A cross-sectional descriptive analysis of complex rehabilitation technology (CRT) supplier opinions on the current state of wheelchair repair services

Abstract Purpose It is documented that wheelchair failures occur frequently, repair times are lengthy, and users often experience adverse consequences. This study aims to gather evidence on efficiency of current wheelchair repair processes from the perspective of complex rehabilitation technology (CRT) suppliers who perform repairs within the United States. Materials and methods A 20 statement survey was developed to identify barriers and facilitators related to wheelchair repairs across the domains of administrative and operational factors as well as to identify future opportunities for improvement. Key statements in these areas included time to perform a repair, documentation requirements, tracking repair progress, reimbursement, technician competency, emerging strategies and preventative maintenance. The online survey was broadly disseminated to a nationwide network of CRT suppliers for data collection. Results A total of 127 responses were received. Results showed that administrative statements received the lowest scores while those statements dealing with future opportunities received the highest scores. Areas of the industry that suppliers were in most disagreement with included wait time for insurance approval, reimbursement for parts, reimbursement for technician travel time and lack of coverage for preventative maintenance. Telehealth system usage, preventative maintenance coverage, tracking repairs and repair scheduling were future opportunities that suppliers were in most agreement with. Conclusions Administrative issues exist in the CRT industry due to restrictive insurance policies associated with repairs and maintenance. Future opportunities to improve the process exist including payment models and the application of telehealth, device monitoring and service-based performance incentives to reduce adverse consequences to the user. Implications for rehabilitation Highlights the direct importance and barriers faced within the wheelchair repair industry by CRT suppliers. In a sample of CRT suppliers, there is agreement there exists many administrative and operational issues related to wheelchair repairs. There is agreement among survey respondents of opportunities to investigate further telehealth and remote strategies, preventative maintenance coverage and online tracking for wheelchair repairs.


Introduction
Wