Occupational therapy practice guidelines for productive aging for community-dwelling older adults


Guideline Developer(s)

American Occupational Therapy Association, Inc.

Date Released

2012

Evidence Supporting the Recommendations

References Supporting the Recommendations

American Occupational Therapy Association. Critically appraised topic, occupation and activity based interventions, focused question: What is the evidence for the effect of occupation and activity-based interventions on the performance of selected instrumental activities of daily living [trunc]. Bethesda (MD): American Occupational Therapy Association, Inc.; 2011.
American Occupational Therapy Association. Standards of practice for occupational therapy. Am J Occup Ther. 2010;64:S106-S111.
Arbesman M, Mosley LJ. Systematic review of occupation- and activity-based health management and maintenance interventions for community-dwelling older adults. Am J Occup Ther. 2012 May-Jun;66(3):277-83. PubMed
Bursztyn M, Ginsberg G, Hammerman-Rozenberg R, Stessman J. The siesta in the elderly: risk factor for mortality. Arch Intern Med. 1999 Jul 26;159(14):1582-6. PubMed
Bursztyn M, Stessman J. The siesta and mortality: twelve years of prospective observations in 70-year-olds. Sleep. 2005 Mar;28(3):345-7. PubMed
Chase CA, Mann K, Wasek S, Arbesman M. Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. Am J Occup Ther. 2012 May-Jun;66(3):284-91. PubMed
Goldman SE, Stone KL, Ancoli-Israel S, Blackwell T, Ewing SK, Boudreau R, Cauley JA, Hall M, Matthews KA, Newman AB. Poor sleep is associated with poorer physical performance and greater functional limitations in older women. Sleep. 2007 Oct;30(10):1317-24. PubMed
Orellano E, Colon WI, Arbesman M. Effect of occupation- and activity-based interventions on instrumental activities of daily living performance among community-dwelling older adults: a systematic review. Am J Occup Ther. 2012 May-Jun;66(3):292-300. PubMed
Stav WB, Hallenen T, Lane J, Arbesman M. Systematic review of occupational engagement and health outcomes among community-dwelling older adults. Am J Occup Ther. 2012 May-Jun;66(3):301-10. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

A total of 192 articles were included in the reviews, with 96% of them being Level I and II evidence. The reviews involved systematic methodologies and incorporated quality control measures.

Table. Number and Levels of Evidence for Articles Included in Each Systematic Review
  Number of Articles Included in Review
Review Question Level I Level II Level III Level IV Total in Each Review
Instrumental Activities of Daily Living (IADLs) 31 3 3 1 38
Home Modification and Fall Prevention Programs 27 2 0 0 29
Health Management 23 3 1 0 27
Occupation and Health 3 95 0 0 98
Total for Each Level 84 103 4 1  
Total in All Reviews 192

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Patient Resources
Resources
Staff Training/Competency Material

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

These guidelines may be used to assist:

  • Occupational therapists and occupational therapy assistants in communicating about their services to external audiences
  • Other health care practitioners, case managers, clients, families and caregivers, and health care facility managers in determining whether referral for occupational therapy services is appropriate
  • Third-party payers in understanding the therapeutic need for occupational therapy services
  • Legislators; third-party payers; federal, state, and local agencies; and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants
  • Health and social services planning teams in determining the scope, benefits, and need for occupational therapy services
  • Program developers; administrators; legislators; federal, state, and local agencies; and third-party payers in understanding the scope of occupational therapy services
  • Researchers, occupational therapists, occupational therapy assistants, program evaluators, and policy analysts in this practice area in determining outcome measures for analyzing the effectiveness of occupational therapy intervention
  • Policy, education, and health care benefit analysts in understanding the appropriateness of occupational therapy services to support productive aging among community-living older adults
  • Policymakers, legislators, and organizations in understanding the contribution occupational therapy can make in prevention, health promotion, remediation of impairments, program development, and health care reform to support productive aging among community-living older adults
  • Occupational therapy educators in designing appropriate curricula that incorporate the diverse roles of occupational therapy within productive aging
Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

A—Strongly recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B—Recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.

