Center for Large Data Research and Data Sharing in Rehabilitation

2020
Using Medicare Data to Build Predictive Understanding of Elderly Abuse

Leila Wood, PhD
Assistant Professor
Center for Violence Prevention, Department of Obstetrics and Gynecology, University of Texas Medical Branch

Collaborator
Monique Pappadis, PhD, University of Texas Medical Branch

General Description

The project focuses on the assessment of elderly mistreatment in inpatient and outpatient Medicare recipients. Using Medicare data, we will build predictive models toward building a health care assessment tool for EM. We will explore the use of APS data to triangulate findings from Medicare data.

Specific Aims:

1. Use inpatient Medicare data to assess mortality, hospital readmission, and associated health conditions with ICD-10 codes for EM. We will produce two publications for peer review.
2. Use outpatient Medicare data to assess mortality, hospital readmission, and associated health conditions with ICD-10 codes for EM. We will produce publications for peer review.
3. Secondary analysis of APS data collected for a project on older survivors of domestic and sexual violence to assess for potential utility in project goals of assessment of EM.

2019
Extending the generalizability of the Spinal Cord Injuries Model Systems to United States adults under rehabilitation due to traumatic spinal cord injuries

Navneet Kaur Baidwan, PhD
Post-doctoral Scholar, School of Health Professions
University of Alabama at Birmingham

Collaborator
James Graham, PhD, DC - Colorado State University

General Description
The overall goal of this study is to extend the generalizability of the estimates produced using the National Spinal Cord Injury Model Systems (SCIMS) database to United States adults in rehabilitation with traumatic SCI. This study will develop case-level weights for the SCIMS database using an auxiliary dataset created by combining Uniform Data System for Medical Rehabilitation (UDSMR) and eRehabData.

Specific Aims:

1. Develop weights accounting for differential selection and non-response while accounting for relevant variables, and apply an iterative fitting procedure to match characteristics between sample (SCIMS) and the auxiliary (UDSMR and eRehabData) data.
2. Provide overall representative estimates for those in inpatient rehabilitation due to SCI and to describe the patterns of socio-demographic and other lifestyle-related and behavioral variable that are included in SCIMS but not in the auxiliary dataset.

2019
Using Electronic Health Records to Examine Associations Among Stroke Severity, Social Risk Factors, Function-based Quality Measures, & Community Discharge from Inpatient Rehabilitation

Pamela Bosch, PhD, DPT
Associate Professor, Department of Physical Therapy
Northern Arizona University

Collaborator
Amol Karmarkar, PhD, MPH - Virginia Commonwealth

General Description
The long-term goal of this research is to preemptively identify high-risk, high-need patients with stroke for providing social support and timely home health interventions after discharge from IRF. The objective of this proposal is to examine the associations of NIHSS derived from hospitalization discharge records and function-related quality measures assessed at admission to an IRF. There are two underlying conceptual and clinical rationales of this investigation. First, function-related quality measures assessed at IRF admission can be a reasonable proxy for discharge NIHSS from acute hospitals. Second, the strength of associations between NIHSS and discharge to the community can be better determined after accounting for the mediating effect of social risk factors. Our proposed study will overcome limitations of prior research by using electronic health records (EHR) data from four IRFs capturing stroke in both younger (<65 years) and 65 and older patients.

Specific Aims:

1. Examine the association of NIHSS with the function-related quality measures derived from section GG self-care/mobility data elements
2. Examine the relative contribution of NIHSS and social risk factors along with function-related Quality Measures (GG self-care/mobility measures) to predict community discharge from IRFs

2019
Patient Factors Impacting Discharge to Community after Home Health for Individuals with and without Alzheimer’s Disease and Related Dementias

Sara Knox, PT, PhD, DPT
Assistant Professor, Department of Physical Therapy
MGH Institute of Health Professions

Collaborator
Kenneth J. Ottenbacher, PhD, OTR - UTMB

General Description
The objective of this proposed study is to examine the association between patient-level factors and successful discharge to community (DTC) for individuals with and without ADRD.

Specific Aims:

1. To determine if rates of successful DTC are different for individuals with and without ADRD.
2. To determine if associations between patient-level factors and successful DTC differ for individuals with and without ADRD.
3. To determine if dementia severity is associated with successful DTC for individuals diagnosed with ADRD.

2019
Trends and Predictors of Poor Discharge Outcomes following Inpatient Rehabilitation for Adults with Traumatic Brain Injury

Tolu Oyesanya, PhD, RN
Assistant Professor, Healthcare in Adult Populations Division
Duke University

Collaborator
Janet Prvu Bettger, ScD - Duke University

General Description
The goal of this project is to examine outcomes for adult patients with TBI who received IRF care between 2002 and 2018 using UDSMR data. Findings will inform interventions for transitional care planning.

Specific Aims:

1. To describe contemporary trends in discharge rehabilitation outcomes (discharge living setting and cognitive and motor function) for adult patients with TBI who received IRF care from 2002-2018.
2. To identify patient and facility characteristics that are associated with discharge rehabilitation outcomes.

2019
Pain phenotype, neuromuscular impairment, and development of disability among at-risk older adults: a secondary analysis of the Boston RISE Study

Eric Roseen, DC, MSc
Postdoctoral Research Fellow, Department of Family Medicine
Boston Medical Center

Collaborator
Kenneth J. Ottenbacher, PhD, OTR - UTMB

General Description
Musculoskeletal conditions are the leading cause of disability worldwide.1 Over 60% of adults over the age of 65 report at least one chronic pain condition, e.g., back pain and/or osteoarthritis.2,3 Americans are living longer lives, and the need for effective rehabilitative interventions for chronic musculoskeletal pain conditions is likely to grow. Studying the relationship between pain phenotypes and changes in function can provide novel insights into consequences and potential treatment of chronic pain. This project will use data from the Boston Rehabilitation Impairment Study of the Elderly (BostonRISE), a longitudinal study of 430 thoroughly-characterized older community-dwelling adults (mean age=77) recruited from primary care clinics and followed for functional outcomes over two years.

Specific Aims:

1. To assess whether baseline pain phenotype (e.g., number of pain sites, pain severity tertiles, etc.) is associated with changes in novel measures of neuromuscular attributes across baseline, one- and two years follow-up.
2. To assess whether baseline pain phenotype is associated with changes in patient-reported mobility across baseline, one- and two- years follow-up
3. To assess whether baseline pain phenotype is associated with changes in performance-based mobility across baseline, one- and two- years follow-up.

