion Although measurements of WBA obtained using the Nintendo Wii Fit balance board, and its default factory settings, demonstrate moderate reliability in older adults and individuals with stroke, the relatively high associated SEM and MDC values substantially reduce the clinical utility of the Nintendo Wii Fit balance board as an assessment tool for WBA. Conclusions Weight bearing asymmetry cannot be measured reliably in older adults and individuals with stroke using the Nintendo Wii Fit balance board without the use of specialized software.

Key Points Question Do rates of successful community discharge after inpatient rehabilitation vary across US facilities and geographic regions? Findings In this cohort study of 487 862 Medicare fee-for-service beneficiaries discharged from 1154 inpatient rehabilitation facilities submitting claims, risk-standardized rates of successful community discharge ranged from 42.9% to 83.6%. Rates were lowest in the Northeast (Massachusetts, 55.9%; New Hampshire, 57.0%) and highest in the West (Oregon, 70.3%; Hawaii, 73.3%). Meaning The observed facility and geographic variations suggest opportunities for improving this important, patient-centered, and nationally reported quality outcome., This cohort study examines facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation among fee-for-service Medicare beneficiaries., Importance The Improving Medicare Post–Acute Care Transformation (IMPACT) Act of 2014 mandated a quality measure of successful community discharge for postacute care services. Examining variation in performance nationally can help identify opportunities for improving patient-centered quality of care. Objective To examine US facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation. Design, Setting, and Participants This retrospective cohort study of Medicare claims data from December 31, 2013, through October 1, 2015, included 1154 inpatient rehabilitation facilities submitting claims to the Centers for Medicare & Medicaid Services and a total of 487 862 Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation facilities. Analyses were performed from December 8, 2017, through September 11, 2018. Main Outcomes and Measures Successful community discharge as defined for the Discharge to Community—Post–Acute Care Inpatient Rehabilitation Facility Quality Reporting Program measure. To be considered a successful community discharge, patients had to discharge from the inpatient rehabilitation facility to the community (ie, home or self-care) and remain there without experiencing an unplanned rehospitalization or dying within the following 31 days. Centers for Medicare & Medicaid Services specifications were followed to identify the cohort, define the outcome, and calculate risk-standardized facility and state rates. Results Among the 487 862 patients included in the cohort, mean (SD) age was 76.4 (10.8) years, and 56.9% were female. The overall rate of successful community discharge after inpatient rehabilitation was 63.7% (95% CI, 63.6%-63.8%). Risk-standardized rates ranged from 42.9% to 83.6% across inpatient rehabilitation facilities. Two hundred sixteen facilities (18.7%) performed significantly better than the mean national rate and 203 (17.6%) performed significantly worse (P

The objective of this work was to present comprehensive descriptive summaries of program interruptions and short-stay transfers among Medicare fee-for-service beneficiaries receiving inpatient rehabilitation after stroke, traumatic brain injury (TBI), and traumatic spinal cord injury (SCI).Retrospective cohort study of Medicare beneficiaries with any of the 3 conditions of interest who were admitted to inpatient rehabilitation directly from an acute hospital between July 1, 2012, and November 15, 2013.In the final sample (stroke, n = 71 769; TBI, n = 7109; SCI, n = 659), program interruption rates were 0.9% (stroke), 0.8% (TBI), and 1.4% (SCI). Short-stay transfer rates were 22.3% (stroke), 21.8% (TBI), and 31.6% (SCI); 14.7% of short-stay transfers and 12.3% of interruptions resulting in a return to acute care were identified as potentially preventable among those with stroke; 10.2% of transfers and 11.7% of interruptions among those with TBI, and 3.8% of transfers and 11.1% of interruptions among those with SCI.Broad health care policies aimed at improving quality and reducing costs are currently being implemented. Reducing program interruptions and short-stay transfers during inpatient rehabilitative care represents a potential target for care-improvement efforts. Future research focused on identifying modifiable risk factors for potentially undesirable outcomes will allow for targeted preventative interventions.

