Wheelchair Service Delivery Research Articles

Effects of the WHO 8-step wheelchair-service-delivery process on wheelchair users in El Salvador: a cohort study

Purpose To test the hypotheses that, after the delivery of manual wheelchairs following the WHO 8-step service-delivery process, wheelchair-related health and quality of life, wheelchair skills, wheelchair use, and poverty probability would improve; and that the number of wheelchair repairs required, adverse events, caregiver burden, and the level of assistance provided would decrease. Methods This was a longitudinal, prospective within-subject study including 247 manual wheelchair users, and 119 caregivers, in El Salvador who received a wheelchair following the WHO 8-step process as well as maintenance reminders. Outcome measurements were performed via structured questionnaires and dataloggers at the initial assessment, at wheelchair delivery, and at 3- and 6-month follow-up. Results Significant improvements in wheelchair-related health indicators (all with p < 0.004) and quality of life (p = 0.001), and a significant reduction in national and “extreme” poverty probability (p = 0.004 and p = 0.012) were observed by six months. Wheelchair use significantly decreased (p = 0.011 and p = 0.035) and wheelchair skills increased (p = 0.009). Caregiver burden did not change (p = 0.226) but the number of activities of daily living (ADLs) that required no assistance significantly increased (p = 0.001) by three months and those who required complete assistance decreased (p = 0.001). No changes were observed in wheelchair repairs (p = 0.967) and breakdowns over time with new wheelchairs. Conclusions Wheelchair service delivery using the WHO 8-step process on manual wheelchair users in El Salvador has positive effects on health and quality of life, wheelchair skills, caregiver assistance levels, and poverty. Further research is needed to determine the relative contributions of the intervention components.

Investigation of factors from assistive technology professionals that impact timeliness of wheelchair service delivery: a cross-sectional study

Purpose The purpose of this study was to examine factors associated with variability in time from assessment to device delivery (cycle time). Our hypothesis was that device type and type of insurance would be the strongest predictor of cycle time. Materials and methods Data were extracted from the Functional Mobility Assessment/Uniform Dataset (FMA/UDS) Registry that at the time of analysis contained a sample of 2588 people with disabilities (PWD) who were provided with a wheeled mobility device (WMD) between 21 March 2016 and 29 June 2021. To examine the effect of individual factors on the variability in cycle time, a robust linear regression analysis was conducted. Results The average national cycle time was 101.5 (SD = 59.9) d. Geographic area (Capital Metro [p < .001], Great Lakes [p = .016], and Northeast area [p < .001]), higher years since onset of disability (p < .001) and customizable devices (p = .021) were associated with higher cycle time. Non-customizable devices (p = .005), scooters (p < .001), Group 2 power wheelchairs (PWCs; p < .001), and funding source (Medicaid managed care (p < .001) and “other” (p = .028)) were associated with lower cycle time. Conclusions Longer cycle time is likely related to variations in clinical practice, insurance coverage criteria and the level of customizability of the device needed for a particular diagnosis, especially long-term disabilities. Implications for rehabilitation The national average number of days between initial evaluation and device delivery (cycle time) to deliver a wheeled mobility device (WMD) varies based on specific variables such as type of WMD, diagnosis and payer source. Geographic area, years since onset of disability, device type, primary diagnosis and funding source significantly impact cycle times. Increased complexity of the WMD, both manual and power wheelchairs (PWCs), was associated with longer cycle times. As more service delivery models emerge, specific benefits and challenges need to be reported on how they impact cycle time.

Wheelchair Skills Test Outcomes across Multiple Wheelchair Skills Training Bootcamp Cohorts.

