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Objective To examine the association between activity limitation stages and patient satisfaction and perceived quality of medical care among younger Medicare beneficiaries. Design Cross-sectional study. Setting Medicare Current Beneficiary Survey (MCBS) for calendar years 2001-2011. Participants A population-based sample (N=9323) of Medicare beneficiaries Interventions Not applicable. Main Outcome Measures MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physician (PCP), interpersonal skills of PCP, and quality of information provided by PCP. Persons were classified into an activity limitation stage (0-IV) which was derived from self-reported difficulty performing activities of daily living (ADL) and instrumental activities of daily living (IADL). Results Compared to beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (95% confidence intervals) for stage I (mild) to stage IV (complete) for satisfaction with access barriers ranged from 0.62 (0.53-0.72) at stage I to a minimum of 0.31 (0.22-0.43) at stage IV. Similarly, compared to beneficiaries at IADL stage 0, satisfaction with access barriers ranged from 0.66 (0.55-0.79) at stage I to a minimum of 0.36 (0.26-0.51) at stage IV. Satisfaction with care coordination and quality and perceived quality of medical care were not associated with activity limitation stages. Conclusions Younger Medicare beneficiaries with disabilities reported decreased satisfaction with access to medical care, highlighting the need to improve access to health care and human services and to enhance workforce capacity to meet the needs of this patient population.

OBJECTIVE: We sought to develop a risk scoring system for predicting functional deterioration, institutionalization, and mortality. Identifying predictors of poor health outcomes informs clinical decision-making, service provision, and policy development to address the needs of persons at greatest risk for poor health outcomes. DESIGN: Cohort study with 21,257 community-dwelling Medicare beneficiaries aged 65 years and older who participated in the 2001–2008 Medicare Current Beneficiary Survey. Derivation of the model was conducted in 60% of the sample and validated in the remaining 40%. Multinomial logistic regression model generated β-coefficients which were utilized to create a risk scoring system. Our outcome was instrumental activity of daily living stage transitions (stable/improved function and functional deterioration), institutionalization, or mortality over two years of follow-up. RESULTS: A total of 18 factors were identified for functional deterioration (p

Background Significant disparities in health care access and quality persist between persons with disabilities (PWD) and persons without disabilities (PWOD). Little research has examined recommendations of patients and providers to improve health care for PWD. Objective We sought to explore patient and health care provider recommendations to improve health care access and quality for PWD through focus groups in the physical world in a community center and in the virtual world in an online community. Methods In all, 17 PWD, 4 PWOD, and 6 health care providers participated in 1 of 5 focus groups. Focus groups were conducted in the virtual world in Second Life® with Virtual Ability, an online community, and in the physical world at Agape Community Center in Milwaukee, WI. Focus group data were analyzed using a grounded theory methodology. Results Themes that emerged in focus groups among PWD and PWOD as well as health care providers to improve health care access and quality for PWD were: promoting advocacy, increasing awareness and knowledge, improving communication, addressing assumptions, as well as modifying and creating policy. Many participants discussed political empowerment and engagement as central to health care reform. Conclusions Both PWD and PWOD as well as health care providers identified common themes potentially important for improving health care for PWD. Patient and health care provider recommendations highlight a need for modification of current paradigms, practices, and approaches to improve the quality of health care provision for PWD. Participants emphasized the need for greater advocacy and political engagement.

OBJECTIVE Activity of daily living stages and instrumental activity of daily living stage have demonstrated associations with mortality and health service use among older adults. This cohort study aims to assess the associations of premorbid activity limitation stages with acute hospital discharge disposition among community-dwelling older adults. DESIGN Study participants were Medicare beneficiaries aged 65 yrs or older who enrolled in the Medicare Current Beneficiary Survey between 2001 and 2009. Associations of premorbid stages with discharge dispositions were estimated with multinomial logistic regression models adjusted for covariates. RESULTS The proportions of elderly Medicare patients discharged to home with self-care, home with services, postacute care facilities, and other dispositions were 59%, 15%, 19%, and 7%, respectively. The following adjusted relative risk ratios and 95% confidence intervals of postacute care facilities versus home with self-care discharge increased with higher premorbid activity limitation stages (except nonfitting stage III): 1.7 (1.5-2.0), 2.4 (2.0-2.9), 2.4 (1.9-3.0), and 2.5 (1.6-4.1) for activity of daily living stages I-IV; a similar pattern was found for instrumental activity of daily living stages. The adjusted relative risk ratios of discharge to home with services also increased with higher premorbid activity limitation stages compared with no limitation. CONCLUSIONS Routinely assessed activity limitation stages predict posthospitalization discharge disposition among older adults and may be used to anticipate postacute care and services use by elderly Medicare beneficiaries.

Purpose The ability to predict mortality and admission to acute care hospitals, skilled nursing facilities (SNFs), and long-term care (LTC) facilities in the elderly and how it varies by activity of daily living (ADL) and instrumental ADL (IADL) status could be useful in measuring the success or failure of economic, social, or health policies aimed at disability prevention and management. We sought to derive and assess the predictive performance of rules to predict 3-year mortality and admission to acute care hospitals, SNFs, and LTC facilities among Medicare beneficiaries with differing ADL and IADL functioning levels. Methods Prospective cohort using Medicare Current Beneficiary Survey data from the 2001 to 2007 entry panels. In all, 23,407 community-dwelling Medicare beneficiaries were included. Multivariable logistic models created predicted probabilities for all-cause mortality and admission to acute care hospitals, SNFs, and LTC facilities, adjusting for sociodemographics, health conditions, impairments, behavior, and function. Results Sixteen, 22, 14, and 14 predictors remained in the final parsimonious model predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission, respectively. The C-statistic for predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission was 0.779, 0.672, 0.753, and 0.826 in the ADL activity limitation stage development cohorts, respectively, and 0.788, 0.669, 0.748, and 0.799 in the ADL activity limitation stage validation cohorts, respectively. Conclusions Parsimonious models can identify elderly Medicare beneficiaries at risk of poor outcomes and can aid policymakers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.

Many Medicare beneficiaries perceive barriers to receiving healthcare, although the consequences are unknown. Facilitators can aid in the receipt of healthcare services. The objective was to assess the relationship between perceived facilitators and barriers to healthcare and actual receipt of recommended medical care among elderly beneficiaries.A cohort study using data from the 2001-2008 entry panels of the Medicare Current Beneficiary Survey that included 24,607 community-dwelling beneficiaries 65 years of age and older. Surveys elicited perceptions of healthcare with respect to: care coordination and quality; access to medical care; getting or delaying healthcare because of financial reasons; transportation; and usual source of care. The outcome was receipt of recommended medical care, expressed as an aggregate of 38 indicators covering initial evaluation, diagnostic tests, therapeutic interventions, hospitalization follow-up, and routine preventive care. Multivariable survey logistic regression produced odds ratios (ORs) and 95% confidence intervals (CIs) for receipt of recommended medical care, adjusted for sociodemographics, insurance, comorbidities, and disability.Beneficiaries who reported having trouble getting or reported delaying healthcare because of financial reasons (barrier) (adjusted OR=0.79, 95% CI: 0.73-0.86) and those who reported having no usual source of care (facilitator) (adjusted OR=0.55, 95% CI: 0.48-0.63) were less likely to receive recommended medical care.Survey data that capture patient perceptions of facilitators and barriers to healthcare may be useful for identifying system factors that affect timely receipt of recommended medical care. This information can inform the design of policies and programs to improve the healthcare of older adults.

The aim of this study was to examine whether activity limitation stages were associated with patient-reported trouble getting needed health care among Medicare beneficiaries.This was a population-based study (n = 35,912) of Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey for years 2001-2010. Beneficiaries were classified into an activity limitation stage from 0 (no limitation) to IV (complete) derived from self-reported or proxy-reported difficulty performing activities of daily living and instrumental activities of daily living. Beneficiaries reported whether they had trouble getting health care in the subsequent year. A multivariable logistic regression model examined the association between activity limitation stages and trouble getting needed care.Compared with beneficiaries with no limitations (activities of daily living stage 0), the adjusted odds ratios (ORs) (95% confidence intervals [CIs]) for stage I (mild) to stage IV (complete) for trouble getting needed health care ranged from OR = 1.53 (95% CI, 1.32-1.76) to OR = 2.86 (95% CI, 1.97-4.14). High costs (31.7%), not having enough money (31.2%), and supplies/services not covered (24.2%) were the most common reasons for reporting trouble getting needed health care.Medicare beneficiaries at higher stages of activity limitations reported trouble getting needed health care, which was commonly attributed to financial barriers.

