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OBJECTIVE: ImPACT® (Immediate Post-Concussion Assessment and Cognitive Testing) is a computerized neuropsychological screening battery, which is widely used to measure the acute effects of sport-related concussion and to monitor recovery from injury. This study examined the factor structure of ImPACT® in several samples of high school student athletes. We hypothesized that a 2-factor structure would be present in all samples. METHOD: A sample of 4,809 adolescent student athletes was included, and subgroups with a history of treatment for headaches or a self-reported history of learning problems or attention-deficit hyperactivity disorder were analyzed separately. Exploratory principal axis factor analyses with Promax rotations were used. RESULTS: As hypothesized, both the combination of Verbal Memory and Visual Memory Composite scores loaded on one (Memory) factor, while Visual Motor Speed and Reaction Time loaded on a different (Speed) factor, in the total sample and in all subgroups. CONCLUSION: These results provide reasonably compelling evidence, across multiple samples, which ImPACT® measures 2 distinct factors: memory and speed.

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The aim of this study is to evaluate the psychometric properties of the 4-dimension (4-D) itch scale, a modified version of the 5-dimension itch scale, in a sample of individuals with severe burn injury and/or burn injuries to hands, face, and/or feet. Four of the five domains of the 5-dimension itch scale (4-D) were administered to individuals who reported itching (N = 173) in the Burn Injury Model System Centers Program longitudinal study at either 5 or 10 years after injury. Analyses of the scale included evaluation of dimensionality, internal consistency, associations with other symptoms or quality of life measures, and an examination of floor and ceiling effects. Fit values from a one-factor confirmatory factor analysis were acceptable, supporting unidimensionality. Cronbach's α was 0.82, indicating good internal consistency. One item had a corrected item-total score correlation of less than 0.40. Associations between the 4-D and other measures were in the expected direction and magnitude. A negligible number of participants (no more than two) selected the lowest category for all items (ie, minimal floor effect) or the highest category for all items (ie, minimal ceiling effect). 4-D had acceptable psychometric properties in a sample of adult burn injury survivors; however, the scale could be improved by removing the item with a low correlation with the total score.

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OBJECTIVES: Functional status is associated with patient outcomes, but is rarely included in hospital readmission risk models. The objective of this study was to determine whether functional status is a better predictor of 30-day acute care readmission than traditionally investigated variables including demographics and comorbidities. DESIGN: Retrospective database analysis between 2002 and 2011. SETTING: 1158 US inpatient rehabilitation facilities. PARTICIPANTS: 4,199,002 inpatient rehabilitation facility admissions comprising patients from 16 impairment groups within the Uniform Data System for Medical Rehabilitation database. MEASUREMENTS: Logistic regression models predicting 30-day readmission were developed based on age, gender, comorbidities (Elixhauser comorbidity index, Deyo-Charlson comorbidity index, and Medicare comorbidity tier system), and functional status [Functional Independence Measure (FIM)]. We hypothesized that (1) function-based models would outperform demographic- and comorbidity-based models and (2) the addition of demographic and comorbidity data would not significantly enhance function-based models. For each impairment group, Function Only Models were compared against Demographic-Comorbidity Models and Function Plus Models (Function-Demographic-Comorbidity Models). The primary outcome was 30-day readmission, and the primary measure of model performance was the c-statistic. RESULTS: All-cause 30-day readmission rate from inpatient rehabilitation facilities to acute care hospitals was 9.87%. C-statistics for the Function Only Models were 0.64 to 0.70. For all 16 impairment groups, the Function Only Model demonstrated better c-statistics than the Demographic-Comorbidity Models (c-statistic difference: 0.03-0.12). The best-performing Function Plus Models exhibited negligible improvements in model performance compared to Function Only Models, with c-statistic improvements of only 0.01 to 0.05. CONCLUSION: Readmissions are currently used as a marker of hospital performance, with recent financial penalties to hospitals for excessive readmissions. Function-based readmission models outperform models based only on demographics and comorbidities. Readmission risk models would benefit from the inclusion of functional status as a primary predictor.