To determine the degree to which self-selected walking speed (SSWS), maximal walking speed (MWS), and walking speed reserve (WSR) are associated with fall status among community-dwelling older adults.WS and 1-year falls history data were collected on 217 community-dwelling older adults (median age = 82, range 65-93 years) at a local outpatient PT clinic and local retirement communities and senior centers. WSR was calculated as a difference (WSRdiff = MWS - SSWS) and ratio (WSRratio = MWS/SSWS).SSWS (P0.001), MWS (P0.001), and WSRdiff (P0.01) were associated with fall status. The cutpoints identified were 0.76 m/s for SSWS (65.4% sensitivity, 70.9% specificity), 1.13 m/s for MWS (76.6% sensitivity, 60.0% specificity), and 0.24 m/s for WSRdiff (56.1% sensitivity, 70.9% specificity). SSWS and MWS better discriminated between fallers and non-fallers (SSWS: AUC = 0.69, MWS: AUC = 0.71) than WSRdiff (AUC = 0.64).SSWS and MWS seem to be equally informative measures for assessing fall status in community-dwelling older adults. Older adults with SSWSs less than 0.76 m/s and those with MWSs less than 1.13 m/s may benefit from further fall risk assessment. Combining SSWS and MWS to calculate an individual's WSR does not provide additional insight into fall status in this population.Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES:: Upon completion of this article, the reader should be able to: (1) Describe the different methods for calculating walking speed reserve and discuss the potential of the metric as an outcome measure; (2) Explain the degree to which self-selected walking speed, maximal walking speed, and walking speed reserve are associated with fall status among community-dwelling older adults; and (3) Discuss potential limitations to using walking speed reserve to identify fall status in populations without mobility restrictions.Advanced: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity.

Objectives Approximately 14% of Medicare beneficiaries are readmitted to a hospital within 30 days of home health care admission. Individuals with dementia account for 30% of all home health care admissions and are at high risk for readmission. Our primary objective was to determine the association between dementia severity at admission to home health care and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity scale from Outcome and Assessment Information Set (OASIS) items based on the Functional Assessment Staging Tool (FAST). Design Retrospective cohort study. Setting and participants Home health care; 126,292 Medicare beneficiaries receiving home health care (July 1, 2013–June 1, 2015) diagnosed with dementia (ICD-9 codes). Measures 30-day PPR during home health care. Dementia severity categorized into 6 levels (nonaffected to severe). Results The overall rate of 30-day PPR was 7.6% [95% confidence interval (CI) 7.4, 7.7] but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratio (OR) for dementia severity category 6 was 1.37 (95% CI 1.29, 1.46) and the OR for category 7 was 1.94 (95% CI 1.64, 2.31) as compared to dementia severity category 1/2. Conclusions and implications Dementia severity in the later stages is associated with increased risk for potentially preventable readmissions. Our findings suggest that individuals admitted to home health during the later stages of Alzheimer's disease and related dementias may require greater supports and specialized care to minimize negative outcomes such as readmissions. Development of a dementia severity scale based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing potentially preventable readmissions of individuals with severe dementia who receive home health care. Future research is also needed to validate the proposed dementia severity categories used in this study.

Objective Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. Design Retrospective cohort study. Setting Acute care hospitals. Participants Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. Measurements 90-day unplanned readmissions. Results The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. Conclusions We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care.

Approximately 14.0% of Medicare beneficiaries are readmitted to a hospital within 30-days of home health admission. Individuals with dementia account for 30% of all home health care admissions and are at high-risk for rehospitalizations. Our primary objective was to determine the association between dementia severity at admission to home health and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity category from OASIS items based on the Functional Assessment Staging Tool (FAST). Retrospective cohort study of 124,119 Medicare beneficiaries receiving home health (7/2013 – 6/2015) and diagnosed with dementia (ICD-9 codes). The primary outcome was 30-day PPR during home health. The predictor variable of dementia severity was categorized into six levels (non-affected to severe). The overall rate of 30-day PPR was 7.6% (95% CI 7.4, 7.7) but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, patients classified as stage 6 and stage 7 had 1.36 (95% CI 1.28, 1.45) and 1.90 (95% CI 1.59, 2.26) times higher odds to experience a 30-day PPR compared to patients classified as stage 1-2. Dementia severity in the later stages is associated with increased risk for PPR. Development of a dementia severity category based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing PPR during home health for individuals with severe dementia. Future research is needed to validate the proposed dementia severity categories used in this study.

Walking speed (WS) is a valid, reliable, and sensitive measure appropriate for assessing and monitoring functional status and overall health in a wide range of populations. These capabilities have led to its designation as the “sixth vital sign”. By synthesizing the available evidence on WS, this scholarly review article provides clinicians with a reference tool regarding this robust measure. Recommendations on testing procedures for assessing WS, including optimal distance, inclusion of acceleration and deceleration phases, instructions, and instrumentation are given. After assessing an individual’s WS, clinicians need to know what this value represents. Therefore, WS cut-off values and the corresponding predicted outcomes, as well as minimal detectable change values for specific populations and settings are provided.

BACKGROUND: Transcranial direct current stimulation (tDCS) may provide a safe, non-invasive technique for modulating neural excitability during neurorehabilitation. OBJECTIVE: 1) Assess feasibility and potential effectiveness of tDCS as an adjunct to standard upper extremity (UE) physical therapy (PT) for motor impairments resulting from neurological insult. 2) Determine sustainability of improvements over a six month period. METHODS: Five participants with chronic neurologic insult (stroke or traumatic brain injury > 6 months prior) completed 24 sessions (40 minutes, three times/week) of UE-PT combined with bihemispheric tDCS delivered at 1.5 mA over the motor cortex during the first 15 minutes of each PT session. Outcomes were assessed using clinical (UE Fugl-Meyer, Purdue Pegboard, Box and Block, Stroke Impact Scale) and robotic (unimanual and bimanual motor control) measures. Change in scores and associated effects sizes from Pre-test to Post-test and a six month Follow-up were calculated for each participant and group as a whole. RESULTS: Scores on UE Fugl-Meyer, Box and Block, Purdue Pegboard, Stroke Impact Scale, and robotic measures improved from Pre- to Post-test. Improvements on UE Fugl-Meyer, Box and Block, and robotic measures were largely sustained at six months. Combining bihemispheric tDCS with UE-PT in individuals with neurological insult warrants further investi

Background/Objectives Approximately half of individuals newly admitted to long-term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory. Design Retrospective cohort study. Setting SNFs and LTC NHs. Patients Medicare fee-for-service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986). Measurements We used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined “new institutionalization” as LTC NH residence for longer than 90 non-SNF days, starting within 6 months of hospital discharge. Results For individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89–0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27–1.55) and Hispanics (OR = 1.44, 95% CI = 1.25–1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older. Conclusion Associations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.

Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.

Objectives To determine the association between patients' functional status at discharge from inpatient rehabilitation and 30-day potentially preventable hospital readmissions. A secondary objective was to examine the conditions resulting in these potentially preventable readmissions. Design Retrospective cohort study. Setting Inpatient rehabilitation facilities submitting claims to Medicare. Participants National cohort (N=371,846) of inpatient rehabilitation discharges among aged Medicare fee-for-service beneficiaries in 2013 to 2014. The average age was 79.1±7.6 years. Most were women (59.7%) and white (84.5%). Interventions Not applicable. Main Outcome Measures (1) Observed rates and adjusted odds of 30-day potentially preventable hospital readmissions after inpatient rehabilitation and (2) primary diagnoses for readmissions. Results The overall rate of any 30-day hospital readmission after inpatient rehabilitation was 12.4% (n=46,265), and the overall rate of potentially preventable readmissions was 5.0% (n=18,477). Functional independence was associated with lower observed rates and adjusted odds ratios for potentially preventable readmissions. Observed rates for the highest versus lowest quartiles within each functional domain were as follows: self-care: 3.4% (95% confidence interval [CI], 3.3–3.5) versus 6.9% (95% CI, 6.7–7.1), mobility: 3.3% (95% CI, 3.2–3.4) versus 7.2% (95% CI, 7.0–7.4), and cognition: 3.5% (95% CI, 3.4–3.6) versus 6.2% (95% CI, 6.0–6.4), respectively. Similarly, adjusted odds ratios were as follows: self-care: .70 (95% CI, .67–.74), mobility: .64 (95% CI, .61–.68), and cognition: .84 (95% CI, .80–.89). Infection-related conditions (44.1%) were the most common readmission diagnoses followed by inadequate management of chronic conditions (31.2%) and inadequate management of other unplanned events (24.7%). Conclusions Functional status at discharge from inpatient rehabilitation was associated with 30-day potentially preventable readmissions in our sample of aged Medicare beneficiaries. This information may help identify at-risk patients. Future research is needed to determine whether follow-up programs focused on improving functional independence will reduce readmission rates.

