Generative Prior Knowledge for Discriminative Classification

We present a novel framework for integrating prior knowledge into discriminative classifiers. Our framework allows discriminative classifiers such as Support Vector Machines (SVMs) to utilize prior knowledge specified in the generative setting. The dual objective of fitting the data and respecting prior knowledge is formulated as a bilevel program, which is solved (approximately) via iterative application of second-order cone programming. To test our approach, we consider the problem of using WordNet (a semantic database of English language) to improve low-sample classification accuracy of newsgroup categorization. WordNet is viewed as an approximate, but readily available source of background knowledge, and our framework is capable of utilizing it in a flexible way.

Retrofitting of a satellite repeat DNA-based murine artificial chromosome (ACes) to contain loxP recombination sites

A satellite DNA-based mammalian artificial chromosome (ACes) was generated and subsequently modified by targeting of a loxP-red fluorescent protein (RFP) expression cassette via homologous recombination into a ribosomal DNA (rDNA)-containing locus. Clones containing correctly targeted ACes were identified by PCR from populations of RFP-expressing cells enriched by FACS sorting and were further characterized by fluorescent in situ hybridization. The targeted ACes maintained its ability to be purified to near homogeneity. Studies are currently underway to further characterize the functionality, carrying capacity, stability and transfectability of this modified ACes.

Effects of ethanol intoxication on speech suprasegmentals

The effects of ingesting ethanol have been shown to be somewhat variable in humans. To date, there appear to be but few universals. Yet, the question often arises: is it possible to determine if a person is intoxicated by observing them in some manner? A closely related question is: can speech be used for this purpose and, if so, can the degree of intoxication be determined? One of the many issues associated with these questions involves the relationships between a person's paralinguistic characteristics and the presence and level of inebriation. To this end, young, healthy speakers of both sexes were carefully selected and sorted into roughly equal groups of light, moderate, and heavy drinkers. They were asked to produce four types of utterances during a learning phase, when sober and at four strictly controlled levels of intoxication (three ascending and one descending). The primary motor speech measures employed were speaking fundamental frequency, speech intensity, speaking rate and nonfluencies. Several statistically significant changes were found for increasing intoxication; the primary ones included rises in F0, in task duration and for nonfluencies. Minor gender differences were found but they lacked statistical significance. So did the small differences among the drinking category subgroups and the subject groupings related to levels of perceived intoxication. Finally, although it may be concluded that certain changes in speech suprasegmentals will occur as a function of increasing intoxication, these patterns cannot be viewed as universal since a few subjects (about 20%) exhibited no (or negative) changes.

The effect of changes in the health care environment on rehabilitation research: a survey of rehabilitation physicians

OBJECTIVE

To assess what effect organizational, funding, and system changes in the health care environment may have on rehabilitation research.

DESIGN

National survey.

SETTING

Academic and clinical research programs.

PARTICIPANTS

A total of 138 physicians participated in the survey.

INTERVENTION

Mailed instrument requesting information on demographics, research activities, and indicators of change.

MAIN OUTCOME MEASURES

Percentage of respondents reporting specific perceptions on (1) how academic and research programs are affected by organizational changes, (2) availability of research funds, and (3) the overall impact that health care changes have on research; between-group comparisons on survey responses.

RESULTS

Usable responses were obtained from 138 physicians (response rate, 42.5%). Responding physicians reported workplace changes that included organizational restructuring (32.6%), affiliation with managed care plans (24%), and staff decreases (45.9%). Over half (54.8%) indicated that facility changes had detracted from their abilities to conduct research. A third (34.8%) reported declines in numbers of inpatient beds, and 89.6% reported decreased length of stay (LOS). Decreased LOS was cited as detracting from ongoing research by 36.6% and as discouraging new research by 33.3% of respondents. Although not reflected in measures of scholarly productivity, 53.6% reported having less time to devote to scholarship and 48.5% reported decreased professional activities. Over two thirds (67.4%) of responding physicians indicated that health care system changes had a negative impact on current research, and 54.5% indicated that such changes made it less likely that they would pursue new research.

CONCLUSION

Changes in the health care system have had a dampening effect on rehabilitation physicians' research pursuits.

