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UWL: Association With Outcomes (2009)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
  • To identify the amount of change that occurred in functional limitations and activities of daily living over a 12-month period
  • To identify the predictors of change at 12 months in both groups of activities
  • To determine which residents improved, which remained stable and which deteriorated over 12 months.
Inclusion Criteria:

The sample represents patients receiving chronic care with ongoing chronic conditions who need hospitalization either for a short period of time (several months) or long-term care (receive ongoing, complex, continuing care and are not able to live independently but require ongoing nursing care).

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:


Residents of a chronic care and long-term care institution.


Case series study. 

Statistical Analysis

  • Descriptive statistics (mean, range and standard deviation) were used to assess baseline and follow-up scores for both functional limitations and ADL
  • Paired T-tests were used to compare mean scores from baseline to 12 months for FL and ADL scores
  • Univariate regressions were performed for residents who had complete data at baseline and one year follow-up with ADL and functional limitations both as dependent variables
  • Multiple regression using backward stepwise procedures was used to assess the predictors of baseline functioning for functional limitations and ADL separately
  • A correlation matrix was assembled of potential variables for multiple regression with both FL and ADL at baseline separately
Data Collection Summary:

Timing of Measurements

Residents were assessed quarterly using the MDS over a 12-month period (December 1997 to December 1998) by trained MDS case managers.

Dependent Variables

  • Physical functioning, conceptualized in physical limitations (e.g., bed mobility) and disability (e.g., dressing)
  • Items were scored on a five-point scale: one = independent, two = supervision, three = limited assistance, four = extreme assistance, five = total dependence based on the patient's performance over the past 14 days.

Independent Variables

  • Age
  • Sex
  • Marital status.

Control Variables

Indicators of baseline health status included:

  • Balance while standing
  • Range of motion
  • Pain
  • Depression score
  • Mood persistence
  • Vision problems
  • Psychosocial well-being
  • Short-term and long-term memory
  • Weight loss (5% or more in the last month)
  • Weight gain (5% or more in the last month)
  • Whether they had fallen in the last 30 days
  • Whether they had a hip fracture or any other fracture in the last 180 days.
Description of Actual Data Sample:
  • Initial N: 165 residents mentioned in text (72 males, 93 females). 138 residents mentioned in the abstract
  • Attrition (final N): As above
  • Age: Mean age for females, 79 years; males, 76 years
  • Location: Chronic care hospital in Southern Ontario, Canada. 
Summary of Results:

Paired T-test Comparing ADL Scores and Functional Limitation Scores on Individual Activities (Baseline to 12 Months)



Mean Difference 99% CI



Dressing -0.10 (-0.24, 0.026) 0.038
  Eating -0.13 (-0.030, 0.050) 0.063
  Toilet use -0.13 (-0.281, 0.016) 0.021
  Bathing -0.09 (-0.210, 0.020) 0.032


Personal hygiene


(-0.317, 0.061)


Functional limitations Bed mobility -0.19 (0.392, 0.001) 0.010
  Transfer -0.13 (0.310, 0.051) 0.063
  Locomotion 0.01 F value less than one ---
Mean scores ADL -0.12  (-0.233, -0.007) 0.007
  Functional limitations -0.12 (-0.278, 0.0330) 0.041

Other Findings

  • In both FL and ADL, 17 persons (10.3%) showed improvement; however, 53% deteriorated in ADL compared to 50% in FL
  • The greatest deterioration in scores for ADL occurred in dressing, eating and personal hygiene, with a change in scores of -0.13 points, and for FL the function deteriorated most in bed mobility by -0.19 points
  • Gender, range of motion score at baseline, change in bed mobility and change in short-term memory were strong independent predictors of changes in functional activity; FL-adjusted R2 = 0.23, F(5,156) = 10.47, P<0.0001
  • The strongest independent predictors of change in ADL were gender, balance while standing at baseline, joint range of motion at baseline, change in depression scores and weight loss, adjusted R2 = 0.24, F(4,157) = 13.38, P<0.0001.
Author Conclusion:

Most residents' physical functioning showed a deterioration or remained stable. Impairments that best explained changes in functioning, such as range of motion or balance in standing, are modifiable and should be targeted in interventions by nursing and rehabilitation staff.

Funding Source:
St. Peter's Hospital Foundation
Other non-profit:
Reviewer Comments:

Inclusion and exclusion criteria were not well described. All subjects were residents of one care center in Canada. Numbers of subjects differed throughout the article. Authors note the following limitations:

  • Secondary data analysis; therefore, it has all the problems inherent with the design
  • Individual rater drift and less consistency between raters may occur in clinical assessments
  • Analysis did not control for time since admission, which may have explained a component of the variance accounted for by the other factors in the models
  • Sample size did not allow physical functioning by subgroups with disease and associated comorbidities to be examined; therefore, conclusions cannot be made about the types and extent of disability associated with different disease groups.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? ???
  4.1. Were follow-up methods described and the same for all groups? ???
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) ???
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? ???
  4.4. Were reasons for withdrawals similar across groups? ???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? No
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes