Challenges in paying for effective stays.
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Diagnosis-Related Groups↗
Biomedical subjects
Margaret G Stineman
Publications and source records attributed to Margaret G Stineman.
Functional status after childhood traumatic brain injury.
BACKGROUND: Identification of children after traumatic brain injury (TBI) likely to have functional deficits at trauma center discharge will facilitate care. METHODS: Two logistic regression models were derived from data on 4,439 children after TBI 7 to 14 years old enrolled in the National Pediatric Trauma Registry between 1994 and 2001 to predict physical and cognitive disabilities. RESULTS: Children with open or multiple fractures or closed fractures or injured by motor vehicles were 8.2, 3.5, or 2.5 times more likely, respectively, than those without those circumstances to have discharge physical disabilities. Likelihood of cognitive impairment was increased by factors of 3.2 and 5.8 in children obtunded or comatose on arrival. Preexisting cognitive deficits, injury severity, and intubation predicted physical and cognitive disabilities. The C statistic was 0.862 for the motor model and 0.860 for the cognitive model. CONCLUSION: Predicting the likelihood of morbidity after acute management of childhood TBI can provide information pertinent to providing effective care.
Adolescent↗
Functional status measures for integrating medical and social care.
PURPOSE: Identify standard self-report questions about functioning suitable for measuring disability across integrated health and social services. THEORY: Functional activities can be validly grouped according to the International Classification of Functioning, Disability and Health (ICF) chapters of mobility, self-care, and domestic life. METHODS: Cross-sectional analysis using information on 112,601 persons interviewed as part of the United States National Health Interview Survey on Disability. We combined related sets of questions and tested the appropriateness of their groupings through confirmatory factor analyses. Construct validity was addressed by seeking to confirm clinically logical relationships between the resulting functional scales and related health concepts, including number of physician contacts, number of bed days, perception of illness, and perception of disability. RESULTS: Internal consistency for the summed scales ranged from 0.78 to 0.92. Correlations between the functional scales and related concepts ranged from 0.12 to 0.52 in directions consistent with expectations. CONCLUSIONS: Analyses supported the 3 ICF chapters. DISCUSSIONS: The routine collection of this core set of functions could enhance decision-making at the client, professional, organizational, and policy levels encouraging cooperation among the medical and social service sectors when caring for people with disabilities.
Journal Article↗
Estimating health-related quality of life in populations through cross-sectional surveys.
BACKGROUND: Health-related quality of life (HRQL) is optimally reported from the individual vantage point; consequently, prevalence estimates from the National Health Interview Survey (NHIS) could be misleading, because approximately one third of the information is proxy-provided. OBJECTIVE: The objective of this study was to discern the degree to which disparities in the crude prevalence of reduced HRQL is explainable by case-mix differences between proxy- and self-reportees. SUBJECTS: We studied the cross-sectional data on 96,091 persons from the 1994-1995 NHIS Supplement on Disability. RESEARCH DESIGN: We conducted a study of reduced HRQL expressed as a respondent type indicator (proxy vs. self) adjusting for socioeconomic differences and limitations in function. MEASURES: We studied reduced HRQL indicated by 1) perception of poor health, 2) perception of disability, 3) 30 or more bed days in the last year, or 4) 20 or more doctor visits in the last year. RESULTS: The crude estimated prevalence of reduced HRQL for proxy reports was approximately half that of self-reports. Although the unadjusted odds ratios (ORs) for proxy- compared with self-reportees ranged from 0.51 (95% confidence interval [CI], 0.47-0.55) to 0.59 (95% CI, 0.55-0.64), case-mix adjustment resulted in a significant directional change for poor health perception, and all adjusted ORs were substantially closer to 1.0 than their unadjusted counterparts. CONCLUSION: Adjustment for case-mix explained away most of the proxy-/self-report disparity, suggesting that a major component of differences in prevalence between proxy- and self-respondents is case-mix-related. Consequently, compared with excluding proxy reports, inclusion of proxy reports results in relatively less bias when the NHIS-D is applied to obtain prevalence estimates for the indicators studied.
Activities of Daily Living↗
Risks of acute hospital transfer and mortality during stroke rehabilitation.
