Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2014;95:608-9

COUNTER-COMMENTARY

Perfectdthe Enemy of Good Michael L. Boninger, MD, Lynn A. Worobey, PhD From the University of Pittsburgh, School of Medicine, Pittsburgh, PA.

Abstract Our article has limitations, which we thoroughly describe. However, as the article highlights, wheelchairs are requiring repairs much too often, the repairs are causing significant consequences for users, and the problem is getting worse. The commentary concludes that producing a strong study will be difficult and of limited value, but offers no call for better, larger studies or suggestions for improvements. We believe there is much to be learned from our data, and our conclusion is that we need to do better. We need more information, larger cohorts, and better methods. It is the best way to cause changes that will positively impact the millions of wheelchair users around the world. Archives of Physical Medicine and Rehabilitation 2014;95:608-9 ª 2014 by the American Congress of Rehabilitation Medicine

We appreciate the editorial comments put forth by Iezzoni and Ogg1 as related to our article.2 The article includes an extensive limitations section that the editorial further highlights. First and foremost among the criticisms are the methodological problems with the survey study. There are clearly differences in the way individuals use their power wheelchairs (PWCs), the equipment added to chairs, and the way the chairs are serviced. However, for these issues to have influenced the results, there would have to be a systematic bias by which one manufacturer’s PWCs were driven harder, modified more, or serviced worse than any of the other manufacturers reported in the study. To completely discount the results on this basis is wrong; to use them with caution as we concluded is appropriate. The commentary argues that comparison studies of PWCs are not meaningful because chairs have so many options and are changing each year. The authors go on to ask, “Who is responsible for wheelchair performance?” They argue that dealers service the chairs and individuals change them. The exact same 2 statements are true for cars, and yet the information provided by surveys published in Consumer Reports is subscribed to by thousands of readers. Even with model changes and different use and servicing, isn’t it right to proceed with caution when one manufacturer shows the need for more repairs? The commentary states that comparing PWCs would be overall “meaningless,” in part because wheelchair users have no say in the

No commercial party having a direct financial interest in the results of the research supporting this letter has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.

type of assistive technology they are provided. While funding plays a large role in the Healthcare Common Procedure Coding System group and features of a PWC, there are choices in each group. In current times, it’s possible to “Google” anything. You can find reviews on physicians, adverse effects of medications, and the top 10 restaurants in your area. Unfortunately, information on wheelchair performance is not as available. The information a “Consumer Reports for wheelchairs” would provide could empower users. That is what we should be trying to do. Further, the article was also meant for the physical and occupational therapists who are often at the heart of good service delivery. Their knowledge can impact even newly injured individuals, but they must have the information to make the decision. The commentary suggests the Food and Drug Administration is an appropriate safeguard for wheelchair quality. The Food and Drug Administration lists several recognized consensus standards on its website but requires no independent testing.3 Similarly, the Centers for Medicare and Medicaid Services does not require any standards testing for coding verification. References we have cited in the article demonstrate that when tested independently, many PWCs don’t meet international standards. Reporting wheelchair repair rates may be the best mechanism to elicit change. A comparison of performance would be a vital reference for users, clinicians, and payers to start to address subpar performance. In fact, the Centers for Medicare and Medicaid Services asked the United Spinal Association to take on this issue and work with suppliers and consumers to collect data on wheelchair repair (http://www. usersfirst.org/submit-your-story).

0003-9993/14/$36 - see front matter ª 2014 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2014.01.006

Perfectdthe enemy of good Additional limitations highlighted in the editorial include a lack of good outcome variables and a relatively small sample size. Again, we completely agree with these limitations and mentioned them in our article. However, as the article highlights, wheelchairs are requiring repairs much too often, the repairs are causing significant consequences for users, and the problem is getting worse, not better. The editorial concludes that producing a Consumer Reports for PWCs will be difficult and of limited value, but offers no call for better, larger studies or suggestions for improvements to be made. We believe there is much to be learned from our data, and our conclusion is that we need to do better. We need more information, larger cohorts, and better methods. It is the best way we can think of to cause changes that will positively impact the millions of wheelchair users in the United States and around the world.

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References 1. Iezzoni LI, Ogg M. Performance metrics for power wheelchairs: a pipe dream? Arch Phys Med Rehabil 2014;95:604-7. 2. Worobey L, Oyster M, Pearlman J, Gebrosky B, Boninger M. Differences between manufacturers in reported power wheelchair repairs and adverse consequences among people with spinal cord injury. Arch Phys Med Rehabil 2014;95:597-603. 3. U.S. Department of Health and Human Services Food and Drug Administration. Guidance document for the preparation of premarket notification [510k] applications for mechanical and powered wheelchairs, and motorized three-wheeled vehicles. Rockville: Food and Drug Administration Center for Devices and Radiological Health; 1995. Reformatted (December 18, 1997). Available at: http://www.fda.gov/MedicalDevices/ DeviceRegulationandGuidance/GuidanceDocuments/ucm080524.htm. Accessed January 16, 2014.

Perfect--the enemy of good.

Our article has limitations, which we thoroughly describe. However, as the article highlights, wheelchairs are requiring repairs much too often, the r...
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