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OBJECTIVE: Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissions in the inpatient rehabilitation stroke population compared with medical comorbidities using a large, administrative data set. METHODS: A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed examining stroke patients admitted to inpatient rehabilitation facilities. A Basic Model for predicting acute care readmission risk based on age and functional status was compared with models incorporating functional status and medical comorbidities (Basic-Plus) or models including age and medical comorbidities alone (Age-Comorbidity). C-statistics were compared to evaluate model performance. FINDINGS: There were a total of 803,124 patients: 88,187 (11%) patients were transferred back to an acute hospital: 22,247 (2.8%) within 3 days, 43,481 (5.4%) within 7 days, and 85,431 (10.6%) within 30 days. The C-statistics for the Basic Model were 0.701, 0.672, and 0.682 at days 3, 7, and 30 respectively. As compared to the Basic Model, the best-performing Basic-Plus model was the Basic+Elixhauser model with C-statistics differences of +0.011, +0.011, and + 0.012, and the best-performing Age-Comorbidity model was the Age+Elixhauser model with C-statistic differences of -0.124, -0.098, and -0.098 at days 3, 7, and 30 respectively. CONCLUSIONS: Readmission models for the inpatient rehabilitation stroke population based on functional status and age showed better predictive ability than models based on medical comorbidities.

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OBJECTIVES: To test whether functional status is a robust predictor of acute care readmission risk in patients who have been discharged to an inpatient rehabilitation facility (IRF) following a unilateral hip fracture. STUDY DESIGN: Retrospective database study using a large administrative data set. METHODS: A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed, examining patients with an impairment of unilateral hip fracture. A basic prediction model based on functional status was compared with competing models incorporating medical comorbidities. C statistics were compared to evaluate model performance. RESULTS: There were a total of 433,154 patients: 32,783 (7.87%) patients were transferred back to an acute hospital, including 7937 (1.91%) transferred within 3 days, 16,150 (3.88%) transferred within 7 days, and 32,607 (7.83%) transferred within 30 days after IRF admission. The C statistics for the Basic Model are 0.710, 0.674, and 0.667 at days 3, 7, and 30, respectively. Compared with the Basic Model, the best performing Basic-Plus model was the Basic+Elixhauser Model with C statistic differences of +0.013, +0.014, and +0.019, and the best performing Age-Comorbidity Model was the Age+Elixhauser Model with C statistic differences of -0.110, -0.079, and -0.065 at days 3, 7, and 30, respectively. CONCLUSIONS: Functional status is a robust and potentially modifiable risk factor for patients admitted to IRFs following a unilateral hip fracture.

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Musculoskeletal ultrasound (MSUS) training is now a required component of physiatry residency, but formal curriculum guidelines are not yet required or established. The authors' objective was to assess the educational value of a collaborative residency MSUS training program. The authors designed a structured MSUS training curriculum for residents based on the authors' experience and previous literature. Twenty-five residents participated in this MSUS curriculum designed by faculty and chief residents. Resident volunteers were trained by the faculty as "table trainers" who taught their peers in small groups. Hands-on MSUS training sessions were led by a Physical Medicine and Rehabilitation faculty MSUS expert. A Likert scale-formatted questionnaire assessed resident-perceived value of the curriculum. Response rate was 96% (22 of 23). Self-reported MSUS knowledge comparing precurriculum and postcurriculum implementation resulted in significant improvement (P = 0.001). Peer teaching was highly valued, with 86% of residents rating it "very" or "extremely" beneficial (mean [SD] score, 3.9 [1.1]). Self-guided learning, by supplemental scanning and reading, was rated "beneficial" or "very beneficial" by 73% of residents (3.0 [0.7]). The authors' successful pilot program may serve as a teaching model for other residency programs.

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OBJECTIVE: To examine functional status versus medical comorbidities as predictors of acute care readmissions in medically complex patients. DESIGN: Retrospective database study. SETTING: U.S. inpatient rehabilitation facilities. PARTICIPANTS: Subjects included 120,957 patients in the Uniform Data System for Medical Rehabilitation admitted to inpatient rehabilitation facilities under the medically complex impairment group code between 2002 and 2011. INTERVENTIONS: A Basic Model based on gender and functional status was developed using logistic regression to predict the odds of 3-, 7-, and 30-day readmission from inpatient rehabilitation facilities to acute care hospitals. Functional status was measured by the FIM(®) motor score. The Basic Model was compared to six other predictive models-three Basic Plus Models that added a comorbidity measure to the Basic Model and three Gender-Comorbidity Models that included only gender and a comorbidity measure. The three comorbidity measures used were the Elixhauser index, Deyo-Charlson index, and Medicare comorbidity tier system. The c-statistic was the primary measure of model performance. MAIN OUTCOME MEASURES: We investigated 3-, 7-, and 30-day readmission to acute care hospitals from inpatient rehabilitation facilities. RESULTS: Basic Model c-statistics predicting 3-, 7-, and 30-day readmissions were 0.69, 0.64, and 0.65, respectively. The best-performing Basic Plus Model (Basic+Elixhauser) c-statistics were only 0.02 better than the Basic Model, and the best-performing Gender-Comorbidity Model (Gender+Elixhauser) c-statistics were more than 0.07 worse than the Basic Model. CONCLUSIONS: Readmission models based on functional status consistently outperform models based on medical comorbidities. There is opportunity to improve current national readmission risk models to more accurately predict readmissions by incorporating functional data.