User training is a critical component of wheelchair service delivery to ensure individuals with a mobility impairment can negotiate environmental barriers and promote their social participation. A wheelchair “bootcamp”, delivered during professional preparation education, is one strategy to better prepare occupational therapists for clinical rehabilitation practice by developing their own wheelchair skills. The purpose of this study was a retrospective review of a large dataset of student cohorts from a single site and delineate bootcamp effects on the Wheelchair Skills Test-Questionnaire (WST-Q) scores. Participant data from eight cohorts was consolidated (n = 307). Comparison of two WST-Q scoring formats revealed significantly lower scores for cohorts using the 4-point version, which was subsequently standardized to the other 3-point version. WST-Q change scores were similar between cohorts, and differences were more reflective of variability in skill level prior to bootcamp than post-bootcamp scores. Students were able to master most basic and intermediate level skills, while advanced skill acquisition was much more variable. This study provides more precise point estimates of wheelchair skill acquisition among occupational therapy students than previous studies. While confirming the benefits of bootcamp education, recommendations for further investigation were identified.

A cross-sectional survey investigating wheelchair skills training in Ireland

Purpose Wheelchair skills trainings are a vital aspect wheelchair provision yet are arguably overlooked and extent to which training is provided in the Irish context is highly variable. The primary aim of this study was to quantify whether a need exists to further develop wheelchair skills training in Ireland. Methods A cross sectional survey was conducted using SurveyMonkeyTM. Irish health professionals involved in wheelchair service delivery were asked how they offer wheelchair skills trainings and what components of wheelchair skills they train. To collect qualitative information, questions also explored how health professionals would like training to develop. Results Consensus among respondents was that training is often provided to new users (n = 91, 89%), however, it is limited to mostly transfers and simple mobility techniques. Further, it was reported that advanced mobility skills are sometimes (n = 81, 51%) or never taught (n = 81, 21%). The respondent’s confidence instructing various skills corresponded with the frequency of instruction. The responses captured a shared interest in developing standardised training programs and the development of continued education training in the area. Conclusion The findings from this study reinforce that a present need exists to further develop wheelchair skills training in Ireland, with the aim of improving Irish wheelchair service providers’ knowledge and confidence in advanced wheelchair skills needed to mobilise and perform activities of daily living. IMPLICATIONS FOR REHABILITATION Current clinical practice in Irish wheelchair service delivery includes basic wheelchair skills training, whereas training in advanced skills needed for improved independent mobility is highly variable. This study raises awareness that health professionals seek formal education and training in wheelchair skills to improve their knowledge and confidence in providing wheelchair skills training. There is a need to develop wheelchair skills training opportunities, both as a requirement for stakeholders involved in wheelchair provision and to address an unmet need for wheelchair users.

Understanding the Global Challenges to Accessing Appropriate Wheelchairs: Position Paper.

Introduction: Appropriate wheelchairs are often essential for the health and wellbeing of people with mobility impairments to enhance fundamental freedoms and equal opportunity. To date, provision has mainly focused on just delivering the wheelchair instead of following an evidence-based wheelchair service delivery process. In addition, many governments have not committed to a national wheelchair provision policy. Approach: To prepare this position paper, a systemic development model, founded on the sustainable human security paradigm, was employed to explore the global challenges to accessing appropriate wheelchairs. Positions: I: Consideration of key perspectives of wheelchair provision across the life course is essential to meet the needs to children, adults, older people and their families; II: Comprehensive wheelchair service delivery processes and a competent workforce are essential to ensure appropriate wheelchair service provision; III: Evaluations on wheelchair product quality development, performance and procurement standards are key as wheelchair product quality is generally poor; IV: Understanding the economic landscape when providing wheelchairs is critical. Wheelchair funding systems vary across jurisdictions; V: Establishing wheelchair provision policy is a key priority, as specific policy is limited globally. Conclusion: The vision is to take positive action to develop appropriate and sustainable wheelchair service provision systems globally, for me, for you, for us.