Disability, chronic illness, and risk selection

As high-cost users of health care, people with disabilities or chronic conditions are particularly vulnerable to risk selection. Preferred risk selection, in which insurers avoid enrolling high-risk people, threatens their access to coverage. Adverse selection, in which high-risk people enroll in the most generous plans, compromises the financial viability of plans that are most responsive to their specific needs. The Americans with Disabilities Act prohibits some forms of risk selection, but does not prevent all disability-based distinctions in insurance practices. From a disability perspective, risk selection must be addressed in a manner that: (1) adequately reflects the health care costs of such individuals; (2) eliminates their need to engage in adverse selection; (3) does not stigmatize them; (4) preserves confidentiality of information; (5) uses substantial outcome measures to ensure quality; and (6) creates market conditions that discourage disability-based discrimination. A risk adjuster based on prior use/expenditures or on a diagnostic indicator sensitive to disability issues may be effective. Failure of reform to address risk selection may threaten the viability of a market-based health care system.

Production of intoxication states by actors--acoustic and temporal characteristics

This paper is the second of a series; the first has been published (J Forensic Sci, 1998;43:1153-62). The goal in the initial pair of experiments was to determine if speakers (actors) could effectively mimic the speech of intoxicated individuals and also volitionally reduce the degradation to their speech that resulted from severe inebriation. To this end, two highly controlled experiments involving 12 actor-speakers were carried out. It was found that, even when sober, nearly all of them were judged drunker (when pretending) than when they actually were severely intoxicated. In the second experiment, they tried to sound sober when highly intoxicated; here most were judged less inebriated than they were. The goal of this second paper is to identify some of the speech characteristics that allowed the subjects to achieve the cited illusions. The focus here is on four paralinguistic factors: fundamental frequency (F0), speaking rate, vocal intensity, and nonfluency level. For the simulation of intoxication study, it was found that F0 was raised along with increased intoxication but raised even more when this state was feigned. A slowing of speaking rate was associated with increasing intoxication, but this shift also was greater when the speaker simulated intoxication. The most striking contrast was found for the nonfluencies; they were doubled for actual intoxication, but quadrupled when intoxication was simulated. On the other hand, the shifts exhibited by the subjects when they attempted to sound sober were not as clear cut. Indeed, no systematic relationships were found here for either F0 or vocal intensity. Both speaking rate and the number of nonfluencies shifted appropriately, but these changes were not statistically significant. In sum, discernable suprasegmental relationships occurred for both studies (but especially the first); further, it is predicted that useful cues also will be found embedded in the segmentals (the sounds of speech).

Bax expressed from a herpes viral vector enhances the efficacy of N,N'-bis(2-hydroxyethyl)-N-nitrosourea treatment in a rat glioma model

N,N'-bis(2-hydroxyethyl)-N-nitrosourea (BCNU) is a commonly used agent for treatment of malignant gliomas. The mechanisms of cell death and the role of Bcl-2 and Bax in a BCNU-treated rat glioma cell line were investigated. Our results indicate that apoptosis occurs only at a high concentration of BCNU with elevated levels of Bax and a reversed ratio of Bax/Bcl-2. Overexpression of Bax delivered by a herpes simplex viral vector in combination with BCNU chemotherapy enhanced the efficacy of BCNU in a rat glioma model. These findings suggest that conventional treatment with BCNU may be combined with gene therapy that delivers a bax gene into the glioma cells to achieve a high level of Bax, facilitating BCNU-induced cytotoxicity.

The rehabilitation marketplace: economics, values, and proposals for reform

This article examines whether the ideals, goals, and values of medical rehabilitation can be realized in a market-based health care system. The article observes that rehabilitation is greatly disadvantaged in today's health care marketplace, which violates virtually all the assumptions of a perfectly competitive one. Nevertheless, the authors argue that rehabilitation goals and market economics are not inherently incompatible and call for several market reforms that are congruent with both rehabilitation goals and market theory. These reforms will clarify and facilitate providers' fiduciary responsibilities to patients as well as their accountability to payers. The authors conclude that while the marketplace is an inevitable medium for realizing rehabilitation goals, the vision and value of rehabilitation will not derive from the internal workings of the marketplace but ultimately from committed individuals and socially responsible institutions outside the marketplace.