Prediction models can help clinicians provide the best and most appropriate care to their patients and can help policy makers design services for groups at highest risk for poor outcomes.To develop prediction models identifying both risk factors and protective factors for functional deterioration, institutionalization, and death.Cohort study using data from the Medicare Current Beneficiary Survey (MCBS).Community survey.This study included 21,264 Medicare beneficiaries 65 years of age and older who participated in the MCBS from the 2001-2008 entry panels and were followed up for 2 years.The index was derived in 60% and validated in the remaining 40%. β Coefficients from a multinomial logistic regression model were used to derive points, which were added together to create scores associated with the outcome.The outcome was activity of daily living (ADL) stage transitions over 2 years following entry into the MCBS. Beneficiaries were categorized into 1 of 4 outcome categories: stable or improved function, functional deterioration, institutionalization, or death.Our model identified 16 factors for functional deterioration (age, gender, education, living arrangement, dual eligibility, proxy use, Alzheimer disease/dementia, angina pectoris/coronary heart disease, diabetes, emphysema/asthma/chronic obstructive pulmonary disease, mental/psychiatric disorder, Parkinson disease, stroke/brain hemorrhage, hearing impairment, vision impairment, and baseline ADL stage) after backward selection (P.05). Compared to stable or improved function, the risk of functional deterioration ranged from ≤1 to ≥6, ≤4 to ≥22 for the risk of institutionalization, and ≤3 to ≥16 for the risk of death.Predictive indices, or point and scoring systems used to predict outcomes, can identify elderly Medicare beneficiaries at risk for functional deterioration, institutionalization, and death and can aid policy makers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.III.

Purpose To examine the association between vision impairment and all-cause hospitalization among elderly Medicare beneficiaries. Methods A population-based study (N = 22,681) of community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Current Beneficiary Survey for the years 2001-2007. Beneficiaries were classified into self-reported presence of vision impairment versus no vision impairment. Inpatient hospitalizations were identified using Medicare claims data. A multivariable Cox proportional hazard model examined the association between presence of vision impairment and time to first hospitalization within 3 years of survey entry after adjusting for sociodemographics, comorbidities, hearing impairment, and activity limitation stages derived from difficulty performing the activities of daily living. Results Medicare beneficiaries who self-reported the presence of vision impairment were significantly more likely to be hospitalized over 3 years compared to beneficiaries without vision impairment even after adjustment for potentially influential covariates (hazard ratio = 1.14 and 95% confidence interval: 1.05-1.23). Conclusions Medicare beneficiaries with self-reported vision impairment were at higher risk of hospitalization during a 3-year period. Further research may identify reasons that are amenable to policy interventions.

Objective To examine how patient satisfaction with care coordination and quality and access to medical care influence functional improvement or deterioration (activity limitation stage transitions), institutionalization, or death among older adults. Design National representative sample with 2-year follow-up. Setting Medicare Current Beneficiary Survey from calendar years 2001 to 2008. Participants Community-dwelling adults (N=23,470) aged ≥65 years followed for 2 years. Interventions Not applicable. Main Outcome Measures A multinomial logistic regression model taking into account the complex survey design was used to examine the association between patient satisfaction with care coordination and quality and patient satisfaction with access to medical care and activities of daily living (ADL) stage transitions, institutionalization, or death after 2 years, adjusting for baseline socioeconomics and health-related characteristics. Results Out of 23,470 Medicare beneficiaries, 14,979 (63.8% weighted) remained stable in ADL stage, 2508 (10.7% weighted) improved, 3210 (13.3% weighted) deteriorated, 582 (2.5% weighted) were institutionalized, and 2281 (9.7% weighted) died. Beneficiaries who were in the top quartile of satisfaction with care coordination and quality were less likely to be institutionalized (adjusted relative risk ratio [RRR], .68; 95% confidence interval [CI], .54–.86). Beneficiaries who were in the top quartile of satisfaction with access to medical care were less likely to functionally deteriorate (adjusted RRR, .87; 95% CI, .79–.97), be institutionalized (adjusted RRR, .72; 95% CI, .56–.92), or die (adjusted RRR, .86; 95% CI, .75–.98). Conclusions Knowledge of patient satisfaction with medical care and risk of functional deterioration may be helpful for monitoring and addressing disability-related health care disparities and the effect of ongoing policy changes among Medicare beneficiaries.

Background Activity limitation stages based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are associated with 3-year mortality in elderly Medicare beneficiaries, yet their associations with hospitalization risk in this population have not been studied. Objective To examine the independent association of activity limitation stages with risk of hospitalization within a year among Medicare beneficiaries aged 65 years and older. Design Cohort study. Setting Community. Participants A total of 9447 community-dwelling elderly Medicare beneficiaries from the Medicare Current Beneficiary Survey for years 2005-2009. Methods Stages were derived for ADLs and IADLs separately. Associations of stages with time to first hospitalization and time to recurrent hospitalizations within a year were assessed with Cox proportional hazards models, with which we accounted for baseline sociodemographics, smoking status, comorbidities, and the year of survey entry. Main Outcomes Time to first hospitalization and time to recurrent hospitalizations within 1 year. Principle Findings The adjusted risk of first hospitalization increased with greater activity limitation stages (except stage III). The hazard ratios (95% confidence intervals) for ADL stages I-IV compared with stage 0 (no limitations) were 1.49 (1.36-1.63), 1.61 (1.44-1.80), 1.54 (1.35-1.76), and 2.06 (1.61-2.63), respectively. The pattern for IADL stages was similar. For recurrent hospitalizations, activity limitation stages were associated with the risk of the first hospitalization but not with subsequent hospitalizations. Conclusion Activity limitation stages are associated with the risk of first hospitalization in the subsequent year among elderly Medicare beneficiaries. Stages capture clinically interpretable profiles of ADL and IADL functionality and describe preserved functions and activity limitation in an aggregated measure. Stage can inform interventions to ameliorate disability and thus reduce the risk of a subsequent hospitalization in this population. Level of Evidence IV

Objective To determine whether higher activity of daily living (ADL) limitation stages are associated with increased risk of hospitalization, particularly for ambulatory care sensitive (ACS) conditions. Data Source Secondary data analysis, including 8,815 beneficiaries from 2005 to 2006 Medicare Current Beneficiary Survey (MCBS). Study Design ADL limitation stages (0-IV) were determined at the end of 2005. Hospitalization rates were calculated for 2006 and age adjusted using direct standardization. Multivariate negative binomial regression, adjusting for baseline demographic and health characteristics, with the outcome hospitalization count was performed to estimate the adjusted rate ratio of ACS and non-ACS hospitalizations for beneficiaries with ADL stages > 0 compared to beneficiaries without limitations. Data Collection Baseline ADL stage and health conditions were assessed using 2005 MCBS data and count of hospitalization determined using 2006 MCBS data. Principal Findings Referenced to stage 0, the adjusted rate ratios (95 percent confidence interval) for stage I to stage IV ranged from 1.9 (1.4–2.5) to 4.1 (2.2–7.8) for ACS hospitalizations compared with from 1.6 (1.3–1.9) to 1.8 (1.4–2.5) for non-ACS hospitalizations. Conclusions Hospitalization rates for ACS conditions increased more dramatically with ADL limitation stage than did rates for non-ACS conditions. Adults with ADL limitations appear particularly vulnerable to potentially preventable hospitalizations for conditions typically manageable in ambulatory settings.

Objective To examine whether patient satisfaction and perceived quality of medical care are related to stages of activity limitations among older adults. Design Cross-sectional study. Setting Medicare Current Beneficiary Survey (MCBS) for calendar years 2001 to 2011. Participants A population-based sample (N=42,584) of persons aged ≥65 years living in the community. Interventions Not applicable. Main Outcome Measures MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physicians, interpersonal skills of primary care physicians, and quality of information provided by primary care physicians. Persons were classified into a stage of activity limitation (0–IV) derived from self-reported difficulty levels performing activities of daily living (ADL) and instrumental ADL. Results Compared with older beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (ORs) for stage I (mild) to stage III (severe) for satisfaction with care coordination and quality ranged from .85 (95% confidence interval [CI], .80–.92) to .79 (95% CI, .70–.89). Compared with ADL stage 0, satisfaction with access barriers ranged from OR=.81 (95% CI, .76–.87) at stage I to a minimum of OR=.67 (95% CI, .59–.76) at stage III. Similarly, compared with older beneficiaries at ADL stage 0, perceived quality of the technical skills of their primary care physician ranged from OR=.87 (95% CI, .82–.94) at stage I to a minimum of OR=.81 (95% CI, .72–.91) at stage III. Conclusions Medicare beneficiaries at higher stages of activity limitation, although not necessarily the highest stage of activity limitation, reported less satisfaction with medical care.