2019
Utilization of Outpatient Physical Therapy and the Impact on Opioid Use and Healthcare Utilization for Older Adults with Osteoarthritis

Cathy Schmidt, PT, PhD
Assistant Professor, Department of Physical Therapy
MGH Institute of Health Professions

Shweta Gore, PhD, DPT, GCS, CLT (Co-PI)
Assistant Professor, Department of Physical Therapy
MGH Institute of Health Professions

Collaborator
Kenneth J. Ottenbacher, PhD, OTR -Virginia Commonwealth University

General Description
The long-term goal of this research is to improve quality and access to non-opioid based rehabilitation for older adults with OA. The overall objective of this study is to explore the impact of a lost-cost, low medical risk intervention such as PT on healthcare outcomes in older adults with OA. Based on previous research in select cohorts of individuals with spinal conditions, our central hypothesis is that the utilization of PT will be associated with a decreased odds of opioid use and unplanned healthcare utilization. We will use the electronic health record (EHR) from Partners Healthcare to address the following specific aims.

Specific Aims:

1. Determine patient, provider and practice-level factors associated with receipt of outpatient PT at 30, 60 and 90 days for community-dwelling older adults with incident diagnosis of OA.
2. Evaluate the association of PT utilization (at 30, 60 and 90 days) on opioid use, planned healthcare utilization (diagnosing provider follow-up visits and elective hospitalizations) and unplanned healthcare utilization (emergent care and non-elective hospitalizations) for a period of 3 and 6 months following PT utilization.

Examining the impact of admission latency and functional status on post-acute outcomes in individuals with spinal cord injury

Shivayogi Hiremath, PhD
Assistant Professor, Division of Health and Rehabilitation Sciences
Temple University

Collaborator
Amol Karmarkar, PhD -Virginia Commonwealth University

General Description
Research has shown that individuals with spinal cord injury (SCI) undergoing surgery within 24 hours of admission to an acute hospital have better neurological outcomes compared to individuals undergoing later surgery. However, the delay (or latency) in admission to an acute hospital from the site of injury needs to be studied as it will influence the timing of surgery and subsequently functional recovery, post-acute trajectory and outcome. In addition, poor functional status across all conditions during acute hospitalization is strongly associated with increased use of post-acute care services, unintended institutionalization, hospital readmission, and greater likelihood of mortality. The overall purpose of this study is to assess latency in admission and clinical outcome following discharge from an acute setting in individuals with SCI. The project will be accomplished through a secondary data analysis of the Pennsylvania Trauma Systems Foundation database (data for years 2012 to 2017).

Specific Aims:

1. Examine the association between admission latency to an acute hospital, after a traumatic SCI, with the functional status at discharge from acute hospital.
2. Examine the factors associated with post-acute discharge disposition.

2018
Development of Crosswalks to Aggregate International Spinal Cord Injury Functional Data

Linda Jones, PT, MS (Co-PI)
Division of Clinical Sciences,
University of Colorado
and
Gale Whiteneck, PhD, FACRM (PI)
Director of Research, Department of Research
Craig Hospital

Collaborator
Ken Ottenbacher, PhD, OTR - UTMB

General Description
In the field of spinal cord injury (SCI), there are multiple, independent databases containing information on neurological and functional recovery, but data cannot be pooled or compared due to differences in how function is measured. The primary objective of the proposed work is to create a across items reflecting functional movement. The two functional assessments commonly used to evaluate activities of daily living (ADLs) in SCI are the Functional Independence Measure (FIM), used by Model Systems, and the Spinal Cord Independence Measure III (SCIM III) used by the EMSCI database. While FIM and SCIM III share the same construct, assessment of functional independence, the FIM is a generic functional outcome measure, while the SCIM is a spinal cord specific measure. To address this gap we will use retrospective data from two databases, the Swiss SCI Centers (Swiss) and Rick Hansen Spinal Cord Injury Registry (RHSCIR), which both collect FIM and SCIM III data on SCI patients.

Specific Aim:

1. This pilot project will create and validate a crosswalk between FIM and SCIM III for items reflecting functional movement. Three crosswalk methods (expert panel equivalency, equipercentile equating, and Rasch analysis co‐calibration) will be explored and validated. The method that most closely approximates established crosswalk criteria will be identified and validated

Applying the Behavioral Model of Health Services Use in electronic health records to examine hospital OT and PT utilization, outcomes, and disparities

Matt Malcolm, PhD, OTR/L,
Associate Professor, Department of Occupational Therapy
Colorado State University

Collaborator
James Graham, DC, PhD - Colorado State University

General Description
Rehabilitation utilization and outcomes are under-reported for patients in the acute care hospital (ACH) setting. As a result, little is known about potential disparities in ACH rehabilitation service utilization based upon patient characteristics, nor how disparity and utilization relate to ACH rehabilitation outcomes. Because disparities have been identified in post-acute rehabilitation and ACH medical services, there is critical need to determine if similar disparities exist in the utilization and outcomes of rehabilitation in ACHs. The objective of this proposed study is to identify disparities in ACH occupational therapy (OT) and physical therapy (PT) service utilization based upon by predisposing, enabling, and illness level variables, and to determine how the amount and onset of rehabilitation relates to functional outcomes.

Specific Aims:

1. While controlling for illness variables, identify disparities in ACH rehabilitation utilization by determining which predisposing and enabling variables are associated with receipt of (a) occupational therapy (OT) and (b) physical therapy (PT) during acute hospitalization.
2. Identify predictors of functional improvements for patients who receive ACH OT and/or PT, while accounting for covariate predisposing, enabling, and illness variables.

2018
The Association between Social Engagement, Mild Cognitive Impairment and Falls

Lien Quach, PhD, MPH, MD 
Adjunct Assistant Professor, Department of Gerontology
University of Massachusetts, Boston VA Research Institute, Inc.

Collaborator
Ken Ottenbacher, PhD, OTR - UTMB

General Description
This project will study how social engagement in combination with Mild Cognitive Impairment (MCI) influences the rate of falls, with the objective of identifying health-promoting behaviors that can inform targeted interventions to reduce the number of falls in older adults. Boston RISE is a unique study given that it contains measures of MCI, social engagement and falls reported every quarter and is framed within a clinical model of care following patients over a clinically meaningful window of time (two years).