Cell surface expression of MHC molecules in glioma cells infected with herpes simplex virus type-1

9L glioma cells consistently expressed major histocompatibility complex (MHC) class I but not class II molecules. Herpes simplex type-1 virus (HSV-1) infection significantly reduced the expression of MHC I on the cell surface. Recombinant interferons could enhance the cell-surface expression of MHC I but had no effect on MHC II. This enhancement was partially inhibited by HSV-1 infection. HSV-1 mutants with deletions in ICP4, ICP6, ICP27, ICP47 and UL41 genes do not affect the infection induced inhibition, suggest that a different mechanism may be employed in the inhibition of cell-surface expression of MHC molecules.

Production of intoxication states by actors: perception by lay listeners

The effects of ingesting ethanol have been shown to be somewhat variable in humans; there appear to be but few universals. Yet, questions about intoxication often are asked by law enforcement personnel (especially relative to DUI), clinicians and various individuals in social settings. A key question: Is it possible to determine if a person is intoxicated by observing them in some manner? A closely associated one: Can speech be used for that purpose? Two of the many issues related to the second of these questions involve the possibility that (1) speakers, especially actors, can effectively mimic the speech of intoxicated individuals, and (2) they may be able to volitionally reduce any speech degradation which results from intoxication. The approach used to test these two questions tasked auditors to determine if these simulations were possible. To this end, young, healthy actors chosen on the basis of a large number of selection criteria were asked to produce several types of controlled utterances (1) during a learning phase, (2) when sober, (3) at three simulated levels of intoxication (mildly, legally and severely drunk), (4) during actual, and parallel, levels of intoxication, and (5) at the highest intoxication level attained but when attempting to sound completely sober. Two aural-perceptual studies were conducted; both involved counterbalanced ABX procedures where each subject was paired with him/herself. Listeners were normally hearing university students drawn from undergraduate phonetics and linguistics courses. In the first study, they rated the actors as being more intoxicated--when they actually were sober but simulating drunkenness--88% more often than when they actually were intoxicated. In the second study, they were judged as sounding less inebriated when attempting to sound sober (than they actually were) 61% of the time. These relationships would appear to impact a number of situations; one of special importance would be the detection of intoxication in motorists.

Managed care and people with disabilities: framing the issues

A physical, cognitive, or mental disability presents significant challenges to an individual in gaining access to a coordinated program of preventive, primary, and secondary health care services. This article describes the health care needs of people with disabilities and discusses how the financial incentives in managed care may threaten access to the health care services they need to maintain their health and functional independence. We argue that despite the shortcomings of present models, managed care has the potential to improve the health care of people with disabilities. Moreover, as health plans become increasingly accountable to consumers (and begin to compete on the basis of quality), they will not be able to ignore the distinct health care needs of people with disabilities.

Personal assistance for people with physical disabilities: consumer-direction and satisfaction with services

OBJECTIVE

To determine whether people who receive consumer-directed personal assistance services (PAS) are more satisfied with the services they receive than those receiving PAS that are not consumer-directed.

DESIGN

A quasi-experimental survey comparison of long-term outcomes among people receiving consumer-directed PAS in Virginia and persons on the waiting list to receive those services. Surveys were conducted by mail and telephone.

SETTING

The general community in Virginia.

PARTICIPANTS

Ninety-two Virginia residents with physical disabilities living in the community. Sixty individuals were receiving consumer-directed PAS, and 32 were on the waiting list for consumer-directed PAS and were receiving paid personal assistance that was not consumer-directed.

MAIN OUTCOMES MEASURES

The Personal Assistance Satisfaction Index (PASI); chi2 and t tests were conducted.

RESULTS

People receiving consumer-directed PAS scored significantly higher on the PASI than the waiting-list control group and were consistently more likely to report high levels of satisfaction on the majority of individual PASI items.

CONCLUSION

Consumer-directed PAS are associated with high levels of satisfaction relative to PAS that are not consumer-directed. Individual PASI items related to control over PAS and flexibility of services showed the greatest differences in satisfaction.

Alternative definitions of disability: relationship to health-care expenditures

The purpose of this study is to investigate the relationship between different definitions of disability and health-care expenditures in the working aged population in the United States using the 1987 National Medical Expenditure Survey (NMES). Five different definitions of disability were identified and the health-care expenditures for each group were compared using descriptive analyses. Results reveal that estimates of the prevalence of disability vary dramatically by the definition of disability. A more than three-fold difference in average total health-care expenditures is observed using different specifications of disability. These results suggest that estimates of health-care expenditures should be interpreted cautiously, since the definition influences the magnitude of estimates. Researchers and policy-makers should consider the standardization of the term 'disability'.

Impact of a function-based payment model on the financial performance of acute inpatient medical rehabilitation providers: a simulation analysis

OBJECTIVES

To operationalize research findings about a medical rehabilitation classification and payment model by building a prototype of a prospective payment system, and to determine whether this prototype model promotes payment equity. This latter objective is accomplished by identifying whether any facility or payment model characteristics are systematically associated with financial performance.

DESIGN

This study was conducted in two phases. In Phase 1 the components of a diagnosis-related group (DRG)-like payment system, including a base rate, function-related group (FRG) weights, and adjusters, were identified and estimated using hospital cost functions. Phase 2 consisted of a simulation analysis in which each facility's financial performance was modeled, based on its 1990-1991 case mix. A multivariate regression equation was conducted to assess the extent to which characteristics of 42 rehabilitation facilities contribute toward determining financial performance under the present Medicare payment system as well as under the hypothetical model developed.

PARTICIPANTS

Phase 1 (model development) included 61 rehabilitation hospitals. Approximately 59% were rehabilitation units within a general hospital and 48% were teaching facilities. The number of rehabilitation beds averaged 52. Phase 2 of the stimulation analysis included 42 rehabilitation facilities, subscribers to UDS in 1990-1991. Of these, 69% were rehabilitation units and 52% were teaching facilities. The number of rehabilitation beds averaged 48.

MAIN OUTCOME MEASURE

Financial performance, as measured by the ratio of reimbursement to average costs.

RESULTS

Case-mix index is the primary determinant of financial performance under the present Medicare payment system. None of the facility characteristics included in this analysis were associated with financial performance under the hypothetical FRG payment model.

CONCLUSIONS

The most notable impact of an FRG-based payment model would be to create a stronger link between resource intensity and level of reimbursement, resulting in greater equity in the reimbursement of inpatient medical rehabilitation hospitals.

Managed care and the transformation of the medical rehabilitation industry

This article reports the findings of a study analyzing the impact of managed care on medical rehabilitation providers in three leading markets: San Diego, California; Minneapolis/St. Paul, Minnesota; and Worcester, Massachusetts. Changes in utilization patterns and the increasing pressure to reduce costs have compelled providers to make numerous strategic adjustments.

Primary care for persons with disabilities. An overview of the problem

This article outlines the ongoing health care needs of people with disabilities and how organized health care, particularly primary care, often fails to address these needs in a timely fashion. The article's central argument is that managed care and the ferment present in health care today present enormous opportunities for rehabilitation providers and others to develop creative solutions to address the shortcomings of the present health care system.

Outcomes in traumatic brain injury: self-report versus report of significant others

This paper examines the inter-rater reliability of 148 persons with traumatic brain injury (PwTBI) and their significant others (SO) on the Functional Independence Measure (FIM), and the Community Integration Questionnaire (CIQ). Results reveal that agreement differs across instruments and subscales, with greatest response comparability on the productivity CIQ subscale, followed by the motor FIM, social integration CIQ, cognitive FIM, and home integration CIQ. These findings have important implications for the future of TBI outcomes studies.

Function-based payment model for inpatient medical rehabilitation: an evaluation

OBJECTIVE

To describe the components of a function-based prospective payment model for inpatient medical rehabilitation that parallels diagnosis-related groups (DRGs), to evaluate this model in relation to stakeholder objectives, and to detail the components of a quality of care incentive program that, when combined with this payment model, creates an incentive for provides to maximize functional outcomes.

DATA SOURCES

This article describes a conceptual model, involving no data collection or data synthesis.