To examine the relationship between estimated travel time to admitting hospital and mortality for veterans with acute ischemic stroke, controlling for patient demographic, clinical, facility-level variables, as well as select in-hospital treatments and procedures.A longitudinal observational population-based study. Information on all veterans discharged from a Veterans Administration Medical Center (VAMC) with an ischemic stroke diagnosis between October 1, 2006 and September 30, 2008 were examined. A total of 10,430 patients met the inclusion criteria for the study. Unadjusted differences between patients who died during the hospital stay versus those patients who were discharged alive, used χ analyses or Student t tests, as appropriate. Multivariable logistic regression was used to control for confounding effects of patient, treatment, and facility characteristics to examine the relationship between travel time and the bivariate outcome of in-hospital mortality.Travel time to the admitting VAMC, our primary variable of interest regarding the effect on in-hospital mortality, after adjusting for the patient, treatment, and facility characteristics showed that longer travel times significantly increased the odds of in-hospital mortality. Travel times ≥ 90 minutes had increased odds of in-hospital mortality (OR=1.476; 95% CI, 1.067-2.042) as compared with30 minutes.Even after adjusting for the confounding effects of patient, treatment, and facility characteristics, travel time from home to admitting VAMC was significantly associated with in-hospital mortality.

Background Stages of activity limitation based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) have been found to predict mortality in persons aged 70 years and older but have not been examined in Medicare beneficiaries aged 65 years and older using data that are routinely collected. Objective To examine the association between functional stages based on items of ADLs and IADLs with 3-year mortality in Medicare beneficiaries aged 65 years and older, accounting for baseline sociodemographics, health status, smoking, subjective health, and psychological well-being. Design A cohort study using the Medicare Current Beneficiary Survey (MCBS) and associated health care utilization data. Setting Community administered survey. Participants The study included 9698 Medicare beneficiaries aged 65 years and older who participated in the MCBS in 2005-2007. Main Outcome Measures Death within 3 years of cohort entry. Results The overall mortality rate was 3.6 per 100 person years, and 3-year cumulative mortality was 10.3%. Unadjusted 3-year mortality was monotonically associated with both ADL stage and IADL stage. Adjusted 3-year mortality was associated with ADL and IADL stages, except that in some models the hazard ratio for stage III (which includes persons with atypical activity limitation patterns) was numerically lower than that for stage II. Conclusion We found nearly monotonic relationships between ADL and IADL stage and adjusted 3-year mortality. These findings could aid in the development of population health approaches and metrics for evaluating the success of alternative economic, social, or health policies on the longevity of older adults with activity limitations.

Objective To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning. Design Retrospective cohort study. Setting Veterans Affairs Medical Centers throughout the United States. Participants Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment. Main Outcome Measure Achievement of physical grade IV or above at final rehabilitation assessment. Results Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, ≤69 years=2, 70-79 years=1, ≥80 years=0; initial physical grade, I=0, II=3, III=4; initial cognitive stage, I or II=0, III=2, IV or V=3, VI or VII=4; absence of renal failure=1; no serious nutritional compromise=3; the type of rehabilitation services received, consultative=0, comprehensive=4; and recovery time between admission and discharge physical grade assessment, 1-2 days=0, 3-7 days=4, and ≥8 days=5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant ( P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score ≥9), second (score = 10-12), third (score = 13-15), and fourth (score >15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively. Conclusion By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.

OBJECTIVE This study aimed to examine whether activity limitation stages are associated with admission to facilities providing long-term care (LTC). DESIGN Cohort study using Medicare Current Beneficiary Survey data from the 2005-2009 entry panels. A total of 14,580 community-dwelling Medicare beneficiaries 65 years or older were included. Proportional subhazard models examined associations between activity limitation stages and time to first LTC admission, adjusting for baseline sociodemographics and health conditions. RESULTS The weighted annual rate of LTC admission was 1.1%. In the adjusted model, compared to activity of daily living (ADL) stage 0, the hazard ratios (95% confidence intervals [CIs]) were 2.0 (1.5-2.7), 3.9 (2.9-5.4), 3.6 (2.5-5.3), and 4.7 (2.5-9.0) for ADL stage I (mild limitation), ADL stage II (moderate limitation), ADL stage III (severe limitation), and ADL stage IV (complete limitation), respectively. Compared to instrumental ADL (IADL) stage 0, the hazard ratios, and 95% CIs for IADL stages I to IV were 2.0 (1.4-2.7), 3.7 (2.6-5.4), 4.6 (3.3-6.5), and 7.6 (4.6-12.3), respectively. CONCLUSIONS Activity limitation stages are strongly associated with future admission to LTC and may therefore be useful in identifying specific supportive care needs among vulnerable older community-dwelling adults, which may reduce or the delay need for admission to LTC.

Background Stages quantify severity like conventional measures but further specify the activities that people are still able to perform without difficulty. Objective To develop Activity Limitation Stages for defining and monitoring groups of adult community-dwelling Medicare beneficiaries. Design Cross-sectional. Setting Community. Participants There were 14,670 respondents to the 2006 Medicare Current Beneficiary Survey. Methods Stages were empirically derived for the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs) by profiling the distribution of performance difficulties as reported by beneficiaries or their proxies. Stage prevalence estimates were determined, and associations with demographic and health variables were examined for all community-dwelling Medicare beneficiaries. Main Outcome Measurements ADL and IADL stage prevalence. Results Stages (0-IV) define 5 groups across the separate ADL and IADL domains according to hierarchically organized profiles of retained abilities and difficulties. For example, at ADL-I, people are guaranteed to be able to eat, toilet, dress, and bathe/shower without difficulty, whereas they experience limitations getting in and out of bed or chairs and/or difficulties walking. In 2006, an estimated 6.0, 2.9, 2.2, and 0.5 million beneficiaries had mild (ADL-I), moderate (ADL-II), severe (ADL-III), and complete (ADL-IV) difficulties, respectively, with estimates for IADL stages even higher. ADL and IADL stages showed expected associations with age and health-related concepts, supporting construct validity. Stages showed the strongest associations with conditions that impair cognition. Conclusions Stages as aggregate measures reveal the ADLs and IADLs that people are still able to do without difficulty, along with those activities in which they report having difficulty, consequently emphasizing how groups of people with difficulties can still participate in their own lives. Over the coming decades, stages applied to populations served by vertically integrated clinical practices could facilitate large-scale planning, with the goal of maximizing personal autonomy among groups of community-dwelling people with disabilities.

Objective By using data from Department of Veterans Affairs (VA) national databases, this article presents and internally validates a 1-year all-cause mortality prediction index after hospitalization for acute stroke. Design An observational cohort. Setting VA medical centers. Participants Veterans with a diagnosis of a new stroke who were discharged between October 1, 2006, and September 30, 2008. Main Outcome Measure Death due to any cause that occurred between the index hospital discharge date and the 1-year anniversary of that date. Results Within 1-year after discharge, 1542 (12.3%) of the total 12,565 patients had died. Seventeen risk factors known at the point of hospital discharge remained in the predictive model of 1-year postdischarge mortality after backward selection, including advanced age, admission from extended care, type of stroke, 8 comorbid conditions, 4 types of procedures that occurred during the index hospitalization, hospital length of stay (longer than 3 weeks), and discharge location. We assigned a score to each variable in the final model and a risk score was determined for each patient by adding up the points for all risk factors present. According to these risk scores, the patients were divided into approximate quartiles that yielded low, moderate, high, and highest mortality likelihood strata. The risk of 1-year mortality ranged from 2.24% in the lowest quartile to 29.50% in the highest quartile in the derivation cohort and from 2.11%-30.77% in the validation cohort. Model discrimination demonstrated an area under the receiver operating characteristic curve of 0.785 in the derivation cohort and 0.787 in the validation cohort. The Hosmer-Lemeshow goodness of fit indicated that the model fit was adequate ( P = .69). Conclusion When using readily available data, a simple index that stratifies stroke patients at hospital discharge according to low, moderate, high, and highest likelihood of all-cause 1-year mortality is feasible and can inform the postdischarge planning process, depending on level of risk.

