Biomedical subjects

C V Granger

Publications and source records attributed to C V Granger.

At least 55 records · Page 3Linked to original sources

PubMed1997

Classifying rehabilitation inpatients by expected functional gain.

OBJECTIVES: To create a more suitable payment system for medical rehabilitation, the authors developed a companion classification system to the original functional independence measure-function-related groups (FIM-FRGs), which classify patients having similar lengths of stay in a rehabilitation hospital or inpatient unit. The companion system presented here groups patients according to their gains in functional status during the rehabilitation stay. METHODS: Data from 84,492 patients discharged from 252 rehabilitation facilities in 1992 were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The gain-FRGs system used four predictor variables: (1) diagnosis leading to disability, admission scores on the (2) motor and (3) cognitive subscales of the FIM, and (4) patient age. RESULTS: The gain-FRGs system contained 74 patient groups and explained 21% of the variation in functional gain for patients in a different set of records withheld for validation. CONCLUSIONS: The gain-FRGs system should be considered for prospective payment systems because it gives the provider an incentive to improve patient outcomes, which is missing in a payment system based on FIM-FRGs alone.

Activities of Daily Living↗

PubMed1997

A prediction model for functional recovery in stroke.

BACKGROUND AND PURPOSE: Stroke-related physical disability can diminish quality of daily living, place care burden on families, and increase need for long-term institutionalization. We developed a prognostic index for use in research and with potential for adaptation to clinical practice that establishes the likelihood of an individual achieving a specific stage of functional recovery after stroke rehabilitation. METHODS: We constructed the index using logistic regression based on 3760 patient records from 96 rehabilitation facilities in 31 states. The stage, as measured by the Functional Independence Measure, includes achievement of the following: independence in eating, grooming, and dressing the upper body; continence in bowel and bladder; and transfer between a bed and chair with supervision only. RESULTS: This stage was achieved by 26.1% of patients functioning below it at rehabilitation admission. Disability onset of less than 60 days was associated with more than a 3-fold increase in the likelihood of achieving the stage (adjusted odds ratio, 3.5; 95% confidence interval, 2.0 to 6.0). Each eight-point increase in an eight-item activities of daily living score, measured at admission to rehabilitation, increased the odds 2.5-fold (95% confidence interval, 2.3 to 2.8). For those living alone or employed before the stroke, the odds of achieving the stage increased by factors of 1.3 and 2.2, respectively. The index showed minimal shrinkage on cross validation. The achievement of this profile of function is important because 95.3% of stroke patients who achieved or exceeded it were discharged home, as opposed to only 66.8% of those who did not achieve it. CONCLUSIONS: The index can be used to establish prognoses for individual stroke patients at admission to rehabilitation with regard to achieving this stage. Achievement of the stage is associated with a high likelihood of discharge to home.

Activities of Daily Living↗

PubMed1997

Impact of interferon beta-1a on neurologic disability in relapsing multiple sclerosis. The Multiple Sclerosis Collaborative Research Group (MSCRG).

BACKGROUND AND OBJECTIVE: A phase III double-blind, placebo-controlled clinical trial demonstrated that interferon beta-1a (IFN beta-1a) (Avonex, Biogen) significantly delayed progression of disability in relapsing MS patients. The primary clinical outcome was time from study entry until disability progression, defined as > or = 1.0 point worsening from baseline Kurtzke Expanded Disability Status Scale (EDSS) score persisting for at least two consecutive scheduled visits separated by 6 months. The objective of this study was to examine the magnitude of benefit on EDSS and its clinical significance. METHODS: Post hoc analyses related to disability outcomes using data collected during the double-blind, placebo-controlled phase III clinical trial. RESULTS: (1) Clinical efficacy related to disability did not depend on the definition of disability progression. A significant benefit in favor of IFN beta-1a was observed when > or = 2.0 point worsening from baseline EDSS was required or when worsening was required to persist for > or = 1.0 year. (2) Placebo recipients who reached the primary clinical outcome worsened by a larger amount from baseline EDSS than did IFN beta-1a recipients who reached the primary study outcome. (3) Significantly fewer IFN beta-1a recipients progressed to EDSS milestones of 4.0 (relatively severe impairment) or 6.0 (unilateral assistance needed to walk). (4) Cox proportional hazards models demonstrated that the only baseline characteristic strongly correlated with longer time to disability progression was IFN beta-1a treatment. CONCLUSIONS: The primary clinical outcome for the IFN beta-1a clinical trial underestimated clinical benefits of treatment. Results in this report demonstrate that IFN beta-1a treatment is associated with robust, clinically important beneficial effects on disability progression in relapsing MS patients.