Specific Aims:

1. Examine the rate of falls over two subsequent years of follow up among mobility-limited primary care patients with and without MCI at the baseline.
2. Investigate the relationship between social engagement and the rate of falls among mobility-limited primary care patients over two subsequent years of follow up.
3. Investigate whether social engagement at the baseline moderates the impact of MCI exposure on falls among mobility-limited primary care patients over two subsequent years of follow up.

2018
Long-Term Health Consequences of Severe Burns and Trauma

Evan Ross, MD 
Postdoctoral Research Fellow III, Department of Orthopedic Surgery and Rehabilitation
The University of Texas Medical Branch

Collaborator
Ken Ottenbacher, PhD, OTR - UTMB

General Description
Severe burns and traumatic injury are profound physiological insults that cause significant and persistent disruptions in both metabolism and immune function. The hypermetabolic, catabolic and pro-inflammatory phenotype induced by severe burn and trauma can last for years after injury, which contributes to delays in recovery of pre-injury functional status and quality of life. This study proposes to use the Truven MarketScan Commercial Claims and Encounters (CCAE) nationwide database of private insurance claims in order to examine the effect of severe burn or traumatic injury on the incidence of diseases associated with disordered metabolism and chronic inflammation up to three years after injury.

Specific Aims:

1. Determine the long-term health consequences of severe burn by examining the incidence of illnesses and injuries in the first three years after injury by comparison to age, gender and health status matched contemporaneous, uninjured controls.
2. Determine the long-term health consequences of burn or trauma by determining the incidence of illnesses and injuries in the first three years after injury, by comparison to age, gender and health status matched contemporaneous, uninjured controls.
3. Utilize multivariable regression modelling to determine independent risk factors for the incidence of injury and chronic illness after burn injury or severe traumatic injury.

2018
Identifying subgroups of older adults with back pain and multiple chronic conditions to inform pathways of care and improve population health

Sean Rundell, PT, DPT, PhD 
Assistant Professor, Department of Rehabilitation Medicine
University of Washington

Collaborator
Amol Karmarkar, PhD - UTMB

General Description
The opioid epidemic is a current and serious concern in the US. Although most research on opioid misuse has focused on primarily White males, research concentrating on opioid issues among racial and ethnic minority groups is growing. However, despite the fact that persons with disabilities (PWDs) comprise the largest minority population, they are often overlooked in addiction and substance abuse research. This study will examine rates of opioid misuse among PWDs.

Specific Aims:

1. Estimate the longitudinal associations of the number of chronic conditions, using a standard classification scheme, with long-term function, physical performance, and recurrent falls.
2. Identify specific combinations of chronic conditions that are most strongly associated with long-term function, physical performance, and recurrent falls.
3. Determine the association of the number and type of chronic conditions with rehabilitation service use.

2018
Patterns of Opioid Misuse Among Persons with Disabilities in the United States

Jennifer Sanchez, PhD 
Assistant Professor, Department of Rehabilitation and Counselor Education
The University of Iowa

Collaborator
Kyriakos Markides, PhD - UTMB

General Description
The opioid epidemic is a current and serious concern in the US. Although most research on opioid misuse has focused on primarily White males, research concentrating on opioid issues among racial and ethnic minority groups is growing. However, despite the fact that persons with disabilities (PWDs) comprise the largest minority population, they are often overlooked in addiction and substance abuse research. This study will examine rates of opioid misuse among PWDs.

Specific Aims:

1. To examine differences in rate of opioid misuse among PWDs in the United States and compare them to PWODs in the United States.
2. To examine differences among PWDs rate of opioid misuse versus their misuse of comparator substances, i.e., alcohol or marijuana.
3. To explore differences of opioid misuse among PWDs based on age, sex/gender, and race/ethnicity.

2018
Sleep and rehabilitation outcomes in TBI: A matched-case control Study

Eric Watson, PhD 
Postdoctoral Fellow, Clinical, Neuropsychology & Rehabilitation Research
Clinical Neuropsychology & Rehabilitation Research
Icahn School of Medicine at Mount Sinai

Collaborator
Tim Reistetter, OTR, PhD - UTMB

General Description
Each year an estimated 1.7 million Americans sustain traumatic brain injury (TBI), and a staggering 3.2 million individuals are living with TBI-related disability. Given the benefits regulated sleep has on rehabilitation outcomes, and the availability of effective evidence-based sleep interventions (e.g., Cognitive Behavioral Therapy for Insomnia), it would greatly benefit rehabilitation professionals to advance our understanding of the unique role of sleep and sleep-related characteristics in neurocognitive, health, and functional outcomes after TBI. The goal of this pilot study is to explore the role of sleep on health and functional outcomes among individuals who have sustained TBI as compared to matched controls without TBI. We will also explore the interactive effects of TBI and SWDs on these outcomes.

Specific Aims:

1. Characterize post-traumatic sleep behaviors among adults who have sustained TBI as compared to a sample of matched controls without TBI.
2. Determine the effect of demographic and sleep-related characteristics on neurocognitive, health, and functional statuses among adults who have sustained TBI as compared to matched controls without TBI.

2018
Recovery Dynamics of Depression, Social support, and Functional Status in Stroke Survivors after Inpatient Rehabilitation: Longitudinal Evidence from the Stroke Recovery in Underserved Populations Study

Alex Wong, PhD 
Assistant Professor, Rehabilitation and Participation Science
Washington University School of Medicine

Collaborator
Tim Reistetter, OTR, PhD - UTMB

General Description
Each year, around 795,000 new or recurrent new strokes occur in the US. By 2030, an additional 3.4 million US adults will have had a stroke. Stroke is a leading cause of long-term disability in the US. Most stroke survivors receive intensive therapy at inpatient rehabilitation facilities (IRFs) for 2-3 weeks, focusing on improving stroke-related behavioral deficits and ameliorating their impact on functional outcomes. Because significant functional recovery often occurs 3 months post-stroke, and even greater improvements may occur a year following a stroke, it is important to examine other modifiable factors (i.e., psychosocial factors) that may further optimize functional outcomes while stroke survivors transition into the community. Thus, the goal of this study is to disentangle recovery dynamics by examining longitudinal relationships within and between depressed mood and functional status in stroke survivors after hospital discharge, and to examine whether these longitudinal associations will be attributable to social support.

Specific Aims:

1. To unravel the direction of effects between depressed mood and functional status among stroke survivors
2. To examine the extent of longitudinal relationships between depressed mood and functional status that is attributable to social support among stroke survivors.