DATA SYNTHESIS

The basic payment model described parallels DRGs. Information on the potential impact of this model on medical rehabilitation is gleaned from the literature evaluating the impact of DRGs. The conceptual model described is evaluated against the results of a Delphi Survey of rehabilitation providers, consumers, policymakers, and researchers previously conducted by members of the research team.

CONCLUSIONS

The major shortcoming of a function-based prospective payment model for inpatient medical rehabilitation is that it contains no inherent incentive to maximize functional outcomes. Linkage of reimbursement to outcomes, however, by withholding a fixed proportion of the standard FRG payment amount, placing that amount in a "quality of care" pool, and distributing that pool annually among providers whose predesignated, facility-level, case-mix-adjusted outcomes are attained, may be one strategy for maximizing outcome goals.

Linking data from national trauma and rehabilitation registries

OBJECTIVE

To evaluate te feasibility of retrospectively creating a data base useful in trauma systems evaluations.

MATERIALS AND METHODS

Records for 375 patients in both the Major Trauma Outcome Study and the Uniform Data System for Medical Rehabilitation were linked to create an injury-through-rehabilitation data base, including patients from four impairment groups: traumatic brain injury (TBI); spinal cord injury --paraplegic complete (SCI-PARA) and quadriplegic complete (SCI-QUAD); and hip fracture (HIP-FX).

MEASUREMENTS AND MAIN RESULTS

The average ages (25.1 years SCI-QUAD, 72.6 years HIP-FX); Injury Severity Score (10.2 HIP-FX, 31.7 SCI-PARA); Revised Trauma Score (5.9 TBI, 7.8 HIP-FX); and acute care lengths of stay (13.3 days HIP-FX, 24.2 days TBI) varied substantially over the four groups. On average, patients spent from approximately 20 days (HIP-FX) to nearly 100 days (SCI-QUAD) in rehabilitation. Functional gains during rehabilitation were primarily in motor skills, but TBI patients also made substantial cognitive gains. Nearly 90% of TBI and SCI patients were discharged to their homes; the percentage of HIP-FX patients discharged to their homes, however, was lower (74%). Across all impairment groups, more patients lived with their relatives after rather than before injury. The correlation between a summary Major Trauma Outcome Study-Functional Independence Measure assessed at acute care discharge and the complete Uniform Data System for Medical Rehabilitation-Functional Independence Measure assessed on admission to rehabilitation was significant for all study patients and for each impairment group except SCI_PARA.

CONCLUSIONS

Linking records to create the study data base was arduous and could not be practically accomplished on a large scale or on a continuing basis. Because of the growing emphases on trauma system evaluations and outcomes beyond survival at acute care discharge, we recommend the routine inclusion of rehabilitation data in hospital-based trauma registries.

Criteria for selection of a payment method for inpatient medical rehabilitation

This article presents the results of a 3-stage Delphi survey designed to identify the policy criteria that should govern the evaluation of alternative payment methods and guide the selection of a payment method for inpatient medical rehabilitation. The Delphi survey (n = 85) included four groups of participants: consumers (n = 8), providers (n = 35), payers (n = 15), and health services researchers (n = 27). The Delphi survey uncovered 16 evaluation criteria. Delphi participants evaluated each criterion on a 10-point scale (1 = not important; 10 = greatest importance). Respondents value maximize patient/family outcome, maximize access, and maximize efficiency as the three most important criteria. Respondents report that minimize financial risk is the least important criterion. The results from both stage 2 and stage 3 (response rate = 85%) indicate a high level of consensus across the four respondent groups.

Use of functional status measures for payment of medical rehabilitation services

In the search for an appropriate payment system for medical rehabilitation hospitals and units, the use of a functional status measure (FSM) has emerged as a recurring theme. Conceptually, functional status measurement is important because the primary goal of medical rehabilitation is to enhance patient function and independence. Studies indicate that functional status and functional gain are among the best predictors of resource utilization at rehabilitation facilities. This article examines conceptually the use of FSMs in payment for medical rehabilitation in two different types of payment systems--as a means of classifying patients for purposes of determining the applicable payment amount (ie, a "classification system"), and as a means of justifying that payment, or continued payment, for services is appropriate (ie, a "justification system"). Several payment models using an FSM are described and analyzed. An agenda for future research is proposed.