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PURPOSE: With improved survival, long-term effects of burn injuries on quality of life, particularly community integration, are important outcomes. This study aims to assess the Community Integration Questionnaire's psychometric properties in the adult burn population. METHODS: Data were obtained from a multicenter longitudinal data set of burn survivors. The psychometric properties of the Community Integration Questionnaire (n = 492) were examined. The questionnaire items were evaluated for clinical and substantive relevance; validation procedures were conducted on different samples of the population; construct validity was assessed using exploratory factor analysis; internal consistency reliability was examined using Cronbach's α statistics; and item response theory was applied to the final models. RESULTS: The CIQ-15 was reduced by two questions to form the CIQ-13, with a two-factor structure, interpreted as self/family care and social integration. Item response theory testing suggests that Factor 2 captures a wider range of community integration levels. Cronbach's α was 0.80 for Factor 1, 0.77 for Factor 2, and 0.79 for the test as a whole. CONCLUSIONS: The CIQ-13 demonstrates validity and reliability in the adult burn survivor population addressing issues of self/family care and social integration. This instrument is useful in future research of community reintegration outcomes in the burn population.

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BACKGROUND: Hospital readmissions are expensive and they may signal poor quality of care. Whether functional status is related to hospital readmissions using a representative U.S sample remains unexplored . OBJECTIVE: We aimed to assess the relationship between functional status and all-cause 30-day hospital readmissions using a representative sample of the US population. DESIGN: This was a retrospective observational study (2003-2011). PATIENTS: The study included 3,772 patients who completed the SF-12 before being hospitalized. Three hundred and eighteen (8.4%) were readmitted within 30 days after being discharged. MEASUREMENTS: The Medical Expenditure Panel Survey (MEPS) was employed. Functional status was measured with the Short-Form 12-Item Health Survey Version 2® (SF-12). The probability of being readmitted was estimated using a logistic model controlling for demographic characteristics, comorbid conditions, insurance coverage, physical (PCS) and mental (MCS) summaries of the SF-12, reason for hospitalization, length of hospital stay, region, and residential area. RESULTS: A one-unit difference in PCS reduced the odds of readmission by 2% (odds ratio 0.98 [95% CI, 0.97 to 0.99]; p < 0.001), which implies an 18% reduction in the odds of readmissions for a ten-unit difference (one standard deviation) in PCS. The c-statistic of the model was 0.72. CONCLUSION: Baseline physical function is associated with hospital readmissions. The SF-12 improves the ability to identify patients at high risk of hospital readmission.

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OBJECTIVE: This study aimed to describe the pediatric burn inpatient rehabilitation population and short-term functional outcomes using the Uniform Data System for Medical Rehabilitation. DESIGN: This is a secondary analysis of data from the Uniform Data System for Medical Rehabilitation database between 2002 and 2011 included children younger than 18 yrs at time of admission to inpatient rehabilitation with primary diagnosis of burn injury. Demographic, medical, and functional data were evaluated. Function was assessed with the Functional Independence Measure or the WeeFIM. RESULTS: A total of 509 children were included, of whom 124 were evaluated with Functional Independence Measure and 385 with WeeFIM. The mean age of the population was 8.6 yrs and most were boys (72%). The mean length of stay for the population was 35 days. Functional status improved significantly from admission to discharge; most gains were in the motor subscore. Most patients were discharged home (95%). Of those discharged home, most (96%) went home with family. CONCLUSIONS: Children receiving multidisciplinary inpatient rehabilitation make significant functional improvements in total functional scores and in both motor and cognitive subscores. Most patients are discharged home with family. This study advances understanding of pediatric burn post-acute care outcomes.