Background The focus of health care reform is shifting from all-cause to potentially preventable readmissions. Potentially preventable within-stay readmission rates is a measure recently adopted by the Centers for Medicare and Medicaid Services for the Inpatient Rehabilitation Facility Quality Reporting Program. Objective We examined the patient-level predictors of potentially preventable within-stay readmissions among Medicare beneficiaries receiving care in inpatient rehabilitation facilities. We also studied the reasons for readmissions and the risk-standardized variation across states. Design Retrospective cohort study. Setting Inpatient rehabilitation facilities. Patients Medicare fee-for-service beneficiaries receiving inpatient rehabilitation after hospitalization in 2012-2013 (N = 345,697). Methods Medicare claims were reviewed to identify potentially preventable readmissions occurring during inpatient rehabilitation. Main Outcome Measures (1) Observed rates and odds of potentially preventable within-stay readmissions by patient sociodemographic and clinical characteristics, (2) risk-standardized state rates, and (3) primary diagnoses for hospital readmissions. Results The overall rate of potentially preventable within-stay readmissions was 3.5% (n = 11,945). Older age, male gender, hospitalizations during the previous 6 months, longer hospital lengths of stay, intensive care unit use, and number of comorbidities were associated with increased odds. Dual eligibility and disability status were not associated with increased odds. Greater functional scores at rehabilitation admission were associated with lower odds. Rates and odds varied across rehabilitation impairment groups. Risk-standardized state rates ranged from 3.1% to 4.1%. Readmissions for conditions reflecting inadequate management of infections (36.8%) were the most frequent and readmissions for inadequate injury prevention (6.1%) least frequent. Conclusions Potentially preventable within-stay readmissions may represent a target for inpatient rehabilitation care improvement. Our findings highlight the need for care coordination across providers. Future research should focus on care processes that reduce patients' risk of these potentially preventable rehospitalizations. Level of Evidence II

Approximately 14.0% of Medicare beneficiaries are readmitted to a hospital within 30-days of home health admission. Individuals with dementia account for 30% of all home health care admissions and are at high-risk for rehospitalizations. Our primary objective was to determine the association between functional status and social support at admission to home health and 30-day potentially preventable readmissions (PPR) during home health care. We conducted a retrospective cohort study of 124,119 Medicare beneficiaries receiving home health (7/2013 – 6/2015) and diagnosed with dementia (ICD-9 codes). Approximately 65% of participants were over the age of 81, 61% were female, and 80% were Caucasian. The primary outcome was 30-day PPR during home health. OASIS items were used to create mobility, self-care, social support, and cognition categories. The overall rate of 30-day PPR was 7.6% (95% CI: 7.4-7.7) but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratios (OR) for the most dependent score quartile versus the most independent was 1.68(1.56,1.80 95% CI) for mobility, 1.78 (95% CI: 1.66- 1.91) for self-care, and 1.10(95%CI: 1.03-1.17) for social support. The OR for impaired versus intact cognition was 1.12 (95% CI: 1.05-1.20). Impaired functional and cognitive status as well as limited social support at admission to home health care are associated with increased risk of PPR for individuals with dementia. Future research is needed to determine if strategies targeted at mobility and self-care can decrease PPR during home health for individuals with severe dementia.

Accurate assessment of gait, balance, and mobility in older adults is an important aspect of clinical practice for clinicians working with this population. This report presents evidence regarding assessment in each of these domains. Outcome measures were selected for inclusion if recent evidence (publication within previous 18 months) regarding their properties was available in the literature. Selected measures are as follows: Gait: gait speed, gait symmetry, gait endurance, adaptability of gait, dual task performance during gait, and self-reported confidence during gait; Balance: Berg Balance Scale, Mini-BESTest, Performance-Oriented Mobility Assessment, Dynamic Gait Index, and Falls Efficacy Scale-International; Mobility: Timed Up and Go test, 5 times sit-to-stand test, backwards walking, and Short Physical Performance Battery. Psychometric properties and minimal detectable change values (when available) for the listed measures are presented in order to provide clinicians with a consolidated reference for selecting outcome measures to assess gait, balance, and mobility in older adults.