Toward a health services research capacity in spinal cord injury

Health services research (HSR) is the research field that seeks to examine systematically the organisation, provision, and financing of health care services. There currently is only a rudimentary HSR capacity in the area of spinal cord injury (SCI). To a large extent, the HSR community has not addressed issues concerning persons with SCI, and the disability research and medical rehabilitation communities have not considered issues of HSR that affect the SCI population. However, due to recent changes in (1) the clinical management of SCI; (2) the expectations of persons with SCI, and (3) health care delivery and finance, the time is now ripe for the development of a HSR capacity in SCI. This article summarises current efforts at HSR in SCI in the United States, which have been primarily in the areas of trauma care and medical rehabilitation. It considers an agenda for future health services research in SCI, which must include research on post-rehabilitation health care and personal assistance needs. Finally, this article suggests strategies for developing a comprehensive HSR capacity in SCI.

Characteristics of cost outliers who did not benefit from stroke rehabilitation

The purpose of this paper is twofold: 1) to identify stroke patients who generated substantial charges during inpatient rehabilitation, but did not seem to benefit from that experience and 2) to identify factors that can predict which patients will fall into this group using only variables known at admission to rehabilitation. High cost stroke patients during inpatient medical rehabilitation are examined to determine how they differ from low cost patients and to identify a subset who did not appear to benefit from rehabilitation. This paper is based on longitudinal charge data involving 73 former stroke rehabilitation patients discharged from three Boston area rehabilitation facilities in 1984. Medical charges are presented on initial acute and rehabilitation inpatient stays and on care received in the 12 months after discharge. Among these 73 stroke patients, charges for inpatient medical rehabilitation amounted to nearly 1.8 million dollars, excluding physician fees and out-of-pocket expenses. Of this total, 57.6% was accured by only 33% of the patients. Fourteen patients, who were both rehabilitation cost outliers and apparent rehabilitation "failures," were identified. Rehabilitation charges for these 14 amounted to $673,232 or 37.5% of the total rehabilitation charges for all 73 patients.

Primary health care needs of persons with physical disabilities: what are the research and service priorities?

The three-stage Delphi method was used to build consensus among experts in primary care and disability on research and service priorities in the area of primary health care for persons with physical disabilities. The specific areas of focus were (1) the high rate of rehospitalization, (2) health issues associated with aging, (3) problems of access to primary care, and (4) innovative organizational approaches to financing and providing primary care services. Issues concerning personal attendant/home health care were ranked highly in all four areas and were especially dominant in the area of rehospitalization. The issue of coordinated health care management received high ratings as well, especially in the "access" area. Other prominent issues included the effects of insurance coverage and the training of primary care providers in disability-related primary care. There was a high degree of correlation between the rankings of physicians and nonphysicians, especially in the areas of hospitalization, aging, and access. This paper examines directions in which future research and service efforts should be focused.

Predicting long-term outcome among post-rehabilitation stroke patients

This paper examines correlates of long-term outcome in a sample of 89 stroke patients discharged from medical rehabilitation. Patients in this study were recruited in 1984 and followed prospectively for a 12-month period postdischarge. This analysis builds on previous studies which have called researchers to move beyond single-outcome studies which use only bivariate analysis. Multivariate techniques are used to evaluate the influence of a number of predictor variables on three measures of long-term outcome: 1) a composite variable that includes functional status, mortality and discharge disposition (home v nursing home); 2) life satisfaction; and 3) medical charges. The results show that 1) multivariate analyses present a different picture from that obtained when using bivariate analysis; and 2) the same predictor variables are not equally important in predicting different outcome variables. From 30-42% of the variance in the three dependent variables is explained by severity of illness, function at admission, age, wheelchair use and in- and out-of-house social supports.