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OBJECTIVE: Burn patients exhibit comorbidities that influence outcomes. This study examines whether existing comorbidity measures capture comorbidities in the burn inpatient rehabilitation population. DESIGN: Data were obtained from the Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury. International Classification of Diseases, 9th Revision, codes were used to assess three comorbidity measures (Charlson Comorbidity Index, Elixhauser Comorbidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers). The number of subjects and unique comorbidity codes (>1% of frequency) captured by each comorbidity measure was calculated. RESULTS: The study included 5347 patients with a median total body surface area burn decile of 20%-29%, mean age of 51.6 yrs, and mean number of comorbidities of 7.6. There were 2809 unique International Classification of Diseases, 9th Revision, comorbidity codes. The Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Centers for Medicare and Medicaid Services Comorbidity Tiers did not capture 67%, 27%, and 58% of the subjects, respectively. There were 107 unique comorbidities that occurred with a frequency of greater than 1%. Of these, 67% were not captured in all three comorbidity measures. CONCLUSIONS: Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the burn rehabilitation population. Future work is needed to assess the need for comorbidity indexes specific to the inpatient rehabilitation setting.

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OBJECTIVE: To characterize the manner of functional status difficulties with age across multiple functional domains: lower extremity function, upper extremity function, and cognitive/social function. Construct validity of a functional status measure composed of these domains was assessed as part of this goal. DESIGN: Cross-sectional survey of the community-dwelling civilian population in the United States. SETTING: Community. PARTICIPANTS: Community-dwelling adults aged 60 years and older (N=7968). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Model fit of a 20-item functional status measure to a confirmatory factor analysis model was assessed with the root mean square error of approximation and the root mean square residual. Functional status benchmarks for age were developed with curves plotting activity difficulty percentiles versus age for the general U.S. population. RESULTS: The 20-item activity difficulty index modeled as a 3-factor construct had a root mean square error of approximation of .045 and a root mean squared residual of .052, indicating good fit. Benchmarks based on percentiles show that the median activity difficulty score is quite low for the full range studied but that there is a steady increase with increasing age. The domain regarding cognition and social function appeared to be less sensitive than the upper and lower extremity skills domains to increasing age. CONCLUSIONS: A broad measure of difficulty with functional activities can be meaningfully treated as a 3-domain construct. The scores represented by the index measuring this construct can be used to compare patients to a national sample of age-matched individuals to assess functional status using normative values.

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OBJECTIVE: To investigate the neurobehavioral pattern of recovery of consciousness as reflected by performance on the subscales of the Coma Recovery Scale-Revised (CRS-R). DESIGN: Retrospective item response theory (IRT) and factor analysis. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Rehabilitation inpatients (N=180) with posttraumatic disturbance in consciousness who participated in a double-blinded, randomized, controlled drug trial. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Scores on CRS-R subscales. RESULTS: The CRS-R was found to fit factor analytic models adhering to the assumptions of unidimensionality and monotonicity. In addition, subscales were mutually independent based on residual correlations. Nonparametric IRT reaffirmed the finding of monotonicity. A highly constrained confirmatory factor analysis model, which imposed equal factor loadings on all items, was found to fit the data well and was used to estimate a 1-parameter IRT model. CONCLUSIONS: This study provides evidence of the unidimensionality of the CRS-R and supports the hierarchical structure of the CRS-R subscales, suggesting that it is an effective tool for establishing diagnosis and monitoring recovery of consciousness after severe traumatic brain injury.