Adolescent↗

PubMed1997

A modular case-mix classification system for medical rehabilitation illustrated.

The authors present a modular set of patient classification systems designed for medical rehabilitation that predict resource use and outcomes for clinically similar groups of individuals. The systems, based on the Functional Independence Measure, are referred to as Function-Related Groups (FIM-FRGs). Using data from 23,637 lower extremity fracture patients from 458 inpatient medical rehabilitation facilities, 1995 benchmarks are provided and illustrated for length of stay, functional outcome, and discharge to home and skilled nursing facilities (SNFs). The FIM-FRG modules may be used in parallel to study interactions between resource use and quality and could ultimately yield an integrated strategy for payment and outcomes measurement. This could position the rehabilitation community to take a pioneering role in the application of outcomes-based clinical indicators.

Activities of Daily Living↗

PubMed1997

Development of function-related groups version 2.0: a classification system for medical rehabilitation.

OBJECTIVE: To present a new version (2.0) of the Functional Independence Measure-Function Related Group (FIM-FRG) case-mix measure. DATA SOURCE/STUDY SETTING: 85,447 patient discharges from 252 freestanding facilities and hospital units contained in the 1992 Uniform Data System for Medical Rehabilitation. STUDY DESIGN: Patient impairment category, functional status at admission to rehabilitation, and patient age were used to develop groups that were homogeneous with respect to length of stay. Within each impairment category patients were randomly assigned to one data set to create the system (through recursive partitioning) or a second set for validation. Clinical and statistical criteria were used to increase the percentage of patients classified, expand the impairment categories of FIM-FRGs Version 1.1, and evaluate the incremental predictive ability of coexisting medical diagnoses. Predictive stability over time was evaluated using 1990 discharges. PRINCIPAL FINDINGS: In Version 2.0, the percentage of patients classified was increased to 92 percent. Version 2.0 includes two new impairment categories and separate groups for patients admitted to rehabilitation for evaluation only. Coexisting medical diagnoses did not improve LOS prediction. The system explains 31.7 percent of the variance in the logarithm of LOS in the 1992 validation sample, and 31.0 percent in 1990 discharges. CONCLUSIONS: FIM-FRGs Version 2.0 includes more specific impairment categories, classifies a higher percentage of patient discharges, and appears sufficiently stable over time to form the basis of a payment system for inpatient medical rehabilitation.

Aged↗

PubMed1997

FIM measurement properties and Rasch model details.

To summarize, we take issue with the criticisms of Dickson & Köhler for two main reasons: 1. Rasch analysis provides a model from which to approach the analysis of the FIM, an ordinal scale, as an interval scale. The existence of examples of items or individuals which do not fit the model does not disprove the overall efficacy of the model; and 2. the principal components analysis of FIM motor items as presented by Dickson & Köhler tends to undermine rather than support their argument. Their own analyses produce a single major factor explaining between 58.5 and 67.1% of the variance, depending upon the sample, with secondary factors explaining much less variance. Finally, analysis of item response, or latent trait, is a powerful method for understanding the meaning of a measure. However, it presumes that item scores are accurate. Another concern is that Dickson & Köhler do not address the issue of reliability of scoring the FIM items on which they report, a critical point in comparing results. The Uniform Data System for Medical Rehabilitation (UDSMRSM) expends extensive effort in the training of clinicians of subscribing facilities to score items accurately. This is followed up with a credentialing process. Phase 1 involves the testing of individual clinicians who are submitting data to determine if they have achieved mastery over the use of the FIM instrument. Phase 2 involves examining the data for outlying values. When Dickson & Köhler investigate more carefully the application of the Rasch model to their FIM data, they will discover that the results presented in their paper support rather than contradict their application of the Rasch model! This paper is typical of supposed refutations of Rasch model applications. Dickson & Köhler will find that idiosyncrasies in their data and misunderstandings of the Rasch model are the only basis for a claim to have disproven the relevance of the model to FIM data. The Rasch model is a mathematical theorem (like Pythagoras') and so cannot be disproven by empirical data once it has been deduced on theoretical grounds. Sometimes empirical data are not suitable for construction of a measure. When this happens, the routine fit statistics indicate the unsuitable segments of the data. Most FIM data do conform closely enough to the Rasch model to support generalizable linear measures. Science can advance!