Prospective payment for medical rehabilitation: the DHHS report to Congress

Since 1983, when Congress established the Medicare DRG-based Prospective Payment System (PPS) for inpatient hospital care, rehabilitation hospitals and units that qualify under federal regulations have been exempted from the system. Congress recognized that the DRGs were not designed to consider the specific circumstances of rehabilitation patients. It required the Secretary of the Department of Health and Human Services (DHHS) to report on the feasibility of developing a PPS for rehabilitation (and other excluded) hospitals and units. In October 1987, DHHS released its long-awaited report to Congress on "Developing a Prospective Payment System for Excluded Hospitals." The Report concludes that further research is necessary before DHHS can develop specific legislative and regulatory recommendations. Yet, the report also indicates DHHS' desire ultimately to implement a capitation-based PPS for rehabilitation. Until this goal is achieved, DHHS would like to develop a transitional PPS for rehabilitation. However, given that studies indicate that DRGs are an inappropriate basis for a rehabilitation PPS, and measures that would provide a better basis (eg, functional status or capitation) have not yet been fully developed for purposes of rehabilitation payment, it is uncertain how DHHS will achieve these goals in the short run. Until further studies are conducted, development of a transitional system appears ill-advised. Congress and DHHS should, therefore, continue to exempt rehabilitation hospitals and units until an appropriate payment system for rehabilitation can be developed.

Long-term utilization and charges among post-rehabilitation stroke patients

This paper presents longitudinal charge data on 89 former stroke rehabilitation patients discharged from three Boston area rehabilitation facilities. Medical charges are presented on initial acute and rehabilitation inpatient stays and on care received in the 12 months after discharge. In the sample of 89 stroke patients, charges exceeded four million dollars excluding physician fees and out-of-pocket expenses. Of this total, 23% was for acute hospital care preceding rehabilitation (mean = 18 days), 52% for inpatient rehabilitation (mean = 55 days), 13% for rehospitalizations in the 12 months after discharge from rehabilitation (mean = 22 days) and 12% for a variety of outpatient services.

Total charges for inpatient medical rehabilitation

Descriptive information on inpatient charges for a sample of 151 individuals discharged from three Boston area medical rehabilitation facilities is presented in this article. The total charges for inpatient rehabilitation were nearly $3 million, and the mean charge was $19,568. Also presented are a description of how charges vary by medical, demographic, social, and external factors and an identification of predictors of total charges for inpatient medical rehabilitation. These results establish a reference point for developing prospective payment systems for inpatient medical rehabilitation.

Predicting charges for inpatient medical rehabilitation using severity, DRG, age, and function

We examined the effectiveness of using diagnosis related groups (DRGs), Severity of Illness Index (SII), age and function at admission to predict inpatient charges for medical rehabilitation. Data from our sample of 199 indicate that DRGs alone explained approximately 12 per cent of the variation in charges for inpatient rehabilitation while SII explained 26 per cent of the variation. SII, DRG, and age together yielded the highest regression coefficient, accounting for nearly 39 per cent of the variation in total charges; SII and age accounted for 36 per cent of the variation. Within DRG categories, SII was the only important predictor of inpatient charges accounting for 23 per cent of the variation in charges among stroke patients (DRG 014) and 28 per cent of the variation in charges among hip fracture patients (DRG 210). Function at admission was not a useful predictor of inpatient rehabilitation charges within DRGs. These results suggest that SII and age may be useful in developing a DRG-based prospective payment system for inpatient medical rehabilitation.

Life satisfaction and quality of life among disabled elderly adults

This paper investigates predictors of life satisfaction and quality of life among severely disabled elderly adults. Markides and Martin's (1979) path analysis model was adapted specifically to elderly persons with severe disabilities. The study group comprised 97 patients discharged from three medical rehabilitation facilities in metropolitan Boston during 1984. The adapted model explained about 40% of the variance in quality of life among both men and women, with functional capacity being the most important predictor.

Program evaluation of physical medicine and rehabilitation departments using self-report Barthel

The Barthel Index measures performance of personal care (feeding, dressing, hygiene) and mobility (transferring, walking/wheeling) activities. Since its inception, several revisions of this index have increased its accuracy in measuring functional ability of patients during medical rehabilitation. However, this activities of daily living (ADL) scale is rarely used to determine the abilities of individuals after discharge, leaving assessment of functional outcome incomplete. In this study this index has been converted to a self-report format, which can be completed easily by the patient or family member both during the rehabilitation stay and after discharge. The reliability of the self-report version is examined, by comparing the assessments of patients to those made by the health professionals. A sample of persons at an inpatient rehabilitation facility, who could both read and write, completed the self-report during the week before discharge. Results comparing the assessment of professionals and patients showed a statistically significant difference with p less than 0.001. This paper will suggest reasons for the difference and explore the possibility of using this self-report version as a means to evaluate both the short-and long-term outcomes of rehabilitation programs.

