Enabling Assessments to Better Inform Goal Setting and Treatment Planning for Patients with Elbow, Wrist, and Hand Impairments

Abstract

Musculoskeletal disorders, including elbow, wrist, and hand impairments, are the second most common disability worldwide and place a large burden on the health care system. Due to this prevalence and cost, accurate and precise assessment is critical to ensure that patient treatment is optimal (i.e. efficient and productive). Our first objective was to examine the item-level characteristics of the Elbow, Wrist, and Hand Computer Adaptive Test (EWH CAT) using Rasch analysis, including item difficulty measures, person ability measures, item fit, and item-person match. A unique feature of Rasch analysis is its ability to plot person ability and item difficulty on the same continuum. Awareness of this relationship helped us discern that while our items matched our sample relatively well (i.e. sample mean .13 logits above the item mean) there were slight ceiling and floor effects indicating that the addition of some harder and easier items might increase the breadth of abilities in our sample that could be accurately measured. After identifying the item-level properties of the EWH CAT, our second objective was to develop a data collection form to assist clinicians in goal setting and treatment planning. Using the Winsteps Rasch analysis program, a keyform was generated. Based on this keyform, a data collection form was created that could be used to illustrate how patient responses to specific items (i.e. difficulty indicated) differ from admission and discharge, thus helping to guide clinicians in goal setting and treatment planning. Our third objective was to identify factors that increase the probability of favorable outcomes for patients with elbow, wrist, and hand diagnoses. Seven variables were found to be associated with the likelihood of a poorer outcome: being female, having greater than three comorbidities, having a history of surgery, acuity of > 22 days, exercising less than 3 times a week, no medication use, and payer source. Four variables were significantly associated with a greater probability of a good outcome: no history of surgery, no medication use, shorter acuity, and payer source. This knowledge might indicate when a treatment approach different from traditional rehabilitation may be required and/or additional consults may be necessary.