Activities of Daily Living↗

PubMed1996

Intramuscular interferon beta-1a for disease progression in relapsing multiple sclerosis. The Multiple Sclerosis Collaborative Research Group (MSCRG)

The accepted standard treatment of relapsing multiple sclerosis consists of medications for disease symptoms, including treatment for acute exacerbations. However, currently there is no therapy that alters the progression of physical disability associated with this disease. The purpose of this study was to determine whether interferon beta-1a could slow the progressive, irreversible, neurological disability of relapsing multiple sclerosis. Three hundred one patients with relapsing multiple sclerosis were randomized into a double-blinded, placebo-controlled, multicenter phase III trial of interferon beta-1a. Interferon beta-1a, 6.0 million units (30 micrograms¿, was administered by intramuscular injection weekly. The primary outcome variable was time to sustained disability progression of at least 1.0 point on the Kurtzke Expanded Disability Status Scale (EDSS). Interferon beta-1a treatment produced a significant delay in time to sustained EDSS progression (p = 0.02). The Kaplan-Meier estimate of the proportion of patients progressing by the end of 104 weeks was 34.9% in the placebo group and 21.9% in the interferon beta-1a-treated group. Patients treated with interferon beta-1a also had significantly fewer exacerbations (p = 0.03) and a significantly lower number and volume of gadolinium-enhanced brain lesions on magnetic resonance images (p-values ranging between 0.02 and 0.05). Over 2 years, the annual exacerbation rate was 0.90 in placebo-treated patients versus 0.61 in interferon beta-1a-treated patients. There were no major adverse events related to treatment. Interferon beta-1a had a significant beneficial impact in relapsing multiple sclerosis patients by reducing the accumulation of permanent physical disability, exacerbation frequency, and disease activity measured by gadolinium-enhanced lesions on brain magnetic resonance images. This treatment may alter the fundamental course of relapsing multiple sclerosis.

Adolescent↗

PubMed1996

The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories.

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

Activities of Daily Living↗

PubMed1996

The reliability of the functional independence measure: a quantitative review.

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

Activities of Daily Living↗

PubMed1996

The stability and equivalence reliability of the functional independence measure for children (WeeFIM).

The reliability of the Functional Independence Measure for Children (WeeFIM) was examined in 37 non-disabled children and 30 children with disabilities, from 12 to 76 months of age. The WeeFIM is derived from the Functional Independence Measure (FIM) and includes 18 items involving six functional subscales. Stability was assessed by administering the WeeFIM instrument to each child's caregiver on two occasions separated by 7 to 14 days. Intraclass correlation co-efficients (ICCs) for individual items ranged from 0.90 to 0.99. The ICC for the six WeeFIM subscales ranged from 0.94 for social cognition to 0.99 for transfers and locomotion. The ICC value for total WeeFIM test-retest reliability was 0.98 for children with disabilities and 0.99 for children without disabilities. Equivalence reliability was examined by comparing ratings obtained when using personal assessment with ratings collected during a telephone interview. No statistically significant differences were found for individual items, subscale scores or total WeeFIM values.

Child Behavior↗

PubMed1995

Outcome measurement in medical rehabilitation.

The Uniform Data System for Medical Rehabilitation (UDSmr) provides a method for uniform assessment of the severity of patient disability and the outcomes of medical rehabilitative care. The effectiveness and efficiency of medical rehabilitation services may be analyzed using the Functional Independence Measure (FIM), the functional assessment component of the UDS, and other data. Program evaluation models based on the UDSMR and the FIM are useful for measuring resource cost of disability.

Activities of Daily Living↗

PubMed1995

Efficiency pattern analysis for medical rehabilitation.

Efficiency pattern analysis (EPA) is a technique proposed for use in medical rehabilitation that links patient functional gain to resource use, as approximated by length of stay (LOS), after adjusting for initial severity. The Functional Independence Measure version of the Function Relation Groups (FIM-FRGs) is used to adjust for patient severity and to define the efficiency groups. The efficiency groups are based on LOS and functional gain cut point values in the statistical distribution that are above, below, or within the national interquartile range for each of 53 FRGs. Data from 32,494 patients discharged in 1990 from 123 rehabilitation facilities were used. EPA is a simple way to monitor change in functional gain in response to transformations in health care practices and resource availability. The technique could also provide individual facilities with a means to evaluate treatment efficiencies across time and to compare patterns of LOS and functional gain to national norms.

Activities of Daily Living↗

PubMed1995

A phase III trial of intramuscular recombinant interferon beta as treatment for exacerbating-remitting multiple sclerosis: design and conduct of study and baseline characteristics of patients. Multiple Sclerosis Collaborative Research Group (MSCRG).