Objectives To model 12-month rehospitalization risk among Medicare beneficiaries receiving inpatient rehabilitation for spinal cord injury (SCI) or traumatic brain injury (TBI) and to create 2 (SCI- and TBI-specific) interactive tools enabling users to generate monthly projected probabilities of rehospitalization on the basis of an individual patient's clinical profile at discharge from inpatient rehabilitation. Design Secondary data analysis. Setting Inpatient rehabilitation facilities. Participants Medicare beneficiaries receiving inpatient rehabilitation for SCI (n=2587) or TBI (n=10,864). Interventions Not applicable. Main Outcome Measures Monthly rehospitalization (yes/no) based on Medicare claims. Results Results are summarized through computer-generated interactive tools, which plot individual level trajectories of rehospitalization probabilities over time. Factors associated with the probability of rehospitalization over time are also provided, with different combinations of these factors generating different individual level trajectories. Four case studies are presented to demonstrate the variability in individual risk trajectories. Monthly rehospitalization probabilities for the individual high-risk TBI and SCI cases declined from 33% to 15% and from 41% to 18%, respectively, over time, whereas the probabilities for the individual low-risk cases were much lower and stable over time: 5% to 2% and 6% to 2%, respectively. Conclusions Rehospitalization is an undesirable and multifaceted health outcome. Classifying patients into meaningful risk strata at different stages of their recovery is a positive step forward in anticipating and managing their unique health care needs over time.

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood.To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care.This was a retrospective cohort study.Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013.Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406).Not applicable.Thirty-day unplanned rehospitalization following post-acute rehabilitation.The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %).The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care.

OBJECTIVE: To examine how similar summary scores of physical functioning using the FIM can represent very different patient clinical profiles. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012 and 2013. PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation (N=765,441). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: We used patients’ scores on items from the Functional Independence Measure (FIM) to quantify their level of independence in both self-care and mobility domains. We then identified patients as requiring “No Physical Assistance” at discharge from inpatient rehabilitation using a rule and score-based approach. RESULTS: Among those patients with FIM self-care and mobility summary scores suggesting no physical assistance needed, we found physical assistance was in fact needed frequently in bathroom related activities (e.g., continence, toilet and tub transfers, hygiene, clothes management) and with stairs. In other words, it was not uncommon for actual performance to be lower than what may be suggested by a summary score in those domains. CONCLUSIONS: Further research is needed into creating clinically meaningful descriptions of summary scores from combined performances on individual items of physical functioning.

Objectives The objectives of this study were to determine the association between patients’ functional status at discharge from skilled nursing facility (SNF) care and 30-day potentially preventable hospital readmissions, and to examine common reasons for potentially preventable readmissions. Design Retrospective cohort study. Setting SNFs and acute care hospitals submitting claims to Medicare. Participants National cohort of Medicare fee-for-service beneficiaries discharged from SNF care between July 15, 2013, and July 15, 2014 (n = 693,808). Average age was 81.4 (SD 8.1) years, 67.1% were women, and 86.3% were non-Hispanic white. Measurements Functional items from the Minimum Data Set 3.0 were categorized into self-care, mobility, and cognition domains. We used specifications for the SNF potentially preventable 30-day postdischarge readmission quality metric to identify potentially preventable readmissions. Results The overall observed rate of 30-day potentially preventable readmissions following SNF discharge was 5.7% (n = 39,318). All 3 functional domains were independently associated with potentially preventable readmissions in the multivariable models. Odds ratios for the most dependent category versus the least dependent category from multilevel models adjusted for patients’ sociodemographic and clinical characteristics were as follows: mobility, 1.54 (95% confidence interval [CI] 1.49–1.59); self-care, 1.50 (95% CI 1.44–1.55); and cognition, 1.12 (95% CI 1.04–1.20). The 5 most common conditions were congestive heart failure (n = 7654, 19.5%), septicemia (n = 7412, 18.9%), urinary tract infection/kidney infection (n = 4297, 10.9%), bacterial pneumonia (n = 3663, 9.3%), and renal failure (n = 3587, 9.1%). Across all 3 functional domains, septicemia was the most common condition among the most dependent patients and congestive heart failure among the least dependent. Conclusions Patients with functional limitations at SNF discharge are at increased risk of hospital readmissions considered potentially preventable. Future research is needed to determine whether improving functional status reduces risk of potentially preventable readmissions among this vulnerable population.