OBJECTIVE: To identify demographic, medical, and functional factors associated with transfer of stroke patients to acute hospital services and/or mortality during stroke rehabilitation. DESIGN: Two case-control studies in which logistic regression was used to control for clinical traits associated with differences in likelihood. SETTING: A total of 542 US inpatient and rehabilitation units. PARTICIPANTS: A total of 64,471 patients discharged during 1995. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Transfer to an acute hospital service and death. RESULTS: There were 5847 (9.1%) acute hospital transfers and 320 (0.5%) deaths. Greater disability at admission was associated with higher odds of both acute hospitalization and mortality. Cardiopulmonary arrest, chest pain, gastrointestinal problems, bleeding disorders, hypercoagulable states, and acute renal difficulties increased the relative odds of acute hospitalization from 3.1 (95% confidence interval [CI], 2.3-4.2) to 12.7 (95% CI, 9.2-17.6). The likelihood of mortality for patients 85 years of age or older was more than 2-fold (2.5; 95% CI, 1.7-3.6) that of patients 65 years of age or younger for blacks, it was nearly 2-fold (1.7; 95% CI, 1.3-2.3) compared with whites, after adjusting for clinical differences. CONCLUSION: Higher likelihoods of mortality among older patients versus younger, black patients versus white, and patients with more rather than less disability at admission suggest the need for greater vigilance in monitoring medical status.
Activities of Daily Living↗
Staging functional independence validity and applications.
OBJECTIVES: To establish construct and predictive validity of the activities of daily living, sphincter-management, mobility, and executive-function (ASME) staging system of functional independence and to describe potential applications. DESIGN: National data were used to validate the stages. Sensitivity to functional change was addressed by comparing patients' stages at discharge to their stages at admission. Construct validity was assessed by examining stage distribution differences among groups of patients classified by impairment category. Predictive validity was determined by the degree to which high stages at admission predict discharge to the community and low stages at admission predict serious morbidity or mortality. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Data from 231,686 individuals discharged from 560 US inpatient rehabilitation facilities in 1995. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Stage at rehabilitation discharge, community discharge, acute hospital discharge, or death while in rehabilitation. RESULTS: More than 90% of patients were discharged at a higher stage in at least 1 domain while not declining in any other domain. The odds (95% confidence interval) of community discharge for patients admitted at the highest compared with the lowest stage varied from 2.1 (1.9-2.2) to 3.1 (2.9-3.2), depending on the domain. The odds of acute hospitalization or death were reduced at the highest stages, compared with the lowest, by a factor ranging from .33 (.22-.49) to .65 (.61-.69). CONCLUSIONS: The ASME stages appear valid and sensitive to change. Functional Independence Staging (FIS) has relevance in establishing prognoses and in selecting among therapeutic modalities. FIS will facilitate the identification of meaningful functional goals and interpretable clinical trial endpoints. One of its most important applications could be in the establishment of outcome indicators for quality monitoring under the prospective payment system.
Activities of Daily Living↗
Functional independence staging: conceptual foundation, face validity, and empirical derivation.
OBJECTIVE: To develop a staging system for functional independence across the activities of daily living (ADLs), sphincter-management, mobility, and executive-function domains (ASME) for the FIM instrument that is consistent with the International Classification of Functioning, Disability and Health. DESIGN: National data were used to define the stages. We searched for the most likely configurations of item scores that increased ability to perform component activities in each domain by approximately 1 level per item per stage. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Data from 218,290 people discharged from 560 US inpatient rehabilitation facilities in 1995. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Activity profiles formed from FIM scores. RESULTS: Seven stages were defined separately for each ASME domain. Stages approximate the average amount of effort expended by the patient when performing the component activities included in a domain, beginning with less than 25% of effort at the lowest total assistance (stage 1) and ending with 100% effort at the highest complete independence (stage 7). Consistent with developmental principles, independence is achieved at lower stages in the most fundamental activities of eating, transfers, and communication. Recovery of independence in the more difficult activities of bathing, stair climbing, and problem solving does not occur until the higher stages are reached. The degree of independence is described with a shorthand abbreviation of the domains followed by the stage the patient has reached in each domain. For example, ASME 5,1,6,7 indicates need for supervision in the ADLs (A-5), total assistance in sphincter management (S-1), modified independence in mobility (M-6), and complete independence in executive functions (E-7). CONCLUSIONS: ASME stages serve as a common language and shorthand for expressing the functional consequences of illness and injury, while complementing information about impairment and diagnosis, thereby facilitating communication, assessment, and goal setting in terms that are meaningful to patients and their care givers.
Activities of Daily Living↗
A method for measuring quality of life through subjective weighting of functional status.