Independent living outcomes in spinal cord injury: multivariate analyses

This paper presents results of a study designed to isolate those medical, personal, and environmental factors that best predict a spinal cord injured (SCI) person's ability to live independently following discharge from medical rehabilitation. A formal research model is used to identify the most promising dependent and independent variables. The principal data source is an extensive data file of 111 persons with SCI who were discharged from 10 medical rehabilitation centers across the nation. The two main independent living (IL) outcome variables are (1) a person's ability to live in a less restrictive environment, and (2) a person's ability to live productively--not only in terms of gainful employment but also in terms of other contributions to community and family life. Using multiple regression analysis, the paper reports that approximately 63% of the variance in IL outcome can be explained. The most important predictors of IL outcome are marital status, education, transportation barriers, economic disincentives, and the severity of a person's disability as measured by the Barthel index. All predictors are statistically significant. The paper concludes with implications for medical rehabilitation practice and disability policy.

Predicting the stroke patient's ability to live independently

The objective of this paper is to identify those variables that best predict a stroke patient's ability to live independently following his/her discharge from medical rehabilitation. The paper draws heavily on a formal research model grounded in independent living (IL) theory. Independent living is defined and operationalized as (1) the patient's ability to live in a nonrestrictive environment and (2) the patient's ability to live productively--not only in terms of gainful employment but also in terms of other contributions to community and family life. The main data source for the study is an extensive computer file of 84 stroke patients discharged from 8 medical rehabilitation centers. The multivariate statistical analysis indicates that 56 to 80 percent of the variance in a patient's ability to live independently can be explained or predicted mainly by the patient's marital status, age, Barthel score, communication impairments, and the ability to get into a motor vehicle. The paper concludes by discussing the implications of the findings for medical rehabilitation and public policy.

Independent living: methodology for measuring long-term outcomes

A vexing issue in disability research today is the specification and measurement of long-term outcome measures relevant to the evaluation of independent living (IL) programs and services. The purpose of this article is to present 2 long-term outcome measures that are sensitive to both the philosophy of the IL movement and the policy making needs of funding sources. The method used in the study was to examine the specific outcomes of 111 spinal cord injured persons discharged from 10 medical rehabilitation centers. These outcomes were in turn ranked and weighted by an interagency panel consisting of providers, consumers, and funding agencies. The statistical results indicate a high level of agreement among panelists as to how each outcome should be ranked and weighted. The study concludes that the ranking and weighting methodology is a workable one that can take into account the value judgements implicit in the development of long-term outcome measures for IL and medical rehabilitation programs.

Attendant care as a prototype independent living service

Of all the services and programs associated with the movement for independent living, attendant care has particular symbolic significance for the movement's adherents. Because it is a self-directed service, attendant care can be contrasted with home health services which are directed by professionals and agencies. This article demonstrates how attendant care mirrors key independent living values and concepts, partially by evaluating the provisions of attendant care services under titles XIX and XX of the Social Security Act. An analysis is made of how selected states have used titles XIX and XX authority to make self-directed attendant care services available. Consideration is also given to how selected eligibility criteria for titles XIX and XX create serious work disincentives that compromise the independent living goals implicit in self-directed attendant care services. Funding prospects and their effect are on the future of attendant care also are discussed.

Independent living: from social movement to analytic paradigm

Independent Living (IL) is more than a social movement; it is also an analytic paradigm that is re shaping the thinking of rehabilitation professionals and researchers alike. The IL paradigm is contrasted with the rehabilitation paradigm that has dominated disability policy, practice, and research. This article analyzes how the shift from the rehabilitation to the IL paradigm is likely to affect the future of disability research. To gain an appreciation for the IL paradigm, the article first evaluates independent living as a social movement in terms of the movement's constituency, origins, and its relationship to other social movements.