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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., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: 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., Design: Retrospective cohort study., Setting: Veterans Affairs Medical Centers (VAMCs) throughout the United States., Participants: 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., Main Outcome Measure: 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., Results: 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)., Conclusion: 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., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: 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., Design: A retrospective observational study., Setting: Veterans Affairs Medical Centers., Participants: This study included 1480 male veterans., Methods: 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)., Main Outcome Measurement: Discharged to home., Results: 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)., Conclusions: 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., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objectives: 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., Design: Retrospective database study., Setting: VA medical centers., Participants: A total of 4226 veterans with lower extremity amputations discharged from a VA medical center between October 1, 2002, and September 30, 2004., Outcome: Evidence of a preoperative rehabilitation assessment after the index surgical stay admission but before the surgical date., Results: 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)., Conclusions: 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., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright 2010 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)