OBJECTIVE: To apply a new tool to understand the quality of life (QOL) implications of patients' functional status. DESIGN: Results from the Features-Resource Trade-Off Game were used to form utility weights by ranking functional activities by the relative value of achieving independence in each activity compared with all other component activities. The utility weights were combined with patients' actual levels of performance across the same activities to produce QOL-weighted functional status scores and to form "value rulers" to order activities by perceived importance. SETTING: Persons with severe disabilities living in the community and clinicians practicing in various rehabilitation disciplines. PARTICIPANTS: Two panels of 5 consumers with disabilities and 2 panels of 5 rehabilitation clinicians. INTERVENTIONS: The 4 panels played the Features Resource Trade-Off Game by using the FIMT(TM) instrument definitions. MAIN OUTCOME MEASURES: Utility weights for each of the 18 FIM items, QOL-weighted FIM scores, and value rulers. RESULTS: All 4 panels valued the achievement of independence in cognitive and communication activities more than independence in physical activities. Consequently, the unweighted FIM scores of patients who have severe physical disabilities but relatively intact cognitive skills will underestimate QOL, while inflating QOL in those with low levels of independence in cognition and communication but higher physical function. CONCLUSION: Independence in some activities is more valued than in others; thus, 2 people with the same numeric functional status score could experience very different QOL. QOL-weighted functional status scores translate objectively measured functional status into its subjective meaning. This new technology for measuring subjective function-related QOL has a variety of applications to clinical, educational, and research practices.
Activities of Daily Living↗
Predicting the achievement of 6 grades of physical independence from data routinely collected at admission to rehabilitation.
OBJECTIVE: To develop prognostic indexes with which to establish the likelihood of individuals achieving specific grades of physical independence by the conclusion of inpatient rehabilitation. DESIGN: Logistic regression with prospective validation. SETTING: Five hundred sixty inpatient rehabilitation facilities. PARTICIPANTS: Records of 218,290 adults discharged in 1995 were used to establish the grades and the indexes predicting those grades. There were 259,806 1997 discharges included in the validation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six physical independence grades reflecting the most likely profiles of performance across the 13 motor FIM items. RESULTS: After severity adjustment, patients 65 years of age or younger, compared with those 84 years of age or older, had odds ratios of reaching higher grades ranging from 1.5 (95% confidence interval [CI], 1.4-1.7) to 7.5 (95% CI, 4.3-13.1). Admission to rehabilitation within 2 weeks of disability was associated with more favorable prognoses. Areas under the receiver operating characteristic curve ranged from.80 to.94 for the indexes, with minimal shrinkage on prospective validation. CONCLUSION: The models have sufficient reliability to establish from admission information the likelihood that a patient will achieve a specific grade of physical independence by the time of discharge from rehabilitation. The capacity to quantify prognosis has clinical, policy, and research applications.
Activities of Daily Living↗
Prospective payment, prospective challenge.
The Centers for Medicare and Medicaid Services has implemented an inpatient rehabilitation facility prospective payment system (IRF-PPS) based on case-mix groups (CMGs). The CMGs, now almost identical in structure to the Functional Independence Measure-Function-Related Groups (FIM-FRGs), will measure patients' functional severity by the FIM trade mark instrument, rather than by the Minimum Data Set for Post-Acute Care, as was initially planned. Although this late change in plans is a major triumph for physical medicine and rehabilitation and for the patients we serve, economic incentives inherent in the IRF-PPS may still transform inpatient rehabilitation as it is currently practiced in the United States. This commentary compares the CMGs with the FIM-FRGs; addresses the implications of the CMGs' implementation for patients, researchers, and clinicians; and highlights ways of adapting previous FIM-FRG applications and research to help meet the challenges presented by the new IRF-PPS.
Cost-Benefit Analysis↗
Effect of assessment method on the discrepancy between judgments of health disorders people have and do not have: a web study.
Three experiments on the World Wide Web asked subjects to rate the severity of common health disorders such as acne or arthritis. People who had a disorder ("Haves") tended to rate it as less severe than people who did not have it ("Not-haves"). Two explanations of this Have versus Not-have discrepancy were rejected. By one account, people change their reference point when they rate a disorder that they have. More precise reference points would, on this account, reduce the discrepancy, but, if anything, the discrepancy was larger. By another account, people who do not have the disorder focus on attributes that are most affected by it, and the discrepancy should decrease when people make ratings on several attributes. Again, if anything, the discrepancy increased when ratings were on separate attributes (combined by a weighted average). The discrepancy varied in size and direction across disorders. Subjects also thought that they would be less affected than others.
Adaptation, Psychological↗