Daily ambulatory activity is associated with health and functional status in older adults; however, assessment requires multiple days of activity monitoring. The objective of this study was to determine the relative capabilities of self-selected walking speed (SSWS), maximal walking speed (MWS), and walking speed reserve (WSR) to provide insight into daily ambulatory activity (steps per day) in community-dwelling older adults. Sixty-seven older adults completed testing and activity monitoring (age 80.39 [6.73] years). SSWS (R2 = .51), MWS (R2 = .35), and WSR calculated as a ratio (R2 = .06) were significant predictors of daily ambulatory activity in unadjusted linear regression. Cutpoints for participants achieving < 8,000 steps/day were identified for SSWS (≤ 0.97 m/s, 44.2% sensitivity, 95.7% specificity, 10.28 +LR, 0.58 −LR) and MWS (≤ 1.39 m/s, 60.5% sensitivity, 78.3% specificity, 2.79 +LR, 0.50 −LR). SSWS may be a feasible proxy for assessing and monitoring daily ambulatory activity in older adults.

Study Design Single group, pretest-posttest study. Objectives To determine the effects of a non-task-specific, voluntary, progressive aerobic exercise training (AET) intervention on fitness and walking-related outcomes in ambulatory adults with chronic motor-incomplete SCI. Setting Rehabilitation research center. Methods Ten ambulatory individuals (50% female; 57.94 ± 9.33 years old; 11.11 ± 9.66 years post injury) completed voluntary, progressive moderate-to-vigorous intensity AET on a recumbent stepper three days per week for six weeks. The primary outcome measures were aerobic capacity (VO2peak) and self-selected overground walking speed (OGWS). Secondary outcome measures included: walking economy, six-minute walk test (6MWT), daily step counts, Walking Index for Spinal Cord Injury (WISCI-II), Dynamic Gait Index (DGI), and Berg Balance Scale (BBS). Results Nine participants completed all testing and training. Significant improvements in aerobic capacity (P=0.011), OGWS (P=0.023), the percentage of VO2peak utilized while walking at self-selected speed (P=0.03), and daily step counts (P=0.025) resulted following training. Conclusions The results indicate that total-body, voluntary, progressive AET is safe, feasible, and effective for improving aerobic capacity, walking speed, and select walking-related outcomes in an exclusively ambulatory SCI sample. This study suggests the potential for non-task-specific aerobic exercise to improve walking following incomplete SCI and builds a foundation for further investigation aimed at the development of exercise based rehabilitation strategies to target functionally limiting impairments in ambulatory individuals with chronic SCI.

Body weight-supported treadmill training (BWSTT) has produced mixed results compared with other therapeutic techniques.The purpose of this study was to determine whether an intensive intervention (intensive mobility training) including BWSTT provides superior gait, balance, and mobility outcomes compared with a similar intervention with overground gait training in place of BWSTT.Forty-three individuals with chronic stroke (mean [SD] age, 61.5 [13.5] years; mean [SD] time since stroke, 3.3 [3.8] years), were randomized to a treatment (BWSTT, n = 23) or control (overground gait training, n = 20) group. Treatment consisted of 1 hour of gait training; 1 hour of balance activities; and 1 hour of strength, range of motion, and coordination for 10 consecutive weekdays (30 hours). Assessments (step length differential, self-selected and fast walking speed, 6-minute walk test, Berg Balance Scale [BBS], Dynamic Gait Index [DGI], Activities-specific Balance Confidence [ABC] scale, single limb stance, Timed Up and Go [TUG], Fugl-Meyer [FM], and perceived recovery [PR]) were conducted before, immediately after, and 3 months after intervention.No significant differences (α = 0.05) were found between groups after training or at follow-up; therefore, groups were combined for remaining analyses. Significant differences (α = 0.05) were found pretest to posttest for fast walking speed, BBS, DGI, ABC, TUG, FM, and PR. DGI, ABC, TUG, and PR results remained significant at follow-up. Effect sizes were small to moderate in the direction of improvement.Future studies should investigate the effectiveness of intensive interventions of durations greater than 10 days for improving gait, balance, and mobility in individuals with chronic stroke.

