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Wheeled Mobility (Wheelchair) Service Delivery: Scope of the Evidence FREE

Nancy Greer, PhD; Michelle Brasure, PhD, MSPH, MLIS; and Timothy J. Wilt, MD, MPH
[+] Article and Author Information

From the Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minnesota Evidence-based Practice Center, and University of Minnesota School of Medicine, Minneapolis, Minnesota.


Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, AHRQ, the U.S. Department of Health and Human Services, or the U.S. government.

Acknowledgment: The authors thank Robert Kane, MD; Mary Butler, PhD; and Karen Siegel, PT, MA, for their guidance on the project.

Grant Support: By the Minnesota Evidence-based Practice Center, under contract to AHRQ (grant 290-07-10064-I).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1433.

Requests for Single Reprints: Nancy Greer, PhD, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Mail Code 111-O, Minneapolis, MN 55417; e-mail, nancy.greer@va.gov.

Current Author Addresses: Drs. Greer, Brasure, and Wilt: Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Mail Code 111-O, Minneapolis, MN 55417.

Author Contributions: Conception and design: N. Greer, M. Brasure, T.J. Wilt.

Analysis and interpretation of the data: N. Greer, M. Brasure, T.J. Wilt.

Drafting of the article: N. Greer, M. Brasure.

Critical revision of the article for important intellectual content: N. Greer, M. Brasure, T.J. Wilt.

Final approval of the article: N. Greer, M. Brasure, T.J. Wilt.

Provision of study materials or patients: M. Brasure.

Obtaining of funding: T.J. Wilt.

Administrative, technical, or logistic support: N. Greer, M. Brasure, T.J. Wilt.

Collection and assembly of data: N. Greer, M. Brasure.


Ann Intern Med. 2012;156(2):141-146. doi:10.7326/0003-4819-156-2-201201170-00010
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Identifying the appropriate wheelchair for a person who needs one has implications for both disabled persons and society. For someone with severe locomotive problems, the right wheelchair can affect mobility and quality of life. However, policymakers are concerned about the increasing demand for unnecessarily elaborate chairs. The Office of Inspector General, U.S. Department of Health and Human Services, issued 4 reports between 2009 and 2011 detailing fraud and misapplication of Medicare funds for powered wheelchairs, more than a decade after similar concerns were first raised by 4 contractors who process claims for durable medical equipment. Subsequent concerns have arisen about whether some impaired persons who need wheeled mobility devices may now be inappropriately denied coverage. A transparent, evidence-based approach to wheeled mobility service delivery (the matching of mobility-impaired persons to appropriate devices and supporting services) might lessen these concerns.

This review describes the process of wheeled mobility service delivery for long-term wheelchair users with complex rehabilitation needs and presents findings from a survey of the literature (published and gray) and interviews with key informants. Recommended steps in the delivery process were identified in textbooks, guidelines, and published literature. Delivery processes shared many commonalities; however, no research supports the recommended approaches. A search of bibliographic databases through March 2011 identified 24 studies that evaluated aspects of wheeled mobility service delivery. Most were observational, exploratory studies designed to determine consumer use of and satisfaction with the process. The evidence base for the effectiveness of approaches to wheeled mobility service delivery is insufficient, and additional research is needed to develop standards and guidelines.

Key Summary Points

Evidence on the effectiveness of recommended steps for wheeled mobility service delivery is sparse.

Available research consists primarily of studies with lower-quality designs, small sample sizes, heterogeneous populations, and inconsistent definitions and measurement of interventions and outcomes.

Several issues complicate wheeled mobility service delivery and may limit the ability of persons with complex rehabilitation needs to obtain the best equipment to maximize their functional abilities.

A consistent, transparent, and evidence-based approach to wheeled mobility service delivery is needed.

The use of wheelchairs and other wheeled mobility devices in the United States is at an all-time high and is increasing. Approximately 1.4% of the population aged 15 years or older (3.3 million persons) used a wheelchair or similar device in 2005 (1). Some wheelchair users have complex rehabilitation needs (2). Recent advances in mobility device and component technologies, such as postural seating and positioning systems (Figure), can increase activity levels and greatly improve quality of life for such persons, as well as for long-term wheelchair users and their families or caregivers (35). However, for persons to achieve those benefits, they must have access to providers and suppliers familiar with the advanced equipment, appropriate devices and components must be selected for them, and they must use the equipment. Inappropriate mobility devices may result in harms, including overuse or repetitive strain injuries, pressure sores, falls, and accidents; equipment abandonment; and underutilization (610).