User Perspectives on the Service Delivery of Complex Power Wheelchairs

The purpose of this study was to explore users’ perspectives on power wheelchair service delivery and understand their involvement in the equipment trial and selection process. Five power wheelchair users participated in. Responses and interview data analysis supported four main themes describing variability in the evaluation practices of the provider team, how consumers’ participation goals were impacted by equipment usability, consumer involvement in equipment selection influenced satisfaction, and illustrated the complexities in the service delivery process. The conclusion suggests consumer involvement in the trial and selection process may contribute to power wheelchair outcome usability, satisfaction, and occupational engagement.

Trends in wheelchair recommendations in a dedicated seating department

ABSTRACT Introduction In the early 2000 s, investigators at the federal government noted growing Medicare expenditures for power mobility devices, which were related to high profit margins and fraudulent activity. Medicare responded with policy and program changes, and stakeholders in wheelchair service delivery have noticed an impact on their services and changes in wheelchair user access to needed equipment. Methods This study examined 4,252 wheelchair clinical recommendations made by full-time wheelchair seating department therapists between 2007 and 2017 through a retrospective chart review. Demographic counts and percentages were examined in relationship with equipment over time. Results The number of recommendations increased over time in all age groups, but most for people aged 19–64. Fifty percent of people with Medicare were younger than 65, and 63% of Medicare recommendations were for complex wheelchair bases. Overall, decreased recommendations were noted in 2008, consistent with the economic recession. An increase in recommendations occurred from 2014 to 2017, consistent with the onset of the Affordable Care Act. Conclusions Most change occurred for middle and older age groups, complex manual wheelchairs, and standard power mobility devices. This study supports the need for a separate Medicare category of Complex Rehabilitation Technology for those with severe disabilities.

Development of Wheeled Mobility indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Background: Wheeled mobility is critical for individuals with Spinal Cord Injury or Disease (SCI/D) related paralysis. The World Health Organization (WHO) developed guidelines highlighting eight steps in wheelchair service delivery: (1) referral and appointment; (2) assessment; (3) prescription; (4) funding and ordering; (5) product preparation; (6) fitting; (7) user training; and, (8) follow-up maintenance/repairs. This article describes the processes used to develop structure, process and outcome indicators that reflect the WHO guidelines within the Domain of Wheeled Mobility rehabilitation for Canadians.Methods: Wheeled mobility experts within the SCI-High Project Team used the WHO guideline to inform the Construct refinement and development of a Driver diagram. Following seven meetings, the Driver diagram and review of outcome measures and literature synthesis regarding wheelchair service delivery informed indicator selection and group consensus.Results: The structure indicator examines the proportion of SCI/D service providers within a rehabilitation program who have specialized wheelchair training to ensure prescription, preparation, fitting, and maintenance quality. The process indicator evaluates the average number of hours of wheelchair service delivery provided per patient during rehabilitation. The intermediary outcome indicator (rehabilitation discharge), is a target capacity score on the Wheelchair Skills Test Questionnaire (WST-Q). The final outcome indicators (at 18 months post rehabilitation admission) are the Life Space Assessment (LSA) and the Wheelchair Use Confidence Scale (WheelCon) short form mean scores.Conclusion: Routine implementation of the selected Wheeled Mobility structure, process and outcome indicators should measurably advance care within the Wheeled Mobility Domain for Canadians living with SCI/D by 2020.

Community-based rehabilitation workers' perspectives of wheelchair provision in Uganda: A qualitative study.