C—There is weak evidence that the intervention can improve outcomes, and the balance of the benefits and harms may result either in a recommendation that occupational therapy practitioners routinely provide the intervention to eligible clients or in no recommendation because the balance of the benefits and harm is too close to justify a general recommendation.

D—Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

I—Insufficient evidence to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.

Note: Recommendation criteria are based on the standard language of the Agency for Healthcare Research and Quality (2009). Suggested recommendations are based on the available evidence and content experts' opinions.

Qualifying Statements

Qualifying Statements
  • This guideline does not discuss all possible interventions, and although it does recommend some specific occupational therapy interventions, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given intervention in light of a specific client's circumstances, needs, and available evidence to support the intervention.
  • This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
  • It is the objective of the American Occupational Therapy Association to be a forum for free expression and interchange of ideas. The opinions expressed by the contributors to this work are their own and not necessarily those of the American Occupational Therapy Association.

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Databases and sites searched included Medline, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature/CINAHL, AgeLine, and OTseeker. In addition, consolidated information sources, such as the Cochrane Database of Systematic Reviews and the Campbell Collaboration, were included in the search. These databases are peer-reviewed summaries of journal articles and provide a system for clinicians and scientists to conduct evidence-based reviews of selected clinical questions and topics. Moreover, reference lists from articles included in the systematic reviews were examined for additional potentially relevant articles, and selected journals were hand searched to ensure that all appropriate articles were included. Search terms for the reviews were developed by the consultant to the American Occupational Therapy Association (AOTA) Evidence-Based Practice (EBP) project and AOTA staff in consultation with the authors of each systematic review and reviewed by the advisory group. The search terms were developed not only to capture pertinent articles but also to ensure that the terms relevant to the specific thesaurus of each database were included. Table E2 in the original guideline document lists the search terms related to populations and interventions included in each systematic review. A medical research librarian with experience in completing systematic review searches conducted all searches and confirmed and improved the search strategies. In addition, a filter based on one developed by McMaster University was used to narrow the search.

The review of the following four questions was limited to the peer-reviewed scientific literature published in English:

  1. What is the evidence for the effect of occupation and activity-based interventions on the performance of selected instrumental activities of daily living (IADLs) for community-dwelling older adults?
  2. What is the evidence for the effectiveness of home modification and fall prevention programs on the performance of community-dwelling older adults?
  3. What is the evidence for the effect of occupation and activity-based health management and maintenance interventions on the performance of community-dwelling older adults?
  4. What is the evidence that participation in occupations and activities supports the health of community-dwelling older adults?

Literature published in Spanish also was included in the IADL review. The review included consolidated information sources such as the Cochrane Collaboration. Except as described here, the literature included in the review was published between January 1990 and October 2008. More recent articles (2009–2011) for Questions 1, 2, and 4 were also included based on the recommendations of content experts who participated in the external review process. For Question 3, a second search was completed through November 2010.

The review excluded data from presentations, conference proceedings, non–peer-reviewed research literature, research reports, dissertations, and theses. In addition, studies of participants in the hospital, skilled nursing facilities, and hospice were excluded from the review because they were not considered to be community-dwelling older adults. Also excluded from the review were studies of participants with major diagnoses such as stroke, dementia, and Parkinson's disease. Level IV and V evidence (see the "Rating Scheme for the Strength of the Evidence" field) as well as studies outside the scope of practice of occupational therapy were excluded from the review.

See Appendix E in the original guideline document for more information.

Number of Source Documents

A total of 192 articles were included in the review.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence Definitions
Level I Systematic reviews, meta-analyses, randomized controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case-control)
Level III One group, nonrandomized (e.g., before and after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinion that include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The teams working on each focused question reviewed the articles according to their quality and levels of evidence. Each article included in the review was then abstracted using an evidence table that provides a summary of the methods and findings of the article and an appraisal of the strengths and weaknesses of the study based on design and methodology. Review authors also completed a Critically Appraised Topic (CAT), a summary and appraisal of the key findings, clinical bottom line, and implications for occupational therapy of the articles included in the review for each question. American Occupational Therapy Association (AOTA) staff and the Evidence-Based Practice (EBP) project consultant reviewed the evidence tables and CATs to ensure quality control.

Limitations of selected studies incorporated in the reviews include the following: small sample size, lack of blinding, wide variation of interventions included in reviews, high rates of attrition during follow-up, or the use of imprecise or outdated measures. Depending on the level of evidence, there may have been a lack of randomization, lack of control group, and limited statistical reporting. Some studies were conducted in simulated settings, and it may be difficult to generalize the findings to real-life daily activities. It is difficult to separate the effects of a single intervention that is part of a multifactorial intervention. Studies included in the fall prevention and home modification review had different or unreported definitions of falls. A wide range of diagnoses and clinical conditions may have been included in meta-analyses and systematic reviews incorporated in these reviews.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

A series of focused questions were developed in conjunction with a group of content experts in productive aging and evidence-based practice (EBP) on the basis of all components of the areas of occupation (activities of daily living [ADLs], instrumental activities of daily living [IADLs], education, work, play, leisure, social participation, rest, and sleep).

  1. What is the evidence for the effect of occupation and activity-based interventions on the performance of selected IADLs for community-dwelling older adults?
  2. What is the evidence for the effectiveness of home modification and fall prevention programs on the performance of community-dwelling older adults?
  3. What is the evidence for the effect of occupation and activity-based health management and maintenance interventions on the performance of community-dwelling older adults?
  4. What is the evidence that participation in occupations and activities supports the health of community-dwelling older adults?

The content experts included occupational therapy practitioners, researchers, and educators in this area. Content experts prioritized the questions on the basis of the types of evidence occupational therapy practitioners need to inform and guide their practice with community dwelling older adults.

Suggested recommendations (recommended, no recommendation, not recommended) are based on the available evidence and content experts' clinical expertise regarding the value of using the intervention in practice.

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Identifying Information and Availability

Bibliographic Source(s)

Leland N, Elliott SJ, Johnson KJ. Occupational therapy practice guidelines for productive aging for community-dwelling older adults. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2012. 167 p.

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Occupational Therapy Association, Inc.

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors: Natalie Leland, PhD, OTR/L, BCG, Assistant Professor, University of Southern California, Los Angeles; Sharon J. Elliott, DHS, GCG, OTR/L, BCG, FAOTA, Adult Therapy Service Coordinator, Therapeutic Life Center, Greenville, NC; Kimberly J. Johnson, MS, MSW, Research Associate, University of Massachusetts-Boston, Department of Gerontology, Boston

Issue Editor: Marian Arbesman, PhD, OTR/L, President, ArbesIdeas, Inc., Consultant, AOTA Evidence-Based Practice Project, Clinical Assistant Professor, Department of Rehabilitation Science, State University of New York at Buffalo

Series Editor: Deborah Lieberman, MHSA, OTR/L, FAOTA, Program Director, Evidence-Based Practice Project, Staff Liaison to the Commission on Practice, American Occupational Therapy Association, Bethesda, MD

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone:1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online at the AOTA Web site.

Availability of Companion Documents

The following is available:

Fact sheets and various other resources on productive aging are available from the AOTA Web site.

Case studies are available in the original guideline document.

Patient Resources

Tip sheets on various topics for aging adults, including driving, low vision, fall prevention and aging in place, are available from the American Occupational Therapy Association Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on December 7, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Scope

Disease/Condition(s)

Mental and physical health as related to productive aging

Guideline Category

Counseling
Evaluation
Management
Prevention
Rehabilitation
Risk Assessment
Screening
Treatment

Clinical Specialty

Family Practice
Geriatrics
Internal Medicine
Physical Medicine and Rehabilitation
Preventive Medicine

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Managed Care Organizations
Nurses
Occupational Therapists
Patients
Physical Therapists
Physician Assistants
Physicians
Public Health Departments
Social Workers
Utilization Management

Guideline Objective(s)
  • To help occupational therapists and occupational therapy assistants, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, to understand the contribution of occupational therapy in treating community-living older adults to facilitate productive aging
  • To serve as a reference for health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations to assist in understanding the role of occupational therapy services in the community
Target Population

Community-dwelling older adults

Interventions and Practices Considered
  1. Screening to identify need for occupational therapy
  2. Referral for occupational services
  3. Evaluation
    • Occupational profile
    • Analysis of occupational performance
  4. Developing an intervention plan
    • Interventions to improve instrumental activities of daily living (IADLs) (e.g., physical training, cognitive skills training, visual rehabilitation, visual skills training)
    • Fall prevention and home modification
    • Health management and maintenance interventions
  5. Follow-up, including reevaluation and adaptive modification
Major Outcomes Considered
  • Activities of daily living (ADL) and instrumental ADL (IADL) performance and participation
  • Efficacy of interventions to prevent falls
  • Outcomes related to health (e.g., mortality, depression, dementia)

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse: In addition to the evidence-based recommendations below, the guideline includes extensive information on the referral and evaluation process, including creation of the occupational profile and the development of an intervention plan.

Implications for Occupational Therapy Practice

Occupational therapy practice with community-dwelling older adults includes not only traditional practice using the medical model but also practice in nontraditional settings. The wealth of opportunities are endless.

The evidence-based literature review examined how involvement in occupations and activities supports health of older adults and facilitates productive aging. Potential areas of growth for occupational therapy practice to enhance productive aging fell into the following categories: physical activity, social activity, leisure activity, religious activity, general activity, work/volunteering, sleep, and instrumental activities of daily living (IADL) participation (American Occupational Therapy Association [AOTA], 2011; Stav et al., 2012). Examples of emerging types of employment related to productive aging and the evidence-based literature review are presented in Table 4 in the original guideline document.

The systematic review on productive aging identified evidence for the effectiveness of occupation and activities on occupational performance and health and the effect of fall prevention interventions and home modifications on occupational performance (Arbesman & Mosley, 2012; Chase et al., 2012; Orellano, Colón, & Arbesman, 2012; Stav et al., 2012). Occupational therapy practitioners must be "knowledgeable about evidence-based research and [apply] it ethically and appropriately to provide occupational therapy services consistent with best practice approaches" (AOTA, 2010). The following general recommendations are based on the evidence described in the original guideline document (also see table below).

  • Consistently use standardized assessment tools and outcome measures for evaluating occupational performance, home safety (Chase et al., 2012), and IADLs whenever possible to facilitate reimbursement and enhance outcome data collection (Orellano, Colón, & Arbesman, 2012).
  • Discuss sleep and sleep patterns as a part of the occupational profile because a lack of, too much, or poor quality sleep can affect older adults' occupational performance (Bursztyn et al., 1999; Bursztyn & Stessman, 2005; Goldman et al., 2007).
  • Use client-centered intervention plans that include a "mix of exercise, education, home modifications or assistive technology [to provide] the best results in fall prevention and performance support for community-dwelling older adults" (Chase et al., 2012).
  • Use occupation-based interventions that are individualized for the specific needs of the client (individual, organization, or population) and promote health (Stav et al., 2012)
  • Identify how occupational therapy interventions will affect each older adult client’s participation and performance of meaningful occupations (Orellano, Colón, & Arbesman, 2012).
  • Assimilate the use of functional and occupation-based activities within the older adults' relevant contexts to facilitate IADL performance (Orellano, Colón, & Arbesman, 2012).
  • Use a holistic intervention approach focusing on each older adult's engagement in meaningful IADLs, in addition to activities of daily living (ADLs) and other areas to promote health and well-being (Orellano, Colón, & Arbesman, 2012; Stav et al., 2012).
  • Encourage community-dwelling older adults' involvement or participation in a variety of occupations and activities to support their health, such as physical activity, social activity, leisure activity, religious activity, work/volunteer work, general activity, and IADLs (Stav et al., 2012).
  • Use evidence-based interventions to facilitate the development of health routines and habits among community-dwelling older adults (Arbesman & Mosley, 2012).
  • Incorporate successful health management approaches within the evaluation, intervention planning, and intervention implementation process (Arbesman & Mosley, 2012).
  • Inform older adults about health education programs, including self-management programs, which may help lessen pain, improve physical activity levels, and improve participation and functioning (Arbesman & Mosley, 2012).
  • Integrate diverse driving interventions to positively affect the driving performance of community-dwelling older adults (Orellano, Colón, & Arbesman, 2012).
  • Consult with aging organizations to develop and implement primary, secondary, and tertiary preventive educational and intervention programs and to develop resources for community-dwelling older adults (AOTA, 2011; Stav et al., 2012).
  • Consider alternative funding sources to help pay for preventive and health promotion services or equipment not currently reimbursable under Medicare or private insurance (AOTA, 2011; Stav et al., 2012).