Questions have also been raised about the increasing demand for unnecessarily elaborate wheelchairs. The Office of Inspector General, U.S. Department of Health and Human Services, issued 4 reports between 2009 and 2011 detailing fraud and misapplication of Medicare funds for powered wheelchairs (1114), more than a decade after similar concerns were first raised by 4 contractors who process claims for durable medical equipment (15). New concerns have been raised about whether some impaired persons who need wheeled mobility devices, especially powered wheelchairs, are being inappropriately denied coverage because of Medicare requirements that are too restrictive. A transparent, evidence-based approach to wheeled mobility service delivery might address these concerns.

The wheeled mobility service delivery process starts when a person identifies the need or is referred for a wheeled mobility device and continues, in theory, for the lifetime of the device (including maintenance and repairs). However, wheeled mobility devices may be obtained in various ways, including retail stores and online vendors. As a result, patients, providers, and payers may not be fully aware of or well-versed in the service delivery components that are necessary for the most appropriate match between the person and the equipment, features, and services. Our review outlines currently recommended approaches and models, describes research evaluating the effectiveness of the process, and identifies potential issues that influence the effectiveness of matching mobility-impaired persons who have complex rehabilitation needs with wheeled mobility devices.

We gathered information from various sources and interviewed knowledgeable representatives from a broad range of relevant occupations and organizations. Our key informant group included 5 providers and assessors, 2 consumers, 2 payer representatives, 1 researcher, and 1 equipment supplier representative. Key informants were identified by the topic nominator, topic experts contacted by the Minnesota Evidence-based Practice Center, the Agency for Healthcare Research and Quality (AHRQ) Scientific Resource Center, and other key informants. The key informants initially helped to define the scope of the review and identify resources in the peer-reviewed and gray literature. We subsequently used structured discussion questions to interview the key informants during June and July 2010. Our questions focused on experiences with service delivery, barriers to effective service delivery, and research gaps. Although we did not systematically analyze the responses, we did identify recurrent ideas from the responses and used them in our report to describe issues with service delivery and future research needs.

We searched the gray literature in July 2010 for descriptions of and critical issues related to the wheeled mobility service delivery process. Search terms included wheelchair or wheeled mobility and delivery, prescription, assessment, selection, or fit. Several databases were searched, including ProQuest Digital Dissertations, REHABDATA, the National Institute on Disability and Rehabilitation Research Program Directory, and the National Rehabilitation Information Center Knowledgebase. Payment policies were obtained by searching relevant online databases and by targeted requests for information. Library catalogs were searched to identify occupational and physical therapy textbooks and other reference materials. We also reviewed references identified by key informants and peer reviewers.

We searched MEDLINE, CINAHL, and ERIC from the earliest time permitted electronically through March 2011 for primary, English-language studies that focused on wheeled mobility service delivery and its relationship with a wheeled mobility outcome (such as use of or satisfaction with the device). Appendix Table 1 presents our MEDLINE search strategy. We included all publication types. Studies were excluded if they did not address components of the wheeled mobility service delivery process or their relationship to wheeled mobility outcomes; addressed aspects of wheeled mobility that were not relevant to service delivery questions (such as wheeled mobility used outside of routine activities, specific aspects of seating and mobility, outdated technology, or research and development on equipment that was not widely available); or addressed the creation or validation of or research on particular outcome measurement tools. From the selected studies, we abstracted and summarized the study purpose, population, study design, sample size, elements of service delivery studied, primary outcomes assessed, and user concerns with service delivery.

Table Jump PlaceholderAppendix Table 1.  MEDLINE Search Strategy
Role of the Funding Source

The Minnesota Evidence-based Practice Center prepared this technical brief with funding from the AHRQ Effective Health Care Program. The center collaborated with AHRQ to develop the protocol. The AHRQ reviewed the draft report but was not involved in study selection, data extraction, or drafting of the manuscript.

Recommended Approaches for Wheeled Mobility Service Delivery

The wheeled mobility service delivery process has been outlined by providers, organizations that represent patients, payers, suppliers, researchers, and health care agencies. Three of the 10 delivery models identified were developed for the broader area of assistive technology and 7 were specific to wheeled mobility service delivery, with 1 focused specifically on patients with spinal cord injury. Table 1(1625) provides an overview of these sources.

Table Jump PlaceholderTable 1.  Recommended Elements of Wheeled Mobility Service Delivery

All 10 models called for determining the person's goals and assessing his or her physical, cognitive, and functional ability as components of the evaluation. All but 1 model included an assessment of the person's environment (home and workplace). The models also included product selection, delivery, and fitting as key elements. Only 6 models recommended that persons be allowed to try the selected and assembled equipment before purchasing, possibly because not all equipment is available in all settings and some reimbursement systems do not cover equipment trials. In addition, equipment trials may be difficult because of the high degree of customization often required for persons with complex rehabilitation needs.