Prevalence and Correlates of School-based Medicaid-funded Services for Children with Autism Spectrum Disorder

Lucy Bilaver, PhD
Assistant Professor, Department of Pediatrics
Northwestern University Feinberg School of Medicine

Collaborator
Amol Karmarkar, PhD - UTMB

General Description
This project will examine the relationship between state and county-level Medicaid payment methodologies and the rates of service utilization and expenditures for school- based Medicaid funded health services for children with ASD.

Specific Aims

1. To examine the effect of Medicaid payment methodologies on patterns of school-based service utilization among children with ASD.
2. To examine the effect of Medicaid payment methodologies on patterns of school-based expenditures among children with ASD.

2017
Development and validation of a mobility disability algorithm

Yochai Eisenberg
PhD Student, School of Public Health
University of Illinois at Chicago

Elizabeth Tarlov, PhD, RN
Assistant Professor, College of Nursing
University of Illinois at Chicago

Collaborator
Amol Karmarkar, PhD - UTMB

General Description
The goal of the proposed study is to facilitate the use of large healthcare datasets for research on populations with mobility disability by developing and validating an algorithm, derived from a regression model that will identify individuals with mobility disability for inclusion in study samples.

Specific Aims

1. Use VA healthcare, Medicare claims data and statistical modeling, to develop an algorithm that will reliably identify individuals with mobility disability in large healthcare administrative and clinical databases.
2. Validate the algorithm using survey responses to questions regarding difficulty walking provided by a sample of veteran respondents to the Medicare Current Beneficiary Survey that have been linked to their VA and Medicare data

2017
Variation in Hospital-Based Rehabilitation Services in Joint Replacement and its Impact on Post- Acute Outcomes

Amit Kumar, PT, PhD, MPH
Postdoctoral Research Associate, Department of Health Services, Policy & Practice
Brown University, School of Public Health

Collaborator
Kenneth J. Ottenbacher, PhD, OTR

Description
This study will generate evidence on the effectiveness of hospital-based rehabilitation services to improve quality of care, outcomes, and reduce costs. Furthermore, this study will explore variation in hospital-based rehabilitation services and the association between this variation and post-acute outcomes by performing secondary data analysis using Medicare claims data.

Specific Aims

1. To estimate and identify sources of hospital-level variation associated with the utilization of hospital-based rehabilitation services after lower extremity joint replacement.
2. To examine the association between hospital-based rehabilitation services and two post-acute outcomes: 1) discharge destinations and 2) hospital readmission.

2017
Predictors of Lumbar Surgery in Patients with Low Back Pain

Jack Magel, PT, PhD
Research Assistant Professor, Department of Physical Therapy and Athletic Training
The University of Utah

Collaborator
James Graham, DC, PhD
Associate Professor, Division of Rehabilitation Sciences
University of Texas Medical Branch

Description
This study will leverage the combined power of two unique linked databases, the Utah Population Database (UPDB) and Utah’s All Payer Claims Database (APCD) to uncover social and economic determinants of health that play a role in the decision to have lumbar surgery for low back pain (LBP).

Specific Aims

1. Examine the association between social and socioeconomic DoH and having lumbar surgery over a 1-year period following a new consultation with a health care provider for LBP.
2. Examine the differences in DoH between patients who access a primary care or an emergency department provider for an initial consultation for LBP.

2017
The Burden of Disease, Disability, and Functional Limitation for Ethnically Diverse Older Adults in the United States: Disability-Adjusted Life Years

Ryan McGrath, PhD
Postdoctoral Research Fellow, Physical Medicine & Rehabilitation
University of Michigan

Collaborators
Soham Al Snih, MD, PhD
Associate Professor, Division of Rehabilitation Sciences
University of Texas Medical Branch

Kyriakos S. Markides, PhD
Professor
Department of Preventive Medicine & Community Health
University of Texas Medical Branch

General Description
The purpose of this study is to determine the burden of 11 highly prevalent diseases and functional limitations in a nationally-representative sample of older adults in the United States by performing a secondary analysis of Health and Retirement Study data. 

Specific Aims

1. Determine how years a person has lived with a disease or disability (YLDs) and years of life lost (YLLs) contribute to the burden of 11 diseases and functional limitations as older adults become more advanced in age.
2. Identify ethnic differences in the burden of 11 diseases and functional limitations.

2017
Effects of demographic and cancer-related clinical characteristics on future disability status among older survivors of breast and colorectal cancer using administrative data

Maria Swartz, PhD*
Post-doctoral Fellow, Division of Rehabilitation Sciences
University of Texas Medical Branch

*Funded through matching funds provided by the UTMB Center for Recovery, Physical Activity and Nutrition

Collaborator
Amol Karmarkar, PhD
Assistant Professor, Division of Rehabilitation Sciences
University of Texas Medical Branch

Description
More than half of adult cancer survivors report functional limitations that negatively impacted their quality of life and yet despite the high prevalence of functional limitations, treatment rates remain low. This study will utilize data from the Texas Cancer Registry and Medicare claims data to identify an approach that can be consistently used to identify at-risk individuals and prevent the development of severe functional limitations.

Specific Aims

1. Determine the effect of demographic and cancer-related clinical characteristics on the development of disability status in older survivors of breast and colorectal cancer within five years post cancer diagnosis
2. Compare the development of disability status among older adults without cancer diagnosis to older survivors with breast and colorectal cancer diagnosis, adjusted for demographic characteristics and comorbidity status.

The Influence of Rehabilitation-Intensive Discharge Destination on 30-day Rehospitalization Rates Among Older Adults Receiving Lumbar Spinal Fusion Surgery

Chad Cook, PhD, PT
Professor, Department of Physical Therapy 
Duke University

Collaborator
James Graham, PhD - UTMB

General Description
The proposed study will examine case mix characteristics and patient risk profiles across different hospital facilities in Medicare beneficiaries receiving spinal fusion. This study will utilize Medicare Provider and Analysis Review (MedPAR) files and asses the association of discharge destination with 30-day rehospitalization rates.

Specific Aim
This pilot project will explore, develop, and examine relationships of case mix characteristics, risk profiles, and discharge disposition categories. In addition, the project will examine the independent effects of rehabilitation-intensive discharge destination in existing risk-adjustment models for 30-day rehospitalization.