Objectives To study the degree to which initial physical grades and cognitive stages of independence assessed by physical medicine and rehabilitation (PM&R) staff early after hospitalization for acute stroke relate to the decision to either provide rehabilitation in consultation or admission to a specialized rehabilitation unit (SRU) for comprehensive, high-intensity, multidisciplinary rehabilitation. Design An observational study. Setting Early rehabilitation assessment by PM&R staff during patients' acute hospitalization for stroke in 112 Veterans Affairs facilities. Patients The sample included 8,783 veterans who were assessed by PM&R staff. Methods Shortly after hospital admission, functional status was determined according to 7 physical grades and 7 cognitive stages of increasing independence. Patients' physical grades and cognitive stages ranged at initial PM&R assessment from the lowest and most dependent “I” through intermediate “II, III, IV, V, or VI,” and ended with the highest at total independence “VII.” To assess the statistically independent effects of physical grade and cognitive stage, a multivariable generalized estimating equation was applied to account for within Veterans Affairs facilities correlation and to adjust for demographics, stroke type, comorbidities, clinical events before PM&R assessment, and facility-related factors. Main Outcome Measurements The decision to admit patients to an SRU for comprehensive rehabilitation. Results Only 11.2% of those patients assessed after stroke were admitted to an SRU after the acute management phase. After statistical adjustment, patients at the lowest physical grade (I) of independence had a 9-fold increased odds of admission to an SRU compared with those at the highest combined physical grades VI/VII (adjusted odds ratio 9.15, 95% confidence interval 4.31-19.39). In contrast, patients at intermediate cognitive stages of independence were the most likely to be admitted to an SRU. The presence of an SRU within the treating Veterans Affairs facility was strongly related to admission. Conclusions Patients' physical grades and cognitive stages assessed early after stroke are strong determinants of referral for comprehensive rehabilitation.

Amputation is catastrophic and costly, resulting in loss of mobility and independence with the possibility of expensive treatment or being hospitalized for months. In an era of cost containment, policy makers are concerned with maintaining care quality while limiting expenditures.1 Lower extremity amputation accounts for more than $250 million in direct expenditures each year in healthcare costs in the US.2 Thus, understanding the factors associated with cost is critical to informed decision-making about maximizing service cost-efficiency, benefit, and positive outcomes. The objectives of this study were to identify patient- and facility-level factors associated with total inpatient costs and length of stay (LOS) among veterans who underwent lower extremity amputation in Veterans Affairs Medical Centers (VAMCs) nationwide. Our prior work documents the benefits of rehabilitation services in terms of survival, home discharge, receipt of a prescription for a prosthetic limb, and gains in functional improvement among veterans who underwent lower extremity amputation.3, 4 Andersen's Behavioral Model of Health Service Use5 formed the foundation for this work and was used to conceptualize the factors that determine need and lead to the use of health services measured as patients' total inpatient costs and LOS. Demographic factors were considered predisposing, while diagnostic and other clinical information were seen as driving health services need. We recognized that an understanding of the predisposing and need factors associated with total inpatient costs for these patients, including rehabilitation as an integral component of the overall continuum of care, could helps shed light on the quality implications of ongoing pressures to reduce both total inpatient costs and LOS. We hypothesized that there would be similar predisposing and need factors associated with total inpatient costs and LOS, but there could also be some differences among the factors associated with total inpatient costs and LOS. Limited information is available in the literature regarding the factors associated with total inpatient costs and LOS among veterans who undergo lower extremity amputation. Prior studies have shown that greater comorbidity is related to adverse outcomes such as in-hospital mortality and one-year survival,6-10 and that patients with more severe illnesses oftentimes require hospitalizations for a long period of time.6-8, 11 With respect to patients with lower extremity amputations specifically, information is quite limited. Only one study showed that LOS was associated with patients' payer source, amputation level, and injury characteristics.12 We were unable to find more recent studies on factors associated with total inpatient costs or LOS among veterans who underwent lower extremity amputation.

Background Receipt of recommended care among older adults is generally low. Findings regarding service use among persons with disabilities supports the notion of disparities but provides inconsistent evidence of underuse of recommended care. Objective To examine the extent to which receipt of recommended care among older Medicare beneficiaries varies by disability status, using a newly developed staging method to classify individuals according to disability. Methods In a cohort study, we included community-dwelling Medicare beneficiaries aged 65 and older who participated in the Medicare Current Beneficiary Survey between 2001 and 2008. Logistic regression modeling assessed the association of receiving recommended care on 38 indicators across different activity limitation stages. Results Nearly one out of every three elderly Medicare beneficiaries did not receive overall recommended care. Adjusted odds ratios (ORs) revealed a decrease in use of recommended care with increasing activity limitation stage. For instance, ORs (95% CIs) across mild, moderate, severe and complete limitation stages (stages I–IV) compared to no limitation (stage 0) in ADLs were 0.99 (0.94–1.05), 0.89 (0.83–0.95), 0.81 (0.75–0.89) and 0.56 (0.46–0.68). Disparities in receipt of recommended care by disability stage were most marked for care related to post-hospitalization follow-up and, to a lesser degree, care of chronic conditions and preventive care. Conclusions Elderly beneficiaries at higher activity limitation stages experienced substantial disparities in receipt of recommended care. Tailored interventions may be needed to reduce disparities in receipt of recommended medical care in this population.

Background Concerns about using Instrumental Activities of Daily Living (IADLs) in national surveys come up frequently in geriatric and rehabilitation medicine due to high rates of non-performance for reasons other than health. We aim to evaluate the effect of different strategies of classifying “does not do” responses to IADL questions when estimating prevalence of IADL limitations in a national survey. Methods Cross-sectional analysis of a nationally representative sample of 13,879 non-institutionalized adult Medicare beneficiaries included in the 2010 Medicare Current Beneficiary Survey (MCBS). Sample persons or proxies were asked about difficulties performing six IADLs. Tested strategies to classify non-performance of IADL(s) for reasons other than health were to 1) derive through multiple imputation, 2) exclude (for incomplete data), 3) classify as “no difficulty,” or 4) classify as “difficulty.” IADL stage prevalence estimates were compared across these four strategies. Results In the sample, 1853 sample persons (12.4 % weighted) did not do one or more IADLs for reasons other than physical problems or health. Yet, IADL stage prevalence estimates differed little across the four alternative strategies. Classification as “no difficulty” led to slightly lower, while classification as “difficulty” raised the estimated population prevalence of disability. Conclusions These analyses encourage clinicians, researchers, and policy end-users of IADL survey data to be cognizant of possible small differences that can result from alternative ways of handling unrated IADL information. At the population-level, the resulting differences appear trivial when applying MCBS data, providing reassurance that IADL items can be used to estimate the prevalence of activity limitation despite high rates of non-performance.

To determine patient, treatment, or facility characteristics that influence decisions to initiate a rehabilitation assessment before transtibial or transfemoral amputation within the Veterans Affairs (VA) health care system.Retrospective database study.VA medical centers.A total of 4226 veterans with lower extremity amputations discharged from a VA medical center between October 1, 2002, and September 30, 2004.Evidence of a preoperative rehabilitation assessment after the index surgical stay admission but before the surgical date.Evidence was found that 343 of 4226 veterans (8.12%) with lower extremity amputations received preoperative rehabilitation assessments. Veterans receiving preoperative rehabilitation were more likely to be older, admitted from home, or transferred from another hospital. Patients who underwent surgical amputation at smaller-sized hospitals or in the South Central or Mountain Pacific regions were more likely to receive preoperative rehabilitation compared with patients in mid-sized hospitals or in the Northeast, Southeast, or Midwest regions. Patients with evidence of paralysis, patients treated in facilities with programs accredited by the Commission on Accreditation of Rehabilitation Facilities (P.01), and patients in the second data wave were less likely to receive preoperative rehabilitation. After accounting for patient-, treatment-, and facility-level structural characteristics, we found that older patients were more likely to receive preoperative rehabilitation services (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01-1.02). Patients with a contributing amputation etiology of a previous amputation complication were more likely to receive preoperative consultation rehabilitation services (OR 1.50, 95% CI 1.02-2.19) compared with patients who did not have this etiology. Compared with patients treated in the Southeast region of the United States, those treated in the South Central region (OR 2.52, 95% CI 1.82-3.48) or Mountain Pacific region (OR 1.62, 95% CI 1.11-2.37) were more likely to receive preoperative consultation rehabilitation services. Patients with evidence of paralysis were less likely to receive preoperative rehabilitative services compared with patients who did not have this condition (OR 0.29, 95% CI 0.09-0.93), and patients treated in mid-sized hospitals also were less likely to receive preoperative rehabilitative services compared with patients treated in smaller-sized facilities (OR 0.38, 95% CI 0.27-0.53). Veterans in the second data year were less likely to receive services compared with patients in the first year (OR 0.74, 95% CI 0.58-0.94).Rehabilitation assessment before lower extremity amputation surgery is a rare occurrence in the VA health care system. Practice patterns appear to be driven by location and not by patient characteristics.