BackgroundThe challenges of wheelchair provision and use in less resourced settings are the focus of global efforts to enhance wheelchair service delivery. The shortage of professional wheelchair service providers in these settings necessitates the collaboration of multiple stakeholders, including community-based rehabilitation (CBR) workers, whose role needs to be further understood.ObjectivesThe aim of this study was to determine what CBR workers in three areas of Uganda perceived as (1) the challenges with wheelchair provision and use, (2) the factors contributing to these challenges, (3) the role they themselves can potentially play and (4) what facilitators they need to achieve this.MethodThis qualitative study in the transformative paradigm comprised focus group discussions to gather perceptions from 21 CBR workers in three areas of Uganda, each with an operational wheelchair service, participant observations and field notes. Thematic analysis of data was implemented.ResultsCommunity-based rehabilitation workers’ perceptions of challenges were similar while perceived causes of challenges differed as influenced by location, historical and current wheelchair availability and the CBR workers’ roles. Their main responsibilities included assistance in overcoming barriers to access the service, transfer of skills and knowledge related to wheelchairs, follow-up of users for wheelchair-related problem-solving, and user and community empowerment.ConclusionCommunity-based rehabilitation workers can contribute in various ways to wheelchair service delivery and inclusion of wheelchair users; however, their capabilities are not consistently applied. Considering the diversity of contextual challenges, CBR workers’ range of responsive approaches, knowledge of networks and ability to work in the community make their input valuable. However, to optimise their contribution, specific planning for their training and financial needs and effective engagement in the wheelchair services delivery system are essential.Keywordswheelchairs; less resourced settings; community-based rehabilitation; wheelchair service provision; service steps; Uganda; empowerment; inclusion; assistive device.

Relationships Between Wheelchair Services Received and Wheelchair User Outcomes in Less-Resourced Settings: A Cross-Sectional Survey in Kenya and the Philippines

ObjectiveTo explore the relationships between wheelchair services received during wheelchair provision and positive outcomes for users of wheelchairs. DesignSecondary analysis of cross-sectional data. SettingUrban and periurban communities in Kenya and the Philippines. ParticipantsAdult basic manual wheelchair users (N=852), about half of whom reported having received some wheelchair services with the provision of their current wheelchairs. InterventionsNot applicable. Main Outcome MeasuresParticipants completed a survey that included questions related to demographic, clinical, and wheelchair characteristics. The survey also included questions about the past receipt of 13 wheelchair services and 4 positive outcomes for users of wheelchairs. The relationships between individual services received and positive outcomes were assessed using logistic regression analyses. In addition to assessing individual services and outcomes, we analyzed a composite service score (the total number of services received) and a composite outcome score (≥3 positive outcomes). ResultsThe top 3 individual services from the perspective of relationships with the composite outcome score were “provider did training” (P=.0009), “provider assessed wheelchair fit while user propelled the wheelchair” (P=.002), and “peer group training received” (P=.033). The composite service score was significantly related to “daily wheelchair use” (P<.0001), “outdoor unassisted wheelchair use” (P<.0001), “high performance of activities of daily living” (P=.046) and the composite outcome score (P=.005), but not to the “absence of serious falls” (P=.73). ConclusionsThe receipt of wheelchair services is associated with positive outcomes for users of wheelchairs, but such relationships do not exist for all services and outcomes. These findings are highly relevant to ongoing efforts to optimize wheelchair service delivery.

Development of “My Wheelchair Guide” app: a qualitative study

Background: The smartphone app “My Wheelchair Guide” is designed to provide essential information about wheelchair use and service delivery for new wheelchair users. It aims to empower wheelchair users in taking ownership in acquiring appropriate wheelchairs, and guiding them to use their wheelchairs in a safe and effective manner.Objective: This paper describes the development of the “My Wheelchair Guide” app and the usability evaluation of one of the app sections “Use a Wheelchair”.Method: Ten manual wheelchair users and four seating/mobility professionals completed a survey on the ease of use and perceived usefulness of the app, and a semi-structured interview. Wheelchair users used checklists in the app to self-assess their wheelchairs’ fit and set-up, and their wheelchair skills. Two investigators independently conducted content analysis of the interview transcripts and identified salient themes.Results: All participants perceived the app to be easy to use. Both wheelchair users and wheelchair seating professionals recognized that the “Use a Wheelchair” section would be very beneficial for new wheelchair users. Self-assessment checklists facilitated participants to review their wheelchair set-up and skills. Participants also provided several suggestions and recommendations to revise and refine the app section.Conclusion: The app section was perceived to be a useful and easy-to-use educational tool by most of the study participants. Participants’ feedback will be used to guide the app revision for a better user experience. Further studies could be conducted to assess the app effectiveness on improving wheelchair users’ knowledge and facilitating self-advocacy for appropriate wheelchairs.Implications for rehabilitationSmartphone apps designed to support patient education and self-management regarding wheelchair use are perceived beneficial by both wheelchair users and clinical professionals.Smartphone apps support multimedia information presentation and user interaction, and can potentially create an effective learning environment for wheelchair users and their families to learn about their everyday devices.Users of educational apps prefer reduced text-based content and care about app aesthetics.