Frailty and Disability in Cardiovascular Disease: Predictors of 30-day Hospital Readmission

Tamra Keeney, DPT
Graduate Student, 
MGH Institute of Health Professions

Alan Jette, PhD
Professor, Center for Interprofessional Studies and Innovation,
MGH Institute of Health Professions

Collaborator
Ken Ottenbacher, PhD, OTR - UTMB

General Description
The proposed study will utilize National Health and Aging Trends Study database as well as linked Medicare Claims Data to explore the relationship between frailty status, disability status, and 30-day readmission rate for individuals with cardiovascular disease.

Specific Aim
This pilot project will examine the comparative ability of measures of frailty and disability to predict risk of 30-day readmission in patients with cardiovascular disease.

Rehabilitation Services and Outcomes for Rural-residing Medicare Beneficiaries

Tracy Mroz, PhD, OTR/L
Assistant Professor, Division of Occupational Therapy
University of Washington

Collaborator
Amol Karmarkar, PhD - UTMB

General Description
The proposed study will utilize Medicare administrative data from 2011 to 2013 to describe rehabilitation service provision in home health for rural-residing, fee-for-service Medicare beneficiaries who undergo total hip and knee replacement by type of rural community and region of the U.S. The relationships between quality outcomes and the amount and mix or rehabilitation service provision will be examined, accounting for patient, home health agency, and community factors. Results will identify variation in service provision and outcomes of home health care for rural beneficiaries after total joint replacement and help to inform continued payment policy transformation and quality improvement strategies for post-acute care in rural areas.

Specific Aims
This study will attempt to determine:

1. Whether or not rehabilitation service provision in home health vary by type or rural community and region
2. If quality outcomes for rural home health care recipients are associated with the amount of rehabilitation services provided while accounting for patient, agency and community characteristics

2016
TBI: Trauma-Rehabilitation Merger Database—Expansion, Validation, and Clinical Research Utilization

Amy Wagner, MD
Associate Professor, Department of Physical Medicine, Rehabilitation, and Neuroscience
University of Pittsburgh

Collaborator
Ken Ottenbacher, PhD, OTR - UTMB

General Description
The purpose of this study is to validate and further expand the TBI: Trauma-Rehabilitation Merger Database (TBI-TRMD). This database was created using a previously developed algorithm that matched subject data from the National Trauma Databank (NTDB) and the TBI Model System (TBIMS).

Specific Aims
This project will:

1. Validate the previously published algorithm using an independent local trauma registry and TBIMS population.
2. Update the TBI-TRMD by grooming, matching and incorporating newly available 2013-2014 data from the NTDB with recent data from the TBIMS
3. Develop a no-TBI trauma matched database as a comparator group for the TBI-TRMD to assess difference in presentation, acute complications and procedures between populations
4. Use the TBI-TRMD to evaluate the relationship between ECI severity and HAP/Sepsis frequency while controlling for relevant covariates affecting TBI severity among survivors receiving inpatient rehabilitation at a TBIMS center.
5. Evaluate the impact of ECI severity, HAP, and sepsis on acute (e.g. complication-relevant) procedures and length of stay (LOS), subsequent health care utilization (rehab LOS, functional improvement, acute rehospitalization), and long-term multidimensional outcome.
6. Evaluate Sepsis/HAP as moderating/mediating relationships between ECI severity and healthcare utilization and long-term multi-dimensional outcomes

The Impact of a Medicaid Managed Care Program on Health Services Utilization and Cost among Adults with Psychiatric Disabilities

Xioalong Xiang, PhD
Postdoctoral Fellow, Center for Education in Health Sciences
Northwestern University

PI: Randal Owen, PhD
Research Assistant Professor, Department of Disability and Human Development
University of Illinois

Collaborator
Amol Karmarkar, PhD - UTMB

General Description
The purpose of this project is to evaluate the effect of the Illinois Integrated Care Program (ICP) on health services utilization and cost for adults with psychiatric disabilities.

Specific Aims
This project will:

1. Assess the effects of the ICP on health services utilization and cost for adults with psychiatric disabilities
2. Investigate whether patterns of physical-psychiatric comorbidities moderate the impact of the ICP on health services utilization and cost

Physical Functioning as a Marker for 30-day Readmission

Steve Fisher, PhD, PT
Assistant Professor
Department of Physical Therapy
University of Texas Medical Branch

Collaborator
Soham Al Snih, MD, PhD - UTMB

General Description
This proposal will use an existing data set of 800 acutely hospitalized older adults to determine measures of physical functioning with the best predictive power for 30-day readmission. The data includes a variety of physical function measures (timed walking tests, standing balance, chair rise ability, accelerometry derived amount of walking, and self report ADLs), as well as 30-day readmission and medical record information.

The specific aims of this pilot study are:

1. Identify preliminary functional forms and cut points for predicting 30-day readmission among measures of physical functioning collected during acute hospitalization.
2. Calculate estimates of improved algorithm performance by adding the different function measures to known risk factor models.

Exploring the Influence of Neighborhood Characteristics and Functional Limitations on Physical and Social Participation Trajectories among Older Adults

Carri Hand, PhD
Assistant Clinical Professor
McMaster University

Collaborator
Bret Howrey, PhD - UTMB

General Description
The proposed study will examine how neighborhood characteristics, in interaction with individual characteristics, relate to participation in social and physical activities over time for older adults. The study will involve secondary analysis of Health and Retirement Study (HRS) data from 2008, 2010, 2012 combined with 2010 census data.

The specific aims of this pilot study are:

1. Examine the effects of neighborhood social cohesion, neighborhood physical disorder, housing density, and land-use diversity on frequency of social participation in older adults.
2. Examine the effects of neighborhood social cohesion, neighborhood physical disorder, housing density, and land-use diversity on frequency of physical participation in older adults.
3. Compare six-year trajectories of frequency of social and physical participation between older adults living in neighborhoods with and without key age-friendly neighborhood characteristics and with and without key individual characteristics.

Individual Trajectories for Risk of Hospitalization Following Inpatient Rehabilitation

Christopher Pretz, PhD
Lead Biostatistician
National Data and Statistical
Center Craig Hospital

Collaborator
James Graham, PhD, DC - UTMB

General Description
This pilot will demonstrate the utility of applying advanced longitudinal analytic techniques to establish the existence of potential relationships between probability of rehospitalization over time and various demographic and clinical characteristics i.e. covariates. Results will provide detailed understanding of the manner in which probability of rehospitalization changes over time. Data files from the Center for Medicare and Medicaid Services will be used.