OBJECTIVE: The aim of this study was to explore how activity of daily living (ADL) stages and the perception of unmet needs for home accessibility features associate with a history of falling. DESIGN: Participants were from a nationally representative sample from the Second Longitudinal Survey of Aging conducted in 1994. The sample included 9250 community-dwelling persons 70 yrs or older. The associations of ADL stage and perception of unmet needs for home accessibility features with a history of falling within the past year (none, once, or multiple times) were explored after accounting for sociodemographic characteristics and comorbidities using a multinomial logistic regression model. RESULTS: The adjusted relative risk of falling more than once peaked at 4.30 (95% confidence interval, 3.29-5.61) for persons with severe limitation (ADL-III) compared those with no limitation (ADL-0) then declined for those at complete limitation (ADL-IV). The adjusted relative risks of falling once and multiple times were 1.42 (95% confidence interval, 1.07-1.87) and 1.85 (95% confidence interval, 1.44-2.36), respectively, for those lacking home accessibility features. CONCLUSIONS: Risk of falling appeared greatest for those whose homes lacked accessibility features and peaked at intermediate ADL limitation stages, presumably at a point when people have significant disabilities but sufficient function to remain partially active. Language: en

Objectives: To examine the independent association between five stages of activities of daily living (ADLs) and mortality after accounting for known diagnostic and sociodemographic risk factors. Design: For five stages of ADLs (0 to IV), determined according to the severity and pattern of ADL limitations, unadjusted life expectancies and adjusted associations with mortality were estimated using a Cox proportional hazards regression model. Setting: Community. Participants: Nine thousand four hundred forty-seven participants aged 70 and older from the second Longitudinal Study of Aging. Measurements: One-, 5-, and 10-year survival and time to death. Results: Median life expectancy was 10.6 years for participants with no ADL limitations and 6.5, 5.1, 3.8, and 1.6 years for those at ADL stages I, II, III, and IV, respectively. The sociodemographic- and diagnostic-adjusted hazard of death at 1 year was five times as great at stage IV as at stage 0 (hazard ratio = 5.6, 95% confidence interval = 3.8�8.3). The associations between ADL stage and mortality declined over time but remained statistically significant at 5 and 10 years. Conclusion: ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.

Zhou J, Bates BE, Kurichi JE, Kwong PL, Xie D, Stineman MG. Factors influencing receipt of outpatient rehabilitation services among veterans following lower extremity amputation. Objective To determine patient-, treatment-, and facility-level characteristics associated with receiving outpatient rehabilitation services after lower extremity amputation within the Veterans Affairs (VA) system. Design Observational study. Setting All Veterans Affairs Medical Centers (VAMCs). Participants Veterans (N=4165) with lower extremity amputation discharged from VAMCs between October 1, 2002, and September 20, 2004. Interventions Not applicable. Main Outcome Measures Receipt of outpatient rehabilitation services up to 1 year postdischarge. A Cox proportional hazards model was used to determine the adjusted hazard ratio and 95% confidence interval of veterans to receive outpatient services. Results Sixty-five percent of veterans with lower extremity amputation received outpatient services. Older veterans, patients admitted for surgical amputation from extended care rather than transferred from another hospital, and those with transfemoral and/or bilateral rather than unilateral transtibial amputations were less likely to receive outpatient services. Those with serious comorbidities and those who had procedures for acute central nervous system disorders, active cardiac pathology, serious nutritional compromise, and severe renal disease during the surgical hospitalization less often initiated outpatient care. Patients who received inpatient consultative rehabilitation compared with inpatient specialized rehabilitation, and who were treated in the Northeast compared with the Southeast less often initiated outpatient care. Finally, those discharged to home or other locations rather than extended care had an initial increased likelihood of receiving outpatient service, but by 180 days postdischarge those discharged to extended care were more likely to initiate outpatient services. Conclusions Both clinical characteristics and types of rehabilitation services received appear to influence the receipt of outpatient rehabilitation services. Geographic location also affected the receipt of outpatient rehabilitation, suggesting that care patterns are not standardized across the nation.

PURPOSE OF THE STUDY: To assess the recruitment, adherence, and retention of urban elderly, predominantly African Americans to a falls reduction exercise program. DESIGN AND METHODS: The randomized controlled trial was designed as an intervention development pilot study. The goal was to develop a culturally sensitive intervention for elderly persons who suffered a fall and visited an emergency department (ED). Participants were taught exercises during 4 on-site group classes and encouraged to continue exercising at home for 12 weeks and attend additional on-site monthly classes. The protocol included a specifically designed intervention for increasing retention through trained community interventionists drawn from the participants' neighborhoods. RESULTS: The screening of 1,521 ED records after falling yielded the recruitment of 204 patients aged 65 years and older. Half were randomized into the falls prevention program. Of the 102 people in the intervention group, 92 completed the final 6-month assessment, 68 attended all on-site sessions, but only 1 reported exercising at home all 12 weeks. Those who lived alone were more likely (p = .03) and those with symptoms of depression were less likely (p = .05) to attend all on-site exercise classes. The final recruitment rate was estimated as 31.8%. The final retention rates were 90.2% and 87.3% for the intervention and control groups, respectively. IMPLICATIONS: Recruitment of frail elderly African American patients is resource intensive. Adherence to the on-site exercise classes was better than to the home-based component of the program. These findings have implications for the design of future community-based exercise programs and trials. Language: en

OBJECTIVE: To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older. DESIGN: Cross-sectional. SETTING: Community. PARTICIPANTS: Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II). MEASUREMENTS: Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV). RESULTS: ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI)=2.4�4.4) to 41.9 (95% CI=19.6�89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR=17.8, 95% CI=13.0�24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race. CONCLUSIONS: ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.

The AHRQ's Prevention Quality Indicators assume inpatient hospitalizations for certain conditions, referred as ambulatory-care sensitive (ACS) conditions, are potentially preventable and may indicate reduced access to and a lower quality of ambulatory care. Using a cohort drawn from the Medicare Current Beneficiary Survey (MCBS) linked to Medicare claims, we examined the extent to which barriers to healthcare are associated with ACS hospitalizations and related costs, and whether these associations differ by beneficiaries’ disability status. Our results indicate that the regression-adjusted cost of ACS hospitalizations for elderly Medicare beneficiaries with no disabilities was $799. This cost increased six-fold, by $5148, among beneficiaries with mild disability, by $9045 for beneficiaries with moderate disability, by $5513 for those with severe disability, and by $8557 for persons with complete disability (P

Objective To compare the recovery of mobility and self-care functions among veteran amputees according to the timing and type of rehabilitation services received. Design Observational study of inpatient rehabilitation care patterns of 2 types (specialized and consultative) with 2 timings (early and late). Setting Data from inpatient specialized rehabilitation units (SRUs) and consultative services within 95 Veterans Affairs Medical Centers across the United States during fiscal years 2003 to 2004. Patients Medical records of 1502 patients who received early or late consultative or specialized rehabilitation. Assessment of Risk Factors Hypotheses were established and general categories of negative and positive risk factors specified a priori from available clinical characteristics. Linear mixed effects models were used to model motor Functional Independence Measure (FIM) gain scores on patient-level variables accounting for the correlation within the same facility. Main Outcome Measures Recovery of activities of daily living (ADLs) and mobility (physical functioning) expressed as the magnitudes of gains in motor FIM scores achieved by rehabilitation discharge. Results After adjustment, amputees who received specialized rehabilitation had motor FIM gains that were on average 8.0 points greater than those for amputees who received consultative rehabilitation. Although patients whose rehabilitation was delayed until after discharge from the index surgical stay tended to be more clinically complex, they had gains comparable to those of patients who received early rehabilitation. Advanced age, transfemoral amputation, paralysis, serious nutritional compromise, and psychosis were associated with lower motor FIM gains. The variance for the random effect for facility was statistically significant, suggesting extraneous variation within facility that was not explainable by observed patient-level variables. Conclusion On the basis of this analysis, those patients who receive specialized rehabilitation can be expected to make comparatively greater gains than patients who receive consultative services, regardless of timing and clinical complexity. Findings highlight the need for clinicians to adjust prognostic expectations to both clinical severity and the type of rehabilitation that patients receive.

