Computerized Adaptive Testing to Direct Delivery of Hospital-Based Rehabilitation

 描述（由申请人提供）：超过60%的体弱、老年和慢性病患者在住院期间丧失功能能力。其结果是不必要地增加了福尔斯、近期再住院和出院到机构而不是家庭环境的风险。我们 当前的临床护理模式系统地产生这些通常可避免的功能丧失，这是由于其不必要且无效地依赖于忙碌的临床医生来检测功能衰退并启动简单但有效的治疗计划。有一个关键的需要，以重新概念化这种情况：1）尽量减少对负担过重的临床医生检测，解决和监测患者的康复需求的依赖; 2）立即启动资源适当的个性化护理计划。需要一种能够准确描述患者不断发展的功能能力和康复需求的非负担性评估策略。然而，目前没有任何措施提供这种能力。我们建议开发和评估所需的评估工具，通过完善现有的项目反应理论（IRT）建模的活动测量急性期后护理（AM-PAC）的项目库，以创建一个疾病无关的多维计算机自适应测试（MCAT）。除了提高效率和精度，MCAT可以明确解决当项目或IRT模型的心理测量特性在临床相关亚组中存在差异时对测量有效性的威胁（如老年人，症状严重者和少数民族所报告的那样）。这些可实现的努力的好处将是巨大的，因为使用这种多维方法将从根本上提高评估范围和效率，而不会以一种可以容易地集成到当前护理实践中的方式相应增加临床医生的负担。更具体地说，我们的方法将是充实目前的AM-PAC库，并将其管理给1500名住院患者。这些数据与现有的AM-PAC数据集相结合，将用于评价差异项目功能、相关特质范围内的项目密度、多维IRT模型拟合以及评分分层的临界点，以匹配物理治疗师（PT）指定的功能阶段。所得到的参数估计值将用于创建固定长度的简表（SF）和指定的MCAT，以将患者分配到与经验证的护理计划相关联的功能阶段，以及检测有意义的变化。我们将对600名住院患者和300名代理人进行MCAT和SF给药，50%通过口头和50%通过片剂给药，同时由经验丰富的PT进行评价。所得数据将用于评价MCAT和SF相对于PT评估金标准的有效性、与临床结局的相关性、对替代指标的稳健性（即，护理者与患者）和模式效应以及响应性。

 DESCRIPTION (provided by applicant): Over 60% of frail, elderly, and chronically ill patients lose functional capacity during hospitalization. The result is an unnecessarily increased risk of falls, near-term rehospitalizations, and discharges to institutional rather than home settings. Our current clinical care model systemically engenders these often avoidable losses of function due to its unnecessary and ineffective reliance on busy clinicians to detect functional decline and initiate simple, yet effective, treatment plans. There is a critical need to reconceptualize this situation by: 1) minimizing reliance on overburdened clinicians to detect, address, and monitor patients' rehabilitation needs; and 2) immediately initiating resource-appropriate individualized care plans. A non-burdensome assessment strategy capable of accurately profiling patients' evolving functional capabilities and rehabilitation needs is needed. However, no measure currently offers this capability. We propose to develop and evaluate the needed assessment tool by refining the extant item response theory (IRT)-modeled Activity Measure for Post Acute Care (AM-PAC) item banks to create a disease-independent multidimensional computerized adaptive test (MCAT). In addition to enhanced efficiency and precision, MCAT may definitively address threats to measurement validity that arise when an item's or an IRT model's psychometric properties differ across clinically relevant subgroups (as has been reported for the aged, the intensely symptomatic, and ethnic minorities). The benefits of these achievable efforts will be enormous given that the use of this multidimensional approach will radically enhance assessment scope and efficiency without a commensurate increase in clinician burden in a manner that can be easily integrated into current care practices. More specifically, our approach will be to enrich the current AM-PAC banks and administer them to 1500 hospitalized patients. These data, combined with existing AM-PAC data sets, will be used to evaluate differential item functioning, item density across relevant trait ranges, multidimensional IRT model fit, and cut points for score stratification to match physical therapist (PT)-assigned functional stages. The resultant parameter estimates will be used to create a fixed-length short form (SF) and MCAT specified to assign patients to functional stages that link to validated care plans, as well as to detect meaningful change. We will administer the MCAT and SF to 600 hospitalized patients and 300 proxies, 50% verbally and 50% via tablets, who will concurrently be evaluated by experienced PTs. The resultant data will be used to evaluate the MCAT's and SF's validity relative to the gold standard criterion of PT assessment, association with clinical outcomes, robustness to proxy (i.e., caregiver vs. patient) and mode effects, and responsiveness.