The specific aims of this pilot study are:

1. Demonstrate the utility of advanced longitudinal statistical techniques for providing a comprehensive understanding of risk of rehospitalization following discharge from inpatient rehabilitation.
2. Develop computer-based interactive tool that generates patient-level trajectories from the observed relationships between patient demographic / clinical characteristics and time-dependent probabilities of rehospitalization.
3. Provide analytic training and pedagogical support for other rehabilitation and disability researchers. The project PI will travel to Galveston and organize/lead a workshop providing instruction and support for using advanced longitudinal analytic techniques.

Bounce-Back: Predicting Acute Readmissions from Inpatient Rehabilitation for Patients with Stroke

Pamela Roberts, PhD, OTR/L
Clinical Faculty
Cedars-Sinai Medical Center

Collaborator
Paulette Niewczyk, PhD - UDSMR

General Description
The purpose of this study is to identify both medical and functional health risk factors among rehabilitation patients admitted to an Inpatient Rehabilitation Facility (IRF) with primary diagnosis of stroke and subsequently discharged back to an acute care hospital directly from IRF before completion of an IRF program and risk factors for 30-day readmission post IRF discharge. The primary goal is to gain experience using large datasets to produce valuable information for understanding the association of medical and functional health risk factors with rehabilitation outcomes. Data files from the Center for Medicare and Medicaid Services will be used.

The specific aims of this pilot study are:

1. Identify risk factors for discharge to an acute hospital before completion of an inpatient rehabilitation program. Risk factors examined will include medical variables, functional variables, and demographic variable (including geographic region).
2. Identify risk factor for 30-day readmission post inpatient rehabilitation discharge (after completion of an IRF program). Similar risk factors as aim 1 will be examined.

Administrative Data Linkage to Examine Outcomes after Inpatient Rehabilitation

Janet Prvu Bettger, ScD
Assistant Professor
Duke University

Collaborator
James Graham, PhD, DC - UTMB

General Description
The objective of this project is to examine the degree to which patient and health-system characteristics are associated with the total number of days spent at home within 180 days of the index acute hospital admission ("home-time") for the highest users of IRF care: patients with stroke or hip fracture. Investigators will link data from administrative claims, provider and assessment files for 100% of the Medicare fee-for-service population for 2007-2009.

The specific aim of this pilot study is to identify factors associated with the total number of days spent at home within 180 days of acute hospital admission ("home-time") for stroke and hip fracture patients who received IRF care.

Sex Differences in Acquired Brain Injury Profiles and Outcomes in a National Rehabilitation Sample

Angela Colantonio, PhD, OTR
Senior Scientist
Toronto Rehabilitation Institute

Collaborator
Ken Ottenbacher, PhD - UTMB

General Description
The objective of this project is to examine sex differences in profiles and outcomes of patients with acquired brain injury (ABI) in a population based province wide rehabilitation sample. This project will lay the foundation for a larger program of research examining sex differences in different types of comorbidities. Sleep disorder will be examined in detail. The Discharge Abstract Database (DAD) and the National Rehabilitation Reporting System (NRS) will be used.

The specific aims of this pilot study will determine the:

1. Number and demographic, clinical, and environmental/social characteristics of adult ABI patients in inpatient rehabilitation by age groups and sex.
2. Number and type of comorbidities of adult ABI patients in inpatient rehabilitation at admission and discharge by age groups and sex.
3. Number of adults coded with psychiatric and/or sleep disorder by age groups and sex.
4. Independent influence of sex and type and number of comorbidities on rehabilitation outcomes.

Physical Disability and Disparities in Health Care

Elham Mahmoudi, PhD
Postdoctoral Fellow
University of Michigan

Collaborator
Rebecca Wong, PhD - UTMB

General Description
This study will investigate factors associated with disability-related disparities in health care. Specifically, it will identify disparities that exist between adults with physical disabilities and non-disabled adults in three dimensions of health care system: 1) having no doctor visits, 2) having no usual source of care, and 3) having any unmet medical needs. This research will use data from three merged national datasets - the Medical Expenditure Panel Survey (MEPS), the National Health Interview Survey (NHIS), and the Area Resource File (ARF).

The specific aims of this project are to:

1. Analyze the 10-year trends in disability-related disparities in use of/access to physician services and in unmet medical needs.
2. Identify risk factors associated with disparities in use of/access to physician care and in unmet medical needs between adults with and without physical disabilities.

Examining contextual factors and community participation among older adults

Elizabeth Marfeo, PhD
Research Instructor
Boston University

Collaborators
Ken Ottenbacher, PhD - UTMB; James Graham, PhD, DC - UTMB

General Description
This project will investigate the association between contextual factors with participation in community-based instrumental activities of daily living and leisure activities among a national sample of community dwelling older adults. Data from the National Health and Aging Trends Study (NHATS) will be used. The study will examine the extent to which health condition, demographic, and contextual factors are associated with self-reported participation. Results from this study will provide important information that could be used to target future interventions aimed at improving health and functioning in this population.

The specific aims of this pilot study are to:

This project will investigate the association between contextual factors with participation in community-based instrumental activities of daily living and leisure activities among a national sample of community dwelling older adults. Data from the National Health and Aging Trends Study (NHATS) will be used. The study will examine the extent to which health condition, demographic, and contextual factors are associated with self-reported participation. Results from this study will provide important information that could be used to target future interventions aimed at improving health and functioning in this population.

Cognitive Aging and Health among Older Adults with Traumatic Brain Injury

Kristen Dams-O'Connor, PhD
Assistant Professor
Mount Sinai School of Medicine

Collaborator
Ken Ottenbacher, PhD, OTR- UTMB

General Description
This pilot study will identify factors that influence long-term functioning and overall health in individuals with history of TBI. Previous research in the general cognitive aging literature has identified a host of factors that may accelerate or protect against cognitive decline. The extent to which these same factors (or others) are associated with long-term outcomes among individuals with a history of TBI is not well known. Of particular relevance to the field of rehabilitation is the identification of factors that may be modifiable.

The specific aims of this pilot study are to:

1. Examine change in cognitive functioning over time and identify factors that may contribute to cognitive change among adults with a lifetime history of TBI.
2. Examine change in overall health over time and identify factors that contribute to health decline among adults with and without a lifetime history of TBI.
3. Identify risk factors for dementia among people with TBI.