Studying outcomes after rehabilitation is critical. For persons with trauma-related amputations, Pezzin et al found that inpatient rehabilitation led to better outcomes.1 Unfortunately, outcomes after rehabilitation for persons with lower extremity (LE) amputation for nontraumatic etiologies are under studied with little knowledge about how the types or intensities of rehabilitation influence outcomes. We found that for patients with LE amputation, inpatient rehabilitation compared with no inpatient rehabilitation (regardless of type) during the acute postoperative period was associated with improved 1-year survival and greater likelihood of home discharge from the hospital.2 In this study, we determine if there are incremental benefits of receiving rehabilitation on specialized rehabilitation bed units (SRUs) (specialized) compared with rehabilitation on general medical/ surgical units (generalized) among those who received inpatient rehabilitation during the acute postoperative period. Patients who received generalized rehabilitation may have one to many sessions while hospitalized, therapy may vary from intermittent to regular sessions, and functional restoration is not the primary focus. Conversely, specialized rehabilitation occurs in designated units, which consist of a cluster of beds located in a distinct area in the hospital specifically accredited for rehabilitation services by the Commission on Accreditation of Rehabilitation Facilities (CARF). Restorative therapy typically occurs daily, with rehabilitation the primary focus. To achieve accreditation, SRUs must meet CARF’s explicitly defined standards developed to ensure high quality services. In the Veterans Health Administration (VHA), subacute and acute rehabilitation beds are considered similar, and both were categorized as SRUs if they were CARF accredited for LE amputees. Our objective was to determine the effect of receiving specialized versus generalized rehabilitation after LE amputation on 4 patient outcomes: 1-year survival, discharge home from the hospital, prescription of a prosthetic limb within 1 year post surgery, and improvement in physical functioning at rehabilitation discharge. Type of rehabilitation received can be influenced by patient- and facility-level characteristics and clinical practice variations, which may be associated with outcomes. Conclusions drawn about outcome differences that do not adjust for these factors suffer from selection bias and may be inaccurate. To adjust for selection bias due to measured patient- and facility-level characteristics, we applied propensity score (p score) risk adjustment methods.3 We conducted a sensitivity analysis to determine how the presence of an unmeasured characteristic with a moderately strong effect on the outcome and on the probability of receiving specialized would affect our findings.4,5

Bates BE, Kurichi JE, Marshall CR, Reker D, Maislin G, Stineman MG. Does the presence of a specialized rehabilitation unit in a Veterans Affairs facility impact referral for rehabilitative care after a lower-extremity amputation? Objective To determine if the presence of specialized rehabilitation units (SRUs) within Veterans Affairs medical centers (VAMC) influences access to rehabilitation services. Design Retrospective cohort analysis. Setting Two types of VAMCs: those with and without SRUs. Participants Veterans with lower-extremity amputations discharged from VAMCs between October 1, 2002, and September 30, 2003. There were a total of 2375 veterans with amputations: 99% were men; and 60% had transtibial, 40% had transfemoral, and less than 1% had hip disarticulation amputations. Nine hundred sixty-six patients (41%) were seen at a VAMC with an SRU. Interventions Not applicable. Main Outcome Measure Level of service provided expressed as: no evidence of rehabilitation during the hospitalization, generalized rehabilitation through consultation only, or admission to an SRU. Results There were no differences between patients treated at facilities with SRUs and those treated in a facility without SRU beds with respect to age, sex, marital status, source of hospital admission, or level of amputation (all P P P =.56), but were more likely to be admitted for high intensity specialty rehabilitation services (26% vs 11%, P Conclusions Although the majority of patients were seen in consultation, structural differences in service availability among clinically similar populations appear to be causing access disparities to specialized rehabilitation among amputees in the VAMC setting. The implication of these differences with regard to patient outcomes will need to be determined.

Amputation in older people continues to be a large problem in the United States. The number of lower extremity amputations is expected to increase to 58,000 per year by 2030,1,2 and approximately 75% occur in persons aged 65 and older.3 The proportion of amputees aged 85 and older has increased from 20% to 35% over the past 40 years, which is most likely due to the aging of the population.1 Successful mobility, facilitated by prosthetic fitting, is a main concern after surgery.4 Some studies show that clinicians are hesitant to prescribe devices for elderly patients,5 and others demonstrate that, although elderly patients may have multiple comorbidities, fitting can be successful.6,7 Age alone should not be the deciding factor in prosthetic prescription,8–10 although careful selection of the geriatric patient is essential. One study suggests the following contraindications to training: cognitive dysfunction, severe neurological impairment, congestive heart failure (CHF), impaired energy tolerance from chronic obstructive pulmonary disease, and irreducible knee or hip contractures.2 Depending on the population studied, prosthetic fitting rates have ranged from 27% to 86%.1,4,11–14 Younger patients and those undergoing transtibial amputations compared to older patients and those undergoing transfemoral amputations are more likely to receive a prosthesis.1 Those with oncological metastases, wound healing problems,14 and dementia and those receiving renal dialysis2 tend not to perform well and are less likely to be fitted with a prosthetic limb. A Post Amputation Quality-of-Life (PAQ) framework for organizing patient-related factors available from administrative records into clinically meaningful domains to predict patient outcomes and patterns of resource use was proposed and tested. The framework is intended to bridge the surgical episode with rehabilitation processes, capturing the full continuum of care. Linkable administrative datasets available within the Department of Veterans Affairs (VA) provide opportunities to study this population across settings. In this study, the PAQ framework, comprising six domains (sociodemographic contexts, etiologies for limb loss, anatomical level of the remaining limb, comorbidities less directly associated with limb loss, medical acuity according to hospital procedures, and functional status that measures performance of basic physical and cognitive activities of daily living) was used to explore the patient factors that appear to be determining the clinical decision to prescribe a prosthetic limb. The objective of this study was to determine the degree to which prosthetic prescription differs, according to age, after controlling for clinical differences based on the PAQ framework.

The purpose of this study was to determine if there was an increase in the average number of articles published per year for surgery department chairs and if there was an association of publication patterns during their academic careers to authorship position and types and quality of articles written.Computerized literature searches were performed for 299 chairs of departments of surgery between 1950 and 2004. We compiled data on time as chair, number of publications per year, article types, authorship positions, and impact factors of the journals. Nonparametric tests allowed identification of differences between groups, and regression analyses were used to analyze publication trends over time.There was a significant increase in the number of articles published per year from the beginning to the end of the study (P.01). Articles were more likely to be clinical than nonclinical (P.01), and more review articles were written for nonclinical publications (P.01). Individuals overall were most likely to be last authors than first or contributing authors (P.01). More papers were published prior to becoming chairs compared to during tenure as chair or post-chair (P.01). As post-chairs, individuals were most likely to be contributing authors (P.01). There was no difference in the quality of the journals to which chairs' submitted their manuscripts during their academic careers.These findings provide valuable insight into the publication patterns of chairs of surgery departments. Individuals publish fewer articles as chairs and post-chairs, most likely due to the greater emphasis on administration and leadership duties during these career stages. Nevertheless, surgical department chairs tend to publish prolifically throughout their careers.

Traditional ways of measuring disability include summary indices, binary expressions, or counts of limitations. However, counts of activity of daily living (ADL) or instrumental activity of daily living (IADL) limitations do not specify which activities are limited. Activity limitation staging systems within the ADL and IADL domains depict both the severity and types of limitations experienced and specify clinically meaningful patterns of increasing difficulty with self-care.To compare the predictive value and utility of ADL and IADL stages based on dichotomous versus trichotomous responses to ADL and IADL questions based on "difficulty" and "receive help" responses.Data were analyzed from the 2005, 2006, and 2007 Medicare Current Beneficiary Survey (MCBS) entry panels on 11,706 beneficiaries. This was a prospective cohort study that examined time to inpatient admission, all-cause mortality, skilled nursing facility (SNF) admission, and long-term care (LTC) facility admission based on dichotomous versus trichotomous stages.For both ADLs and IADLs, Akaike information criteria for most outcomes were lower (indicating better-performing models) for the trichotomous staging systems than the dichotomous staging systems. The hazard ratios (HRs) and 95% confidence intervals (CIs) of the dichotomous ADL staging system increased as disability increased, whereas the HRs of the other staging systems fluctuated.Both staging systems have strong associations with each outcome. The dichotomous staging system is more clinically relevant while the trichotomous staging system may provide utility for clinicians, health care organizations, and policy makers seeking to predict death or admission to a hospital, SNF, or LTC facility.

Respiratory complications are a leading cause of death in persons with spinal cord injuries and disorders (SCID). We examined same-day and 60-day hospitalizations and 60-day mortality after acute respiratory illness (ARI) outpatient visits.A longitudinal study was conducted of 8775 ARI visits in the Veterans Health Administration (VA) (October. 1997-September 2002) by persons with SCID. ARIs included upper respiratory infections (URI), acute bronchitis, pneumonia, and influenza (PI).URIs accounted for almost half of all (49%) visits. A total of 14.9% of patients with ARIs were hospitalized the same day; 30.8% were hospitalized within 60 days. Predictors of hospitalization included diagnosis of either PI or acute bronchitis, comorbid illness, level of injury, age, and VA SCI center visit. Overall 60-day mortality was 2.9% but was 7.9% for pneumonia. Mortality was related to diagnosis (PI: odds ratio [OR] = 9.80, 95% confidence interval [CI]: 6.27-13.33; acute bronchitis: OR = 2.00, 95% CI: 1.08-2.93), age (65+: OR = 3.96, 95% CI: 2.23-5.70), and comorbid conditions (OR = 1.94, 95% CI: 1.43-2.46).PI and acute bronchitis were associated with increased VA hospitalization and mortality rates. The case fatality rate for pneumonia is higher for SCID than the general population. Level of injury predicted hospitalization but not death. Efforts to improve prevention and treatment of ARIs in persons with SCID are needed.