Barriers and facilitators of integrating the miWe immersive wheelchair simulator as a clinical tool for training powered wheelchair-driving skills

Training is an essential aspect of power wheelchair (PWC) service delivery, but is often insufficient and inadequate, which can lead to sub-optimal wheelchair driving skills and decreased confidence in one's abilities. Training using a validated and portable virtual reality platform could increase access, efficiency and safety in PWC skills training. The McGill Immersive Wheelchair Simulator (miWe) was developed for this purpose and has already been validated for PWC training. Before integrating miWe into clinical practice we need input from stakeholders to optimize uptake. Therefore, the objective of this project is to investigate clinical stakeholders’ acceptance of miWe as a potential PWC skills training tool in a rehabilitation setting. A series of focus groups were used to obtain perspectives from clinical program directors and rehabilitation therapists experienced in PWC skills training from four sites in two Canadian provinces. An online survey was also conducted to obtain perspectives from therapists who were not able to attend the focus groups. Thirteen occupational therapists, seven clinical program directors, two seating clinical specialists and one orthotic/prosthetic mechanic ( n = 23) participated in the focus groups, and seven occupational therapists completed the survey. Participants generally expressed that use of miWe would be complementary to training in a real PWC, and that miWe could be useful for challenging situations in rehabilitation centres (e.g., clients who are anxious; when there is uncertainty around their potential to drive a PWC; tasks that cannot be assessed in a real-life environment). They also provided suggestions to improve miWe (e.g., more feedback during tasks; possibility of adjusting the parameters and adding varied control interfaces). MiWe has the potential to provide a robust platform for the assessment and training of complex PWC driving skills in a realistic and immersive training context. The results of this project will inform its potential distribution in rehabilitation centres.

Wheelchair Service Delivery Quality Improvement Program

Wheelchair Service Delivery Quality Improvement Program

Policy implementation in wheelchair service delivery in a rural South African setting.

BackgroundWheelchairs allow users to realise basic human rights and improved quality of life. South African and international documents guide rehabilitation service delivery and thus the provision of wheelchairs. Evidence indicates that rehabilitation policy implementation gaps exist in rural South Africa.ObjectivesThe aim of this article was to explore the extent to which wheelchair service delivery in a rural, remote area of South Africa was aligned with the South African National Guidelines on Provision of Assistive Devices, The United Nations Convention on the Rights of Persons with Disabilities and The World Health Organization Guidelines on Provision of Wheelchairs in Less-Resourced Settings.MethodQualitative methods were used. Data were collected through semi-structured interviews with 22 participants who were identified through purposive sampling. Content analysis of data was preformed around the construct of wheelchair service delivery.ResultsStudy findings identified gaps between the guiding documents and wheelchair service delivery. Areas where gaps were identified included service aspects such as referral, assessment, prescription, user and provider training, follow up, maintenance and repair as well as management aspects such as staff support, budget and monitoring. Positive findings related to individual assessments, enthusiastic and caring staff and the provision of wheelchairs at no cost.ConclusionThe gaps in policy implementation can have a negative impact on users and the service provider. Inappropriate or no wheelchairs limit user function, participation and quality of life. In addition, an inappropriate wheelchair will have a shorter lifespan, requiring frequent repairs and replacements with cost implications for the service provider.