Mobility and Functional Outcomes from a National Spina Bifida Patient Registry

Brad Dicianno, MD
Associate Professor
University of Pittsburg

Collaborators
Amol Karmarkar, PhD - UTMB; Ken Ottenbacher, PhD - UTMB

General Description
Spina bifida (SB) is the most common birth defect that results in physical disability. The physical manifestations of SB include partial or complete paralysis of the lower limbs and/or trunk muscles and orthopedic deformities of the spine and limbs. Studies to date on functional outcomes in this population have been on small cohorts of individuals. This is the first study to examine functional status in a large, nationally representative sample. Results of this study will not only delineate the breadth of functional abilities within the different age groups and subtypes of SB, but will also inform clinicians of the comorbid conditions that may be related to impairments in function over the course of a lifetime.

The specific aims of this pilot study are:

1. Describe transition rates through frailty states and associated factors by gender.
2. Determine which medical, neurological, or demographic variables contribute significantly to functional ambulatory status.
3. Determine if SB Severity Index Score is significantly associated with functional ambulatory status.

Predictors of Community Participation Among Young Children who have Received Part C Early Intervention Services and are Entering Kindergarten

Mary Khetani, ScD, OTR
Assistant Professor
Department of Occupational Therapy
Joint Appointment Human Development and Family Studies
Colorado State University

Collaborator
James Graham, PhD, DC - UTMB

General Description
Promoting the participation of young children with disabilities in home and community activities is one of the primary service goals for families receiving Part C early intervention services, and is considered to be a key indicator of their full inclusion. Despite its importance, providers of early intervention services have been found to be less likely to address participation as a service-related outcome. There is a paucity of literature to draw upon to understand the impact of child, family, and environmental factors on the participation of young children with disabilities across a full range of home and community-based activities. Further study is needed to understand specific patterns with respect to young children's participation to better guide service planning efforts on this outcome in focused and feasible ways. This 1-year project involves secondary analysis of data from over 2,000 families of young children with disabilities who participated in the National Early Intervention Longitudinal Study (NEILS) that was completed between 1997-2007. We will analyze these data to examine what types of child, family, and environmental factors predict whether families experience participation restriction across a broad range of community activities. Study results will inform the design of a new parent-report survey of young children's participation and environment that is being developed for use in service planning with this population.

The specific aim of this pilot study is:

To determine the child, family and environmental factors that best differentiate between families who report difficulty and those who report no difficulty participating in excursions and outings, community-sponsored activities, and recreational activities.

Arthroplasty Type and Patient Age for Predicting Probability of Re-Operation After Arthroplasty For Displaced Femoral Neck Fractures

Sunny Kim, PhD
Associate Professor
University of California - Davis

Collaborator
Ken Ottenbacher, PhD, OTR- UTMB

General Description
Hip fractures are associated with osteoporosis and mostly caused by low-energy falls from standing heights. Due to the rapidly expanding elderly population, hip fractures are a growing burden in the U.S. and are one of the most challenging public health concerns. The goal of this study is to estimate the probability of undergoing re-operation after hemiarthroplasty (HA) or total hip arthroplasty (THA) on the basis of patient age, stratified by sex. Results will aid in our understanding of patient age in association with arthroplasty type and re-operation risk, and provide a validated probability table of re-operation after THA and HA by age group for men and women that could be used by care providers and patients in making informed decisions.

The specific aims of this pilot study are to:

1. Evaluate the arthroplasty type, age, and sex of patients as a predictor (or confounder) for re-operation after arthroplasty for femoral neck fracture.
2. Estimate the probability of re-operation after arthroplasty for femoral neck facture at three time points (within one year, three years, or five years) on the basis of the arthroplasty type and patient age, stratified by sex.

Obesity Misclassification and Cardiometabolic Risk among Adults with Chronic Physical Disabilities

Mark Peterson, PhD
Research Assistant Professor
University of Michigan

Collaborators
Soham Al Snih, MD, PhD - UTMB; Ken Ottenbacher, PhD, OTR - UTMB

General Description
The prevalence of overweight and obesity in the U.S. has risen dramatically over the past several decades. This is alarming considering the evidence that links obesity with subsequent metabolic disturbances and chronic disease outcomes; however, statistics often fail to account for individuals with chronic physical disabilities, a population in which risk for overweight and obesity is significantly higher. The purpose of this study is to identify the extent of overweight and obesity misclassification, as well as cardiometabolic health status of adults with and without chronic motor-related disabilities. This project will utilize the National Health and Nutrition Examination Survey (NHANES).

The specific aims of this pilot study are:

1. Estimate the degree of discrepancy regarding the classification of overweight and obesity among adults with and without chronic motor-related disabilities.
2. Evaluate the cardiometabolic risk profile of non-obese individuals determined by BMI, but classified as obese by body fat (i.e. normal weight obesity), as well as the extent to which sedentary behavior (SB) plays a mediating role in this risk.

Biopsychosocial Model of Improved Chronic Illness and Healthcare Utilization

Chia-Chang Wang
Assistant Professor
University of Buffalo

Collaborators
Soham Al Snih, MD, PhD - UTMB; Ken Ottenbacher, PhD, OTR - UTMB

General Description
The objective of this project is to systematically examine the associations between biopsychosocial factors and improved chronic illness of people age 50 or older and the consequences of improved chronic illness. The Health and Retirement Study (HRS) will be used to answer research inquires with the information about the improved chronic illness in five chronic diseases: diabetes, cancer, heart conditions, arthritis, and lung disease.

The specific aims of this pilot study are:

1. Compare the biopsychosocial predictors of patient-reported improvement in chronic illness for people age 50 or older with arthritis, cancer, diabetes, heart conditions, lung disease, or multiple conditions.
2. Compare the magnitude and significance of biopsychosocial predictors on outcomes of two age groups (50-64 vs. 65 or above).
3. Test the proposed biopsychosocial model of improved chronic illness and healthcare utilization/cost for people age 50 or older with chronic diseases.

Biopsychosocial Model of Improved Chronic Illness and Healthcare Utilization

Chia-Chang Wang
Assistant Professor
University of Buffalo

Collaborators
Soham Al Snih, MD, PhD - UTMB; Ken Ottenbacher, PhD, OTR - UTMB

General Description
The objective of this project is to systematically examine the associations between biopsychosocial factors and improved chronic illness of people age 50 or older and the consequences of improved chronic illness. The Health and Retirement Study (HRS) will be used to answer research inquires with the information about the improved chronic illness in five chronic diseases: diabetes, cancer, heart conditions, arthritis, and lung disease.