The design and conduct of a randomized, double-blinded, placebo-controlled, multicenter, phase III study of recombinant interferon beta-1a (IFN-beta-1a) as treatment for exacerbating-remitting MS are described, as are baseline characteristics of the study population. The purpose of the study was to determine if 6.0 x 10(6) IU (30 micrograms) of IFN-beta-1a, administered by weekly intramuscular (i.m.) injections, was effective in delaying the onset of sustained disability. The primary outcome measure was time to onset of treatment failure, defined as a worsening on the Kurtzke Expanded Disability Status Scale (EDSS) of greater than or equal to 1.0 point compared with baseline, persisting for at least 6 months. An intent-to-treat design was used. The primary outcome measure was analyzed using the Mantel-Cox log-rank statistic and Kaplan-Meier survival curves. Secondary outcomes included quantitative measures of upper and lower extremity function, neuropsychological test performance, functional and quality of life assessments and several measures derived from annual brain MRI studies. Entry criteria included prestudy exacerbation rates of at least 0.67 per year and EDSS scores of 1.0-3.5. A total of 301 MS patients were randomly assigned to receive weekly i.m. injections of IFN-beta-1a or placebo. The average age of the study population at entry was 37 years; 92% were Caucasian and 73% were women. The mean prestudy disease duration was 6.5 years, mean prestudy exacerbation rate was 1.2 per year and the mean EDSS score was 2.3. The randomization yielded well-balanced treatment arms. Various aspects of the study are discussed, including: (1) the decision to focus study design on sustained disability; (2) the rationale for the treatment regimen; (3) measures taken to assure the reliability of the primary outcome measure; and (4) a description of the secondary outcome measures.

Adolescent↗

PubMed1994

Disability outcomes following inpatient rehabilitation for stroke.

The Uniform Data System for Medical Rehabilitation and the Functional Independence Measure have been utilized to evaluate outcomes of patients undergoing initial comprehensive inpatient medical rehabilitation for stroke. The Functional Independence Measure total, domain, subscale, and item scores were used to monitor patients during and following rehabilitation. The benchmark function values and times from stroke onset were reported, and the functional areas of physical therapy participation were noted. It is expected that these benchmarks may serve as a baseline for future study of the extent and rate of functional return following stroke and for strengthening the scientific basis of rehabilitation practice, leading to improved effectiveness and efficiency of rehabilitation therapy.

Activities of Daily Living↗

PubMed1994

A case-mix classification system for medical rehabilitation.

Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.

Activities of Daily Living↗

PubMed1994

WeeFIM. Normative sample of an instrument for tracking functional independence in children.

A cross-sectional community sample of 417 children, ages 6 months to 8 years without developmental delays or in developmental programs, was seen. The Functional Independence Measure for Children (WeeFIM) was used to assess independence in self-care, sphincter control, transfers, locomotion, communication, and social cognition. Mean total WeeFIM was similar for males and females. There was a significant correlation between the age of the child in months and total WeeFIM scores for children ages 2 to 5 years (n = 222, r = .80, P < .01). There was a progressive increase of functional independence with increasing chronological age across all WeeFIM domains. We conclude that the WeeFIM is a useful instrument for measuring disability in children.

Adaptation, Psychological↗

PubMed1994

Interrater reliability of the 7-level functional independence measure (FIM)

The Functional Independence Measure (FIM) is an 18-item, 7-level scale developed to uniformly assess severity of patient disability and medical rehabilitation functional outcome. FIM interrater reliability in the clinical setting is reported here. Clinicians from 89 US inpatient comprehensive medical rehabilitation facilities newly subscribing to the uniform Data System for Medical Rehabilitation from January 1988-June 1990 evaluated 1018 patients with the FIM. FIM total, domain and subscale score intraclass correlation coefficients (ICC) were calculated using ANOVA; FIM item score agreement was assessed with unweighted Kappa coefficient. Total FIM ICC was 0.96; motor domain 0.96 and cognitive domain 0.91; subscale score range: 0.89 (social cognition) to 0.94 (self-care). FIM item Kappa range: 0.53 (memory) to 0.66 (stair climbing). A subset of 24 facilities meeting UDSMR data aggregation reliability criteria had Intraclass and Kappa coefficients exceeding those for all facilities. It is concluded that the 7-level FIM is reliable when used by trained/tested inpatient medical rehabilitation clinicians.

Activities of Daily Living↗

PubMed1994

Four methods for characterizing disability in the formation of function related groups.

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

Activities of Daily Living↗