Understanding Quality and Equity in Wheelchairs for Veterans

Wheelchairs enable Veterans to participate in home, employment, and social activities that
might otherwise be inaccessible to them, thereby improving their quality of life (QOL).
Despite VA's efforts to remove financial and other barriers to the provision of high quality
wheelchairs to all Veterans, preliminary evidence suggests that disparities exist in the
quality of wheelchairs prescribed to vulnerable (e.g., minority race/ethnicity, lower
socioeconomic status) Veterans with Spinal Cord Injury (SCI) or amputated limbs (AL). This
finding is concerning because patients who receive lower quality wheelchairs may be at risk
for adverse physical, psychological, economic, and QOL outcomes. Mounting research
demonstrates that patient psychosocial characteristics (e.g., medical mistrust, perceived
discrimination, locus of control) and provider factors (e.g., demographics and training) are
associated with disparities in healthcare processes and outcomes. However, for Veterans with
SCI or AL, no studies to date have examined (a) what patient and provider factors are
associated with the prescription of high quality wheelchairs, and (b) how these factors are
associated with wheelchair quality and patient outcomes. The proposed cross-sectional,
multi-site study of Veterans with SCI or AL who use a wheelchair as their primary source of
mobility aims to determine whether: (1) patient demographic (e.g., race, SES) and
psychosocial characteristics (e.g., medical mistrust, experience of discrimination) and
provider factors (e.g., years of practice, certification, demographics) are associated with
wheelchair quality; (2) wheelchair quality is associated with key patient outcomes,
including satisfaction with medical care, QOL, amount of wheelchair activity, and
participation in social and work-related activities; (3) patient and provider factors are
independently associated with key patient outcomes including satisfaction with medical care,
QOL, amount of wheelchair activity, and participation; and (4) the association of patient
and provider factors with patient outcomes is explained by differences in wheelchair
quality. Veterans with SCI or AL, who were prescribed their wheelchairs through the VA, will
be recruited from the Philadelphia, PA, Cleveland, OH, Richmond, VA, and Bronx, NY VA
Medical Centers to participate in an interview to assess their demographic characteristics,
health information, psychosocial characteristics (including, experience of discrimination,
perceived racism, medical mistrust, self-image, anxiety/depression, health beliefs, health
literacy, and communication) and health-related outcomes (including wheelchair skills,
satisfaction, QOL, participation). We will also assess amount of wheelchair activity using
data logging devices, and determine wheelchair quality by its make and model. Data will also
be collected from all health care providers involved in wheelchair provision for study
participants.

Provider factors will include demographics (e.g., race/ethnicity, age, gender), and
specialty (i.e., MD/OT/PT).

For Occupational and Physical Therapists, we will determine if they are certified by the
Rehabilitation Engineering and Assistive Technology Society of North America. Years of
practice since completion of medical training, number of chairs prescribed over the span of
their career, what role each provider plays in the wheelchair provision process, as well as
the number of continuing medical education (CME) credits and/or educational credit units
(ECU) they have obtained in the past 3 years related specifically to wheelchairs, will also
be assessed. Understanding the associations among the proposed patient characteristics and
provider factors is an essential step toward developing tailored interventions, aimed at
patients and providers, to improve the quality and equity of wheelchair service delivery for
Veterans.

Inclusion Criteria:

Veterans

- age >18 years

- must have SCI with discernible neurological impairments or an amputated lower limb
which results in the use of a wheelchair

- must be in power or manual wheelchair >1 year and treated at the participating VAMC

- participants must use a manual or power wheelchair as their primary means of mobility
(e.g., use wheelchair > 40 hours/week

- and be non-ambulatory except for exercise purposes

Exclusion Criteria:

- In wheelchair less than 1 year

- Able to ambulate without the use of a wheelchair

- Other disorders requiring the use of a wheelchair (e.g., MS)