Objective Six years ago an endovascular program for repair of descending thoracic aneurysms was established at the University of Pennsylvania. We report on the hypothesis that results are improving with new stent design iterations and describe our experience and lessons learned. Methods From April 1999 to March 2005, 99 patients with descending thoracic aneurysms underwent repair with a first or second-generation commercially produced endograft; 24 patients had an early-generation device, and 75 patients had a late-generation device. Each patient was enrolled as part of 3 distinct Phase I or Phase II Food and Drug Administration-approved clinical trials in accordance with strict inclusion and exclusion criteria. Results Mean age was 73.1 years. Symptomatic aneurysms accounted for 42% of the cohort. Mean aneurysm size was 63.7 mm (range: 30-105 mm). Twenty percent of the patients underwent a subclavian carotid transposition or bypass preoperatively to obtain an adequate proximal landing zone. No procedures had to be aborted. In-hospital or 30-day mortality was 5.0%. The incidence of permanent spinal ischemia was 2%. Perioperative vascular complications requiring interposition graft, stent repair, or patch angioplasty occurred in 27% and seemed to be less frequent in the late-generation cohort than the early-generation cohort (22.7% vs 41.7%, respectively, P = .069). At the 30-day follow-up, 23 endoleaks were detected in 22 patients (14.7% in late-generation cohort vs 45.8% in early-generation cohort, P = .001). During the follow-up period, 3 new endoleaks were detected, 3 patients died of aortic rupture, and 10 patients underwent aneurysm-related reintervention. Kaplan-Meier estimated 1, 3, and 5-year survival was 84.5%, 70.5%, and 52.4%, respectively. Freedom from aneurysm-related event, defined as freedom from endoleak, aortic rupture, dissection, or any reintervention on the aorta, was 73%, 69%, and 64% at 1, 3, and 5 years, respectively. Conclusion Thoracic aortic stent grafting is a safe procedure in selected patients with the added benefit of a low incidence of paraplegia. However, there is an incidence of late complications and reinterventions. This risk requires further quantification and must be balanced against the benefits of a minimally invasive approach with low perioperative morbidity and mortality. Results are improving as technology evolves and our level of experience increases. Radiologic follow-up is mandatory.

It is important that clinicians understand statistical methods to incorporate statistics into their own research and to correctly translate published literature into improved patient care. The purpose of this study was to identify frequency and appropriate use of statistical methods in clinical surgical publications during the past 18 years.The study included randomly selected issues from odd-numbered years of Annals of Surgery (Annals) and Archives of Surgery (Archives) between 1985 and 2003, and issues in 2003 from Journal of the American College of Surgeons (JACS), Journal of Surgical Research (JSR), and Surgery. We identified all statistical procedures reported in each article, examined correctness of methods, and reported trends in publication of statistical methods over time.The proportion of publications incorporating statistics has increased over time. Declining trends were seen in the proportion of articles with no statistics (p0.0001). Approximately 35% of articles in 1985 did not use statistics compared with10% in 2003. Nonparametric tests increased (p0.0001) during the study period. In Archives of Surgery, nonparametric tests increased from 0% in 1985 to 33% in 2003, and in Annals of Surgery, from 12% in 1985 to 49% in 2003. Twenty-seven percent of studies included incorrect selection or reporting of statistical methods.Overall, the statistical complexity of research in clinical surgery journals is increasing. It is important that clinicians reading this literature have sufficient knowledge of statistical methods to facilitate interpretation of increasingly sophisticated statistical analyses.

Our objective was to determine the relationship between receipt of a prescription for a prosthetic limb and three-year mortality post-surgery among veterans with lower extremity amputation. We conducted a retrospective observational study that included 4,578 veterans hospitalized for lower extremity amputation and discharged in Fiscal Years 2003 and 2004. The outcome was time to all-cause mortality from the amputation surgical date up to the 3-year anniversary of the surgical date. There were 1,300 (28.4%) veterans with lower extremity amputations who received a prescription for a prosthetic limb within a year after the surgical amputation. About 46% (n=2086) died within three-years of the surgical anniversary. Among those who received a prescription for a prosthetic limb, only 25.2% died within 3 years of the surgical anniversary. After adjustment, veterans who received a prescription for a prosthetic limb were less likely to die after the surgery than veterans without a prescription with a hazard ratio of 0.68 (95% CI, 0.60-0.77). Findings demonstrated that veterans with lower extremity amputations who received a prescription for a prosthetic limb within a year after the surgical amputation were less likely to die within three years of the surgical amputation after controlling for patient-, treatment-, and facility-level characteristics.

Comprehensive rehabilitation services postacute stroke have been shown efficacious in European trials; however, their effectiveness in everyday practices in the United States is unknown. We compared outcomes of veteran patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services postacute stroke using propensity scores. Outcomes included change in patients' physical and cognitive independence after rehabilitation, discharge to home as opposed to other settings, and 1-yr posthospital discharge survival. Of the 2,963 patients in the study, 683 (23.1%) received comprehensive rehabilitation while the remaining patients received consultative services. We found, after propensity adjustment, that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 (95% confidence interval [CI]: 9.1 to 16.5) more points of physical independence on a 78-point scale and gained 1.5 (95% CI: 0.8 to 2.2) more points of cognitive independence on a 30-point scale. The likelihoods of discharge to home from the hospital (odds ratio [OR] = 1.61, 95% CI: 1.07 to 2.44) and 1-yr posthospital discharge survival (OR = 1.79, 95% CI: 1.25 to 2.56) were significantly higher among those who received comprehensive rehabilitation. Among patients hospitalized for acute stroke, comprehensive rehabilitation services are associated with greater recovery of physical and cognitive independence, improved home discharge likelihood, and improved 1-yr survival.

To develop a prognostic index for achievement of modified independence (Functional Independence Measure grade VI) after completion of either comprehensive or consultative rehabilitation after stroke.Retrospective cohort study.Veterans Affairs Medical Centers (VAMCs) throughout the United States.Data included 5316 patients with stroke discharged from VAMCs who received rehabilitation services while hospitalized and who were physically dependent at initial assessment. The index was derived with use of 60% of the sample and validated in the remaining 40% of the sample. Points derived from the β coefficients of a multivariable logistic model were added to scores that were associated with the probability of recovery.Recovery to modified independence or above at final rehabilitation assessment, defined as when patients no longer need physical assistance with eating; grooming; dressing the upper and lower body; toileting; sphincter management; bed to chair, toilet, and tub transfers; and walking/wheelchair use and when they require no more than supervision with bathing or climbing stairs.Seven independent predictors were identified through logistic regression in the derivation sample: initial physical grade (I or II = 0 points; III = 2 points; IV = 4 points; V = 5 points), initial cognitive stage (I or II = 0 points; III = 2 points; IV = 3 points, V or VI = 4 points; VII =5 points), type of rehabilitation (consultative = 0 points; comprehensive = 4 points), age (60 years = 3 points; 60-79 years = 2 points; ≥80 years = 0 points), time from initial to final physical grade assessment (1-2 days = 0 points; ≥3 days = 2 points), absence of urinary procedures (3 points), and absence of diabetes with complications (1 point). The following proportions of patients recovered to physical grade VI for the first, second, third, and fourth quartile scores, respectively: 0.59% (score ≤9), 3.87% (score = 9-11), 14.19% (score = 12-15), and 37.38% (score ≥16).Functional recovery to physical grade VI can be predicted on the basis of patients' initial status after a stroke occurs and the type of rehabilitation services to be provided by using a simple scoring system.