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BACKGROUND: Burn survivors tend to have complex medical issues requiring rehabilitation to improve overall function and quality of life. A subset of burn patients treated in inpatient rehabilitation facilities (IRFs) may require more than 1 rehabilitation stay for the same injury. OBJECTIVE: To compare the rehabilitation outcomes among burn patients admitted to an IRF who were discharged to acute care and then readmitted to an IRF with burn patients admitted to an IRF only 1 time. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Burn injury patients aged 18 years or more who were admitted to IRFs between 2002 and 2011. METHODS: We performed a secondary analysis of data from Uniform Data System for Medical Rehabilitation, a national data repository. Outcomes of the repeaters' second stay (n = 188) were compared to the nonrepeaters' first and only stay (n = 6,855), using linear regression and logistic regression to determine whether repeater status was associated with rehabilitation outcomes. MAIN OUTCOME MEASUREMENTS: Functional status (using the Functional Independence Measure [FIM] instrument) at admission, discharge and change, length of stay, FIM efficiency (total FIM points gained per day), and discharge disposition. RESULTS: Repeater status was inversely associated with discharge FIM total (coefficient = -3.42, 95% confidence interval = -5.76, -1.07) and FIM change (coefficient = -4.05, 95% CI = -6.34, -1.75) in linear regression models. No other significant differences were found, and those differences in discharge FIM total and FIM change were small. CONCLUSIONS: Differences found in rehabilitation outcomes between the repeater and nonrepeater groups were small and may not reflect clinically meaningful differences. Burn injury patients who required a second IRF admission had rehabilitation outcomes similar to those of burn injury patients who did not require a second IRF admission, emphasizing the value of inpatient rehabilitation for burn injury IRF readmissions.

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OBJECTIVE: To analyze potential cognitive impairment in patients with burn injury in the inpatient rehabilitation population. DESIGN: Rehabilitation patients with burn injury were compared with the following impairment groups: spinal cord injury, amputation, polytrauma and multiple fractures, and hip replacement. Differences between the groups were calculated for each cognitive subscale item and total cognitive FIM. Patients with burn injury were compared with the other groups using a bivariate linear regression model. A multivariable linear regression model was used to determine whether differences in cognition existed after adjusting for covariates (eg, sociodemographic factors, facility factors, medical complications) based on previous studies. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Data from Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury (N=5347) were compared with other rehabilitation populations (N=668,816). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparison of total cognitive FIM scores and subscales (memory, verbal comprehension, verbal expression, social interaction, problem solving) for patients with burn injury versus other rehabilitation populations. RESULTS: Adults with burn injuries had an average total cognitive FIM score ± SD of 26.8±7.0 compared with an average FIM score ± SD of 28.7±6.0 for the other groups combined (P<.001). The subscale with the greatest difference between those with burn injury and the other groups was memory (5.1±1.7 compared with 5.6±1.5, P<.001). These differences persisted after adjustment for covariates. CONCLUSIONS: Adults with burn injury have worse cognitive FIM scores than other rehabilitation populations. Future research is needed to determine the impact of this comorbidity on patient outcomes and potential interventions for these deficits.

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PURPOSE: This manuscript seeks to explain why applications of item response theory (IRT) and factor analytic methods provide evidence of validity, and why for the same reasons that they provide evidence of validity, they can advance substantive knowledge. METHODS: A narrative review of the psychometrics literature and disability literature is presented explaining the rationale for the use of quantitative validation methods. RESULTS: Both the field of psychometrics and the application of psychometric methods in rehabilitation science are expanding rapidly. Logistic IRT models and factor analytic methods are the most commonly used validation tools in rehabilitation. CONCLUSIONS: Many of the available psychometric tools provide evidence of validity, because they are powerful tests of formally specified hypotheses regarding how specific observable traits relate to underlying latent construct. Thus, while the methods for studying psychometric validity have largely been focused on the question of whether or not rehabilitation outcome measures can be used with legitimacy, they also offer a potential research tool for explaining the mechanisms of disability within the framework of the International Classification of Functioning, Disability, and Health. IMPLICATIONS FOR REHABILITATION: Quantitative validation of a functional status instrument using latent trait modeling techniques (i.e. IRT and CFA) study the measurement value of an instrument and help to ensure that the instrument provides meaningful information to clinical providers. Latent trait modeling has demonstrated that consistent with the ICF, participation restrictions in those with chronic knee osteoarthritis is driven by activity limitations caused by the knee impairments rather than directly by the knee impairments themselves.