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

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.

A Preliminary Model of Wheelchair Service Delivery

Eggers SL, Myaskovsky L, Burkitt KH, Tolerico M, Switzer GE, Fine MJ, Boninger ML. A preliminary model of wheelchair service delivery. Objective To integrate and expand on previously published models of wheelchair service delivery, and provide a preliminary framework for developing more comprehensive, descriptive models of wheelchair service delivery for adults with spinal cord injury within the U.S. health care system. Design Literature review and a qualitative analysis of in-depth interviews. Setting Not applicable. Participants Ten academic, clinical, regulatory, and industry experts (Department of Veterans Affairs [VA] and non-VA) in wheelchair service delivery. Interventions Not applicable. Main Outcome Measures Interviewees were asked to discuss the full range of variables and stakeholders involved in wheelchair service delivery, and to limit their scope to the provision of primary subsequent or replacement chairs (not backup chairs) to adults within the United States. Results Most experts we interviewed stressed that clients who require a wheelchair play a central role in the wheelchair service delivery process. Providers (including clinicians, rehabilitation engineers, and rehabilitation counselors) are also critical stakeholders. More so than in other health care settings, suppliers play an integral role in the provision of wheelchairs to clients and may significantly influence the appropriateness of the wheelchair provided. Suppliers often have a direct role in wheelchair service delivery through their interactions with the clinician and/or client. This model also identified a number of system-level factors (including facility administration and standards, policies, and regulations) that influence wheelchair service delivery and ultimately the appropriateness of the wheelchair provided. Conclusions We developed a detailed, descriptive model of wheelchair service delivery that integrates the delivery process and device outcomes, and includes the patient-level, provider-level, and system-level factors that may directly influence those processes and outcomes. We believe that this detailed model can help clinicians and researchers describe and consider the complexities of wheelchair service delivery. It can be used to identify factors that may be related to disparities in wheelchair service delivery and in the appropriateness of the wheelchair prescribed. Further, this model can help researchers and clinicians identify factors that may be related to disparities in wheelchair service delivery, and intervene to reduce such disparities.

Satisfaction related to wheelchair use in older adults in both nursing homes and community dwelling

Purpose. Older adults commonly use wheelchairs for mobility impairments regardless of their living situations. However, limited outcomes data are available to determine quality of the wheelchairs that older Americans are receiving, as well as their satisfaction with wheelchair service delivery programs. The purpose of this article was to analyze satisfaction data collected from three cohorts of older individuals living at nursing homes and in community settings. Ninety participants were residents in VA (n = 60).Methods. One hundred thirty two older adults completed the standardized Quebec User Evaluation of Satisfaction with Assistive Technology. Ninety participants were residents in VA (n = 30) or private nursing homes (n = 30), and 42 were community dwelling participants. Those enrolled were either independent manual or power wheelchairs users.Results. The community dwelling group reported significantly higher levels of satisfaction with their manual wheelchairs and service delivery when compared with the private nursing home participants (4.3 versus 2.9, p = 0.002). The satisfaction was also higher for VA nursing homes than private (3.9 versus 2.9, p = 0.004). No significant differences were reported for satisfaction levels regarding powered wheelchairs use between three groups.Conclusion. Level of satisfaction should be incorporated as an outcomes measure for evaluating wheelchair prescriptions and service delivery programs. This study also supports the establishment of a re-evaluation process of wheelchair fit as the users' age, to aide in provision of the best quality wheelchairs and service delivery programs.

Provision of electrically powered indoor/outdoor wheelchairs

Variations in NHS wheelchair service delivery result in inequality for service users. The introduction of electrically powered indoor/outdoor wheelchairs was studied in three geographically different wheelchair services. A major reason for inequality was differing interpretation of NHS guidelines and methods of allocating funding. The study also raised issues relating to wider mobility and the environment.