Objective: To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs. Design: Retrospective observational study. Setting: Veterans Affairs facilities nationwide. Participants: Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (NZ12,565). Intervention: Not applicable. Main Outcome Measure: Discharge location after hospitalization. Results: There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]Z1.23; 95% confidence interval [CI]Z1.11e1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (ORZ.04; 95% CIZ.03e.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (ORZ.61; 95% CIZ.50e.74) or other central nervous system hemorrhage (ORZ.78; 95% CIZ.63e.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (ORZ1.36; 95% CIZ1.07e1.73) were more likely to return home. Evidence of congestive heart failure (ORZ.85; 95% CIZ.76e.95), fluid and electrolyte disorders (ORZ.86;95% CIZ.77e.96),internalorgan procedures and diagnostics (ORZ.87; 95% CIZ.78e.97), and serious nutritionalcompromise (ORZ.49; 95% CIZ.40e.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge. Conclusions: We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning. Archives of Physical Medicine and Rehabilitation 2014;95:1277-82

Objective The aim of this study was to develop an index for establishing the probability of being discharged home after hospitalization for acute stroke using information about previous living circumstances, comorbidities, hospital course, and the physical grades and cognitive stages of independence achieved. Design This is a longitudinal observational population-based study. All 6515 persons treated for acute stroke who received rehabilitation services in 110 Veterans Affairs facilities within a 2-yr period were included. Results There were eight independent predictors of home discharge identified, and points were assigned through logistic regression: married (2 points); location before hospitalization (extended care = 0 points, other hospital = 9 points, home = 11 points); discharge physical grade (grade I, II, or III = 0 points; grade IV or V = 3 points; grade VI or VII = 5 points); discharge cognitive stage (stage I = 0 points; stage II, III, IV, or V = 3 points; stage VI or VII = 5 points); and absence of liver disease (2 points), mechanical ventilation (3 points), nonoral feeding (2 points), and intensive care unit admission (1 point). The points were added for all present factors to calculate scores. The probabilities of home discharge ranged from 65.03% in the least likely (≤21 points) to 98.24% in the most likely group (≥27 points). Conclusions The treatment team might apply prognostic estimates from this index in discharge planning and functional goal setting after initial physical medicine and rehabilitation assessment.

To identify patient-level characteristics associated with rehabilitation during the acute poststroke phase.Retrospective cohort. Generalized estimating equations modeled the likelihood of rehabilitation during the index hospitalization to account for patient clusters.Rehabilitation facilities.Sample included veterans (N=9681; average age, 68.7y; 97.4% men) diagnosed with new stroke discharged from Veterans Affairs hospitals between October 1, 2006, and September 30, 2008.Not applicable.Receipt of rehabilitation services.Of the total cohort, 73% received some type of rehabilitation. After adjustment, stroke patients with cerebral arteries occlusion were most likely to receive rehabilitation compared with other stroke types (P.001). Patients with prestroke conditions of metastatic cancer (odds ratio [OR]=.68, P.001) and psychosis (OR=.90, P=.045) were less likely to have rehabilitation, whereas those with hypertension (OR=1.26, P.001) and other neurologic disorders (OR=1.29, P.001) were more likely. Compared with patients admitted from home, patients transferred from a non-Veterans Affairs hospital (OR=1.4, P.004) were more likely to receive rehabilitation, whereas patients admitted from extended care (OR=.59, P.001) were less likely. Married veterans were less likely to receive rehabilitation services (OR=.87, P.001) than unmarried veterans.Within the Veterans Health Administration, initiating rehabilitation in the acute phase poststroke appears to be influenced by patient clinical characteristics and living circumstances.

Objective To determine whether instrumental activity of daily living (IADL) limitation stages can distinguish among elderly, community-dwelling persons with high likelihoods to have fallen once and more than once. Design A cross-sectional survey. Setting A nationally representative sample from the Second Longitudinal Study of Aging (LSOA II). Participants Included were 7401 community-dwelling persons 70 years of age and older. Methods The association of falling once and more than once within the past 12 months and 5 stages of increasing IADL limitation were explored by using a multinomial logistic regression model that controlled for demographics, education, perceived lack of home accessibility features, and health conditions. Sample proportions were weighted to reflect the prevalence in the U.S. population of 1994. Main Outcome Measurements Subject recall of fall history. There were 3 categories for this variable: no fall, falling once, and falling more than once in the past 12 months. Results Compared with IADL stage 0, the adjusted relative risk ratio of falling once peaked in individuals at IADL stage II at 2.0 (95% confidence interval [CI], 1.5-2.6), and those at IADL stage III had a relative risk ratio of 1.8 (95% CI, 1.3-2.6). The relative risk ratio of falling more than once was 2.1 (95% CI, 1.7-2.6), 4.0 (95% CI, 3.0-5.3), 3.7 (95% CI, 2.8-5.0), and 2.7 (95% CI, 1.5-4.9) for IADL stages I, II, III, and IV, respectively, when treating IADL stage 0 as reference. Conclusions IADL limitation stages could represent a powerful and practical tool for screening patients in the U.S. elderly population according to fall risk. Clinical implementation and prospective testing for validation as a screening tool would be necessary.

This study’s objective was to determine how treatment-, environmental-, and facility-level characteristics contribute to postdischarge mortality prediction. The study included 4,153 Veterans who underwent lower-limb amputation in Department of Veterans Affairs facilities during fiscal years 2003 and 2004. Veterans were followed 1 yr postamputation. A Cox regression identified characteristics associated with mortality risk after hospital discharge following amputation. Older age, higher amputation level, and more comorbidities increased mortality likelihood. Patients who had inpatient procedures for pulmonary and renal problems had higher hazards of postdischarge death than those who did not (hazard ratio [HR] = 2.10, 95% confidence interval [CI] = 1.16–3.77, and HR = 2.22, 95% CI = 1.80–2.74, respectively). Patients who had central nervous system procedures had higher hazards of death early postdischarge (HR = 2.23, 95% CI = 1.60–3.11) at 0 d, but this association became insignificant by 180 d. Patients in a surgical intensive care unit (ICU), medical ICU, or medical bed section at the time of discharge were more likely to die than patients on a surgical bed section. Patients hospitalized in the Midwest were less likely to die early after discharge than patients in the Mountain Pacific region, but this regional effect became insignificant by 90 d. Adding treatment-, environmental-, and facility-level characteristics contributed additional information to a mortality risk model.

To determine the patient-, treatment-, and facility-level factors that are associated with home discharge among male veterans with lower extremity amputation who received inpatient rehabilitation after surgery.A retrospective observational study.Veterans Affairs Medical Centers.This study included 1480 male veterans.Generalized estimating equation models were used to model the likelihood of home discharge to account for within-facility clustering. We reported odds ratios (ORs) and 95% confidence intervals (95% CIs).Discharged to home.There were a total of 1163 (78.6%) veterans who were discharged home after the surgical hospitalization, compared with other locations. Patients who were married were more likely to be discharged home compared with patients who were not married (OR = 1.51, 95% CI = 1.14-1.99, P.01). Compared with being transferred from another hospital or extended care, patients who were admitted from home were far more likely to be discharged home (OR = 8.43, 95% CI = 5.48-12.96, P.0001). Patients with evidence of local significant infection were less likely to be discharged home (OR = 0.57, 95% CI = 0.39-0.83, P.01), as were patients with evidence of congestive heart failure (OR = 0.62, 95% CI = 0.45-0.85, P.01) or depression (OR = 0.63, 95% CI = 0.40-0.98, P = .04). Veterans with greater discharge motor Functional Independence Measure scores were more likely to be discharged home (OR = 1.23, 95% CI = 1.16-1.31 per 10-point increase in discharge Functional Independence Measure motor score, P.0001). Conversely, patients undergoing procedures for ongoing active cardiac pathology were less likely to be discharged home (OR = 0.55, 95% CI = 0.37-0.81, P.01).This study showed a strong association between the sociological factors of marital status and living location before hospitalization and home discharge. The significance of discharge functional status highlights the importance of addressing the expected care burden once patients are discharged home.

Objective To examine how health-related, socioeconomic, and environmental factors combine to influence the onset of activity of daily living (ADL) limitations or prognosis for death or further functional deterioration or improvement among elderly people. Design A national representative sample with 2-year follow-up. Setting Community-dwelling people. Participants Included were 9447 persons (≥70 years of age) in the United States from the Second Longitudinal Study of Aging who were interviewed in 1994, 1995, or 1996. Methods Self- or proxy-reported health conditions, ADLs expressed as 5 stages describing severity and pattern of limitations, and other baseline characteristics were obtained. A multinomial logistic regression model was used to predict stage transitions. Because of incomplete follow-up (17.7% of baseline sample), primary analyses were determined by multiple imputation to address potential bias associated with loss to follow-up. Main Outcome Measurement ADL stage transitions in 2 years (death, deteriorated, stable, and improved ADL function). Results In the imputed-case analysis, the percentages for those who died, deteriorated, were stable, and improved were 12.6%, 32.7%, 48.4%, and 6.2%, respectively. Persons at a mild stage of ADL limitation were most likely to deteriorate further. Persons at advanced stages were most likely to die. Married people and high school graduates had a lower likelihood of deterioration. The risk of mortality and functional deterioration increased with age. Certain conditions, such as diabetes, were associated both with mortality and functional deterioration; other conditions, such as cancer, were associated with mortality only, and arthritis was associated only with functional deterioration. Conclusions Although overlap occurs, different clinical traits are associated with mortality, functional deterioration, and functional improvement. ADL stages might aid physical medicine and rehabilitation clinicians and researchers in developing and monitoring disability management strategies targeted to maintaining and enhancing self-care among community-dwelling older people.