The specific aims of this pilot study are:

1. Compare the biopsychosocial predictors of patient-reported improvement in chronic illness for people age 50 or older with arthritis, cancer, diabetes, heart conditions, lung disease, or multiple conditions.
2. Compare the magnitude and significance of biopsychosocial predictors on outcomes of two age groups (50-64 vs. 65 or above).
3. Test the proposed biopsychosocial model of improved chronic illness and healthcare utilization/cost for people age 50 or older with chronic diseases.

Frailty Transitions and Frailty-Free Life Expectancy Among Older Mexican Americans - Gender Differences

Soham Al Snih, MD, PhD
Assistant Professor
Department of Rehabilitation Sciences
University of Texas Medical Branch

Collaborator
Ken Ottenbacher, PhD, OTR - UTMB

General Description
This pilot project explores transitions in frailty and years of frailty-free life and life expectancy in older Mexican Americans using data from the Hispanic Established Populations Epidemiologic Study of the Elderly.

Frailty is considered as a state of high vulnerability for adverse health outcomes such as disability, falls, hospitalization, institutionalization, and mortality in older adults. Prevalence of frailty in older Mexican Americans has been reported to be 17% in men and 20% in women. Previous research has shown that frailty is a dynamic process, with frequents transitions between frailty states over time. Currently, little is known about the probability of transitions between the different frailty states over time among older Mexican Americans.

The specific aims of this pilot study are:

1. Describe transition rates through frailty states and associated factors by gender.
2. Estimate the total life-expectancy and pre-frail/frail free life expectancy by gender.
3. Estimate the disability-free life expectancy by baseline frailty status and gender.
4. Determine the percent of frailty index components that are added from the previous follow-up for each interval of follow-up by gender.

Comparison of Rehabilitation Outcomes of Veterans and Medicare Beneficiates

Diane M. Collins, PhD
Assistant Professor
Department of Rehabilitation Sciences
University of Pittsburgh

Collaborator
Amol Karmarkar, PhD UTMB

General Description
This pilot project examines the impact of assistive devices on functional status in veterans and civilians post-stroke, using the Veteran Affairs' Functional Status Outcomes Database and National Patient Prosthetic Database and comparing these databases with outcomes data of Medicare beneficiaries. This pilot project will generate systematic evidence to support development of healthcare policy that improves access to and equitable provision of assistive technology devices (ATDs) for persons with disability. To study a more homogenous Medicare-age population, the study focus is on the Veterans and civilians who are inpatient for acute post-stroke treatment.

The research questions addressed are:

• Research Question 1.a: How do the demographic characteristics of post-stroke Veterans who received ATD from the Department of Veterans Affairs (VA) compare with the demographic characteristics of post-stroke civilians who received ATD from Medicare?
• Research Question 1.b: How do the demographic characteristics of post-stroke Veterans who did not receive ATD from the VA compare with the demographic characteristics of post-stroke civilians who did not receive ATDs from Medicare?
• Research Question 2.a: How does the functional status of post-stroke Veterans who received ATD from the VA compare with the functional status of post-stroke civilians who received ATD from Medicare?
• Research Question 2.b: How does the functional status of post-stroke Veterans who did not receive ATDs from the VA compare with the functional status of post-stroke civilians who did not receive ATD from Medicare?

Predictors of Functional Disparities among Individuals Living with Spinal Cord Injury

Denise Fyffe, PhD
Research Scientist
Spinal Cord Injury/Assessment & Outcomes Laboratory
Kessler Foundation Research Center

Collaborators
Anne Deutsch, PhD, CRRN - RIC;
Ken Ottenbacher, PhD, OTR - UTMB

General Description
This pilot project investigates demographic, sociocultural and clinical factors associated with disparities in functional outcomes among individuals living with spinal cord injury, using the National Spinal Cord Injury Model Systems database.

Although functional status is an important outcome after SCI injury, there has been little research attention focused on racial/ethnic group differences associated with the type of functional status over time as persons with SCI adjust to their impairment. Understanding the risk factors that affect changes in functional status after injury are essential to enhancing long-term rehabilitation efforts to promote community integration and quality of life for persons living with SCI. This pilot study will examine different types of functional gains, as measured by FIM subscale (i.e., self-care; sphincter control; motor/transfer; locomotion) scores, and functional gains observed over time in the NSCID.

The specific aims of this pilot study are:

Modeling Functional Outcomes from Spinal Cord Injury and Traumatic Brain Injury Model Systems Databases with Individual Growth Models

Alan Kozlowski, PhD, PT
Post Doctoral Fellow
Center for Rehabilitation Outcomes
Research Rehabilitation Institute of Chicago

Collaborators
Anne Deutsch, PhD, CRRN - RIC, James Graham, PhD, DC - UTMB

General Description
This pilot project evaluates the functional independence measures (FIM) outcomes for persons living with spinal cord injury and for those with traumatic brain injury as represented in the Spinal Cord Injury and the Traumatic Brain Injury Model Systems databases respectively, using the individual growth models methodology. The proposed pilot project will focus on the evaluation of clinical rehabilitation outcomes in the form of functional independence measures (FIM) from the Traumatic Brain Injury and the Spinal Cord Injury Model Systems (TBI-MS and SCI-MS respectively) using the individual growth models (IGM) methodologies. Medium (two to five years post discharge) and long-term (fifteen to thirty years post discharge) outcomes for the individuals with SCI and TBI will be evaluated using the above method. The application of IGMs will enable the individual with SCI/TBI to be the primary level of analysis, by integrating time as a factor, and by examining non-linear growth functions for change in FIM outcomes, in the areas of mobility, cognition and self-care, over time.

The specific aims of this pilot study are to:

1. Become familiar with the TBIMS and SCIMS databases and to identify the strengths and limitations inherent to secondary analysis as they apply to the MS databases
2. Complete statistical educational workshops in hierarchical linear modeling (HLM), structural equation modeling (SEM), latent growth curve modeling, and item-response theory.
3. Conduct longitudinal, non-linear IGM analyses of medium and long-term outcomes of the FIM mobility, self-care and cognitive subscales for persons living with SCI and TBI.
4. Present findings of these analyses to relevant audiences, including CLDR researchers, and to researchers and clinical professionals of spinal cord injury and traumatic brain injury
rehabilitation.
5. Submit findings for publication in relevant peer-review journals.
6. Submit a grant application to a federal agency for funding to extend this work, possibly in regard to generating individually predicted recovery curves to facilitate clinical decision-making within rehabilitation settings.