Background In an effort to improve quality and reduce costs, payments are being increasingly tied to value through alternative payment models, such as episode-based payments. The objective of this study was to better understand the pattern and variation in outcomes among Medicare beneficiaries receiving lower extremity joint arthroplasty over 90-day episodes of care. Methods Observed rates of mortality, complications, and readmissions were calculated over 90-day episodes of care among Medicare fee-for-service beneficiaries who received elective knee arthroplasty and elective or nonelective hip arthroplasty procedures in 2013-2014 (N = 640,021). Post–acute care utilization of skilled nursing and inpatient rehabilitation facilities was collected from Medicare files. Results Mortality rates over 90 days were 0.4% (knee arthroplasty), 0.5% (elective hip arthroplasty), and 13.4% (nonelective hip arthroplasty). Complication rates were 2.1% (knee arthroplasty), 3.0% (elective hip arthroplasty), and 8.5% (nonelective hip arthroplasty). Inpatient rehabilitation facility utilization rates were 6.0% (knee arthroplasty), 6.7% (elective hip arthroplasty), and 23.5% (nonelective hip arthroplasty). Skilled nursing facility utilization rates were 33.9% (knee arthroplasty), 33.4% (elective hip arthroplasty), and 72.1% (nonelective hip arthroplasty). Readmission rates were 6.3% (knee arthroplasty), 7.0% (elective hip arthroplasty), and 19.2% (nonelective hip arthroplasty). Patients' age and clinical characteristics yielded consistent patterns across all outcomes. Conclusion Outcomes in our national cohort of Medicare beneficiaries receiving lower extremity joint arthroplasties varied across procedure types and patient characteristics. Future research examining trends in access to care, resource use, and care quality over bundled episodes will be important for addressing the challenges of value-based payment reform.

Objective To determine the feasibility and impact of different dosages of Intensive Mobility Training (IMT) on mobility, balance, and gait speed in individuals with chronic traumatic brain injury (TBI). Design Prospective, single group design with 3-month follow-up. Setting University research laboratory. Participants Volunteer sample of participants with chronic TBI (N=10; ≥3mo post-TBI; able to ambulate 3.05m with or without assistance; median age, 35.4y; interquartile range, 23.5–46y; median time post-TBI, 9.91y; interquartile range, 6.3–14.2y). Follow-up data were collected for all participants. Interventions Twenty days (5d/wk for 4wk), with 150min/d of repetitive, task-specific training equally divided among balance; gait training; and strength, coordination, and range. Main Outcome Measures Pain and fatigue were recorded before and after each session to assess feasibility. Treatment outcomes were assessed before training (pre), after 10 sessions (interim), after 20 sessions (post), and at 3-months follow-up and included the Berg Balance Scale and gait speed. Results Participants averaged 150.1±2.7 minutes per session. Median presession and postsession pain scores were 0 (out of 10) for 20 sessions; median presession fatigue scores ranged from 0 to 2.5 (out of 10); and postsession scores ranged from 3 to 5.5 (out of 10). Four outcome measures demonstrated significant improvement from the pretest to interim, with 7 out of 10 participants exceeding the minimal detectable change (MDC) for fast walking speed. At the posttest, 2 additional measures were significant, with more participants exceeding the MDCs. Changes in fast walking speed and Timed Up and Go test were significant at follow-up. Conclusions Limited fluctuations in pain and fatigue scores indicate feasibility of IMT in this population. Participants demonstrated improvements in walking speed, mobility, and balance postintervention and maintained gains in fast walking speed and mobility at 3 months.

The purpose of this study was to provide novel information regarding the concurrent validity (primary aim) and reliability (secondary aim) of walking speed (WS) calculated via the GAITRite electronic walkway system and 3 meter walk test (3MWT) in the chronic stroke population. The 3MWT is a feasible option for clinicians working in environments where space is limited. Psychometric properties of the test have not been established. Participants with chronic stroke were stratified into three groups: (1) household ambulators (HA) (self-selected WS 0.4 m/s, 12 participants, 31 observations); (2) limited community ambulators (LCA) (self-selected WS 0.4-0.8 m/s, 24 participants, 60 observations); and (3) community ambulators (CA) (self-selected WS 0.8 m/s, 26 participants, 71 observations). Three consecutive trials of GAITRite and 3MWT were performed at participant's self-selected WS. Average WS measurements differed significantly (p 0.05) between GAITRite and 3MWT for all three groups. HA group: GAITRite 0.25 (0.11) m/s, 3MWT 0.27 (0.11) m/s; LCA group: GAITRite 0.56 (0.11) m/s, 3MWT 0.52 (0.10) m/s; CA group: GAITRite 1.03 (0.16) m/s, 3MWT 0.89 (0.15) m/s. Both WS measures had excellent within-session reliability (ICC's ranging from 0.85 to 0.97, SEM95 from 0.04 to 0.12 m/s and MDC95 from 0.05 to 0.16 m/s). Reliability was highest for HA on both measures. Although both the 3MWT and the GAITRite are reliable measures of WS for individuals with chronic stroke, the two measures do not demonstrate concurrent validity.