All models included the postdelivery step of training on use of the mobility device and components, for the person and, if necessary, for family members or caregivers. Seven models included follow-up by the equipment provider or supplier, and 5 included outcome assessment (such as use and user satisfaction). Our key informants corroborated this finding; little follow-up is typically done after delivery, and formal assessments of outcomes are rare.

Effectiveness of Wheeled Mobility Service Delivery

We reviewed 2169 titles (1824 from MEDLINE, 303 from CINAHL, and 42 from ERIC) and included 18 primary studies. Hand-searching of reference lists from relevant studies yielded another 6 for inclusion, for a total of 24 studies (10, 2648) (Appendix Figure). Appendix Table 2 provides details of the included studies.

Grahic Jump Location
Appendix Figure.
Summary of evidence search and selection.
Grahic Jump Location
Table Jump PlaceholderAppendix Table 2.  Studies of Wheeled Mobility Service Delivery

The 24 studies varied in design and included 1 randomized, controlled trial; 1 quasi-randomized, controlled trial; 1 controlled trial; 1 case–control study; 3 retrospective cohort studies; 16 cross-sectional studies; and 1 case series. Sample sizes ranged from 3 to 318 and included persons of all ages, although most studies focused on adults.

The studies enrolled many types of consumers, including persons with spinal cord injuries, multiple sclerosis, spina bifida, cerebral palsy, rheumatoid arthritis, osteoarthritis, and stroke. Overall, 14 of the studies enrolled only persons with complex medical conditions and 5 included a mix of participants, some of whom had complex needs. Of the remaining 5 studies, 2 did not specify the participant population and 3 enrolled participants with noncomplex needs. Most of the included research took place in individual practice settings in the United States, the United Kingdom, Canada, Sweden, Holland, the Netherlands, and Australia.

The studies were primarily exploratory. Two studies (27, 46) identified factors important to persons when considering wheeled mobility options. Another 2 studies (37, 45) assessed caregivers' and parents' opinions about the wheeled mobility used by their child. Four studies (28, 36, 38, 48) that sought to determine user satisfaction with wheeled mobility devices and service delivery focused on a particular service or regional area to describe user satisfaction and opportunities for improvement. A fifth study (47) addressed similar questions with a more comprehensive data collection strategy.

Table 2 summarizes the outcomes. Five studies (30, 32, 35, 43, 47) reported mobility outcomes, but only 1 (32) related the overall delivery process to mobility. Similarly, of the 4 studies that focused on the outcome of goal achievement (26, 38, 4647), only 2 (38, 46) looked at the overall delivery process.

Table Jump PlaceholderTable 2.  References Addressing Each Element of Wheeled Mobility Service Delivery, by Assessed Outcome

Most studies reported on satisfaction; 16 (2631, 3337, 42, 44, 4648) addressed satisfaction with the equipment, and 11 (26, 2829, 32, 36, 39, 42, 4445, 4748) addressed satisfaction with aspects of wheeled mobility service delivery. Five studies compared 2 approaches to wheeled mobility service delivery; 2 of these (26, 43) compared in-person assessments with those done via telerehabilitation, whereas the other 3 compared either different types of treatment or different approaches to assessment. One of these studies (34) compared a multifactorial team approach with usual care, in which a physical or occupational therapy assistant, physical therapist, or occupational therapist provided a standard wheelchair at discharge. A second study (35) compared the provision of a motorized scooter with usual care in adults with arthritis of the knee. The third (30) compared outcomes of patients assessed at specialized assistive technology clinics with outcomes of those who were not assessed.

One study (41) analyzed outcomes for persons who visited a seating clinic and reported particular problems with their wheelchairs. Another (10) explored reasons for abandoning equipment. Five (10, 3133, 47) reported patient concerns with various aspects of service delivery, including wait times for appointments and equipment, patient involvement in the process, and equipment repair.

Issues and Research Gaps

Our review of the gray literature and discussions with key informants highlighted several issues related to wheeled mobility service delivery that future research should evaluate and quantify. Many of these issues could contribute to an inappropriate match between a mobility-impaired person and the wheeled mobility device.

Payer representatives noted the increasing demand for powered mobility devices. Their concerns focused on the role of health insurers when equipment is requested for non–health-related needs; current Medicare policies that restrict coverage to the needs of persons in their homes only and not beyond; and the basing of chair qualification and type on the diagnosis a person receives, not on their functional status.