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OBJECTIVE: To provide evidence of construct validity for the FIM instrument in the inpatient rehabilitation burn population. DESIGN: Confirmatory factor analysis and item response theory were used to assess construct validity. Confirmatory factor analysis was performed on a 2-factor model of the FIM instrument and on a 6-subfactor model. Mokken scale analysis, a nonparametric item response theory, was performed on each of the FIM instrument's 2 major factors, motor and cognitive domains. Internal consistency using Cronbach alpha and Molenaar and Sijtsma's statistic was also examined. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Data from the Uniform Data System for Medical Rehabilitation for patients with an impairment code of burn injury from the years 2002 to 2011 were used for this analysis. A total of 7569 subjects were included in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparative fit index results for the confirmatory factor analyses and adherence to assumptions of the Mokken scale model. RESULTS: Confirmatory factor analysis provided a comparative fit index of .862 for the 2-factor model and .941 for the 6-subfactor model. Mokken scale analysis showed scalability coefficients of .681 and .891 for the motor and cognitive domains, respectively. Measures of internal consistency statistic gave values of >.95 for each major domain of the FIM instrument. CONCLUSIONS: The FIM instrument has evidence of validity and reliability as an outcome measure for patients with burn injuries in the inpatient rehabilitation setting. The 6-subfactor model provides a better fit than the 2-factor model by confirmatory factor analysis. There is evidence that the motor and cognitive domains each form valid unidimensional metrics based on nonparametric item response theory.

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A preliminary investigation of the burn rehabilitation population found a large variability of zero onset day frequency between facilities. Onset days is defined as the time from injury to inpatient rehabilitation admission; this variable has not been investigated in burn patients previously. This study explored if this finding was a facility-based phenomena or characteristic of burn inpatient rehabilitation patients. This study was a secondary analysis of Uniform Data System for Medical Rehabilitation (UDSmr) data from 2002 to 2007 examining inpatient rehabilitation characteristics among patients with burn injuries. Exclusion criteria were age less than 18 years and discharge against medical advice. Comparisons of demographic, medical and functional data were made between facilities with a high frequency of zero onset days versus facilities with a low frequency of zero onset days. A total of 4738 patients from 455 inpatient rehabilitation facilities were included. Twenty-three percent of the population exhibited zero onset days (n = 1103). Sixteen facilities contained zero onset patients; two facilities accounted for 97% of the zero onset subgroup. Facilities with a high frequency of zero onset day patients demonstrated significant differences in demographic, medical, and functional variables compared to the remainder of the study population. There were significantly more zero onset day admissions among burn patients (23%) than other diagnostic groups (0.5- 3.6%) in the Uniform Data System for Medical Rehabilitation database, but the majority (97%) came from two inpatient rehabilitation facilities. It is unexpected for patients with significant burn injury to be admitted to a rehabilitation facility on the day of injury. Future studies investigating burn rehabilitation outcomes using the Uniform Data System for Medical Rehabilitation database should exclude facilities with a high percentage of zero onset days, which are not representative of the burn inpatient rehabilitation population.

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BACKGROUND AND PURPOSE: Nursing facility patients are a population that has not been well studied with regard to functional status and independence previously. As such, the manner in which activities of daily living (ADL) relate to one another is not well understood in this population. An understanding of ADL difficulty ordering has helped to devise systems of functional independence grading in other populations, which have value in understanding patients' global levels of independence and providing expectations regarding changes in function. This study seeks to examine the hierarchy of ADL in the nursing facility population. METHODS: Data were analyzed from the 2004 National Nursing Home Survey, a cross-sectional data set of 13 507 skilled nursing facility subjects with functional independence items. The ADL difficulty hierarchy was determined using Rasch analysis. Item fit values for the Rasch model using Mean-Square infit statistics were also determined. The robustness of the hierarchy was tested for each ADL. Two grading systems were devised from the results of the item difficulty ordering. One was based on the most difficult item that he or she could perform, and the other assigned a grade based on the least difficult item that a subject could not perform. RESULTS: A total of 13 113 patients were included in this analysis, the majority of whom were female and white. They had an average age of 81 years. An ordered hierarchy of ADL was found with eating being the easiest and bathing the most difficult. All items in the Katz index fit the Rasch model adequately well. The majority of patients able to perform any particular ADL were also able to perform all easier ADL. Cohen's κ for the 2 grading systems was 0.73. DISCUSSION: This study is the first to show the expected hierarchy of difficulty of the 6 activities of daily proposed in the Katz index in the nursing facility population. The hierarchy found in this population matches the original hierarchy found in older adults in the community and acute care settings. It is also similar to hierarchy found in the inpatient rehabilitation setting. Patients would be expected to lose or gain function based on the order of difficulty, but this remains to be confirmed. CONCLUSION: Among the 6 activities of daily living tested here, their order from easiest to most difficult is eating, maintaining continence, transferring, toileting, dressing, and bathing. In addition, the index formed by these 6 items has construct validity in the nursing facility population.

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