Table. Recommendations for Occupational Therapy Interventions for Productive Aging
  Recommended* No Recommendation Not Recommended
Instrumental Activities of Daily Living (IADLs)
  • Home-based multicomponent program (including occupational therapy) in adults with differing functional abilities (A)
  • Client-centered occupational therapy program, such as Lifestyle Redesign program (B)
  • Exercise involving functional activities for older adults (B)
  • Progressive resistance strength training to improve community mobility and meal preparation (B)
  • Physical activity for improving self-efficacy and increasing satisfaction with physical function and increasing time spent on activities of moderate or greater intensity in older adults with mobility deficits (B)
  • Physical conditioning to improve driving performance for older adults (B)
  • Short-term classroom and on-road instruction to improve driving knowledge (B)
  • Multidisciplinary vision rehabilitation to improve function in older adults with low vision (B)
  • Occupation-centered interventions in the home setting for community-dwelling older adults (C)
  • Long-term physical exercise program to improve community mobility (C)
  • Cognitive skill training for community-dwelling older adults (C)
  • Simulated IADL programs for older adults (C)
  • Visual skills training, community mobility programs, and vehicle adaptations to improve driving performance in older adults (C)
  • Physical activity programs to improve IADL performance (I)
  • Home modifications to improve IADL performance in older adults (I)
  • Weight training to improve walking performance (I)
   
Fall Prevention and Home Modification
  • Home modification and adaptive equipment provided by occupational therapy practitioners to reduce functional decline and improve safety (A)
  • Multicomponent or multifactorial intervention approach addressing multiple risk factors to reduce falls (A)
  • Physical activity (regardless of type) to reduce falls and decrease fall risk (B)
  • Strengthening, balance retraining, and a walking plan to reduce falls and injuries for those >80 years (B)
  • Occupational therapy assessment followed by home modifications for those with a history of falls (B)
  • Home modification for older adults aging with a disability reduced perceived difficulty with activities of daily living (ADLs) and IADLs (B)
  • Home safety assessment for older adults with visual impairment (B)
   
Health Management
  • Client-centered occupational therapy to improve physical functioning and occupational performance related to health management in frail older adults, and older adults with osteoarthritis and macular degeneration (A)
  • Group health education programs led by educators and other health professionals (A or B)
  • Self-management health programs individually tailored in conjunction with health professionals (B)
  • Peer-led self-management programs that include diagnosis-specific information, medication management, and problem-solving skills (B)
  • Cognitive–behavioral intervention for improving adherence to a physical-activity program (C)
  • Cognitive–behavioral intervention for improving sleep of older adults with insomnia (C)
  • Community-based health management program combined with skills training for community-dwelling older adults with severe mental illness (C)
   

*The terminology used for the recommendations was language used in the article(s) from which the evidence was derived.

Note: Criteria for level of evidence (A, B, C, D, I) are based on standard language (Agency for Healthcare Research and Quality, 2009) (see definitions below). Suggested recommendations (recommended, no recommendation, not recommended) are based on the available evidence and content experts' clinical expertise regarding the value of using the intervention in practice.

Definitions:

Strength of Recommendations

A—Strongly recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B—Recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.

C—There is weak evidence that the intervention can improve outcomes, and the balance of the benefits and harms may result either in a recommendation that occupational therapy practitioners routinely provide the intervention to eligible clients or in no recommendation because the balance of the benefits and harm is too close to justify a general recommendation.

D—Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

I—Insufficient evidence to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence Definitions
Level I Systematic reviews, meta-analyses, randomized controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case-control)
Level III One group, nonrandomized (e.g., before and after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinion that include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Living with Illness
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

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