Consumer representatives were concerned that many persons lack the necessary knowledge and awareness of the wheeled mobility delivery process and available resources. They noted that third-party payer networks may limit user options by specifying providers and suppliers, applying annual caps to durable medical equipment expenses, and restricting the use of private funds to upgrade equipment.

The key informants who were involved in wheeled mobility service delivery indicated that providers must often consider not only what they believe is right for the person but also what will be reimbursed. They also noted that the medical model, in which the physician is responsible for the prescription and the letter of medical necessity, may not be most appropriate for all persons or situations. The informants recommended involving a therapist in the prescription process.

Key informants from the equipment industry noted the limitations of the Current Procedural Terminology code system. Providers may not be adequately reimbursed for user assessments, user environment assessments, equipment trials, equipment adjustments, or training recipients in equipment use.

The research gaps identified in our review and corroborated by our key informants indicate a need for additional research to provide an evidence base for wheeled mobility service delivery. Future research could include persons with different physical and cognitive limitations, funding sources, needs or goals (such as home or vocational), and support systems. Further research could also evaluate different models of specialty seating and mobility clinics; telerehabilitation for persons with no access to specialty clinics; evaluations performed by professionals from different fields and by teams of professionals; and various outcomes, such as functional abilities, comfort with and use of prescribed equipment, adverse effects, and equipment breakdowns. Conducting randomized, controlled trials in this area is challenging because of issues related to study design, population, environments, and equipment variations (35). High-quality observational studies would add value to this field. In addition, funding agencies need to be willing to allocate resources for research in this area.

Wheeled mobility service delivery is not a new concept or technology. However, dramatic changes have occurred in recent decades, including changes to funding, provider qualifications, consumer needs and desires, and advances in technology. Providers, payers, and consumers may therefore lack the necessary knowledge and awareness to ensure that persons with complex rehabilitation needs get the most appropriate seating and mobility services and equipment. Recent evidence of inappropriate prescribing and reimbursement, including in the Medicare system, may have resulted in inappropriate limitations on a person's ability to get medically indicated equipment. Lack of access to (or underprescription of) necessary wheeled mobility equipment poses a substantial threat to quality of life for impaired persons with mobility needs. However, overprescription or inappropriate prescription could result in wasted resources or harms to the user.

Our literature searches and discussions with key informants revealed several elements of the wheeled mobility service delivery process that probably affect the quality of the match between the person and the wheeled mobility device. First, service delivery for persons with complex rehabilitation needs is probably best facilitated by a team of providers and professionals, which should include a physician, a physical or occupational therapist, a certified rehabilitation technology supplier, and a rehabilitation technician. However, rural areas often have fewer experienced providers and suppliers, and little is known about other factors that might limit access to high-quality providers. For persons with complex rehabilitation needs, the recommended setting for service delivery is a hospital seating clinic. Second, training and consumer education are important factors in reducing accidents (49), preserving limb function (50), increasing wheelchair skills (51), and increasing use of the wheeled mobility device (5253). Third, involving the person in the prescription process may reduce the risk that the device will be abandoned (910, 54). Finally, active follow-up has reduced accidents (55) and allowed for adjustments to improve fit (54).

Our review underscores the lack of standardization across wheeled mobility delivery processes and the lack of research evaluating delivery approaches. Seating and mobility experts generally agree on how wheeled mobility service delivery should work; however, relatively little is known about how delivery processes work in practice. Evidence of effectiveness of delivery processes is lacking, as are clear, standard, validated models of wheeled mobility delivery. Thus, health care systems may not offer specialized seating and positioning clinics with teams of providers and ongoing services, and third-party payers may not realize the need to fund the recommended steps. Not all persons who need wheeled mobility devices require every step outlined for service delivery, nor will all such persons require or benefit from highly technical, customized equipment. A consistent, transparent, and valid approach is needed to best align wheeled mobility services with consumer needs.

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Tables

Table Jump PlaceholderAppendix Table 1.  MEDLINE Search Strategy
Table Jump PlaceholderTable 1.  Recommended Elements of Wheeled Mobility Service Delivery
Table Jump PlaceholderAppendix Table 2.  Studies of Wheeled Mobility Service Delivery
Table Jump PlaceholderTable 2.  References Addressing Each Element of Wheeled Mobility Service Delivery, by Assessed Outcome

References

Brault M.  Americans with disabilities: 2005.  Current Population Reports. Washington, DC: U.S. Census Bureau; 2008; 70-117.
 
National Coalition for Assistive and Rehab Technology.  Proposal to Create a Separate Benefit Category for Complex Rehab Technology. Buffalo, NY: National Coalition for Assistive and Rehab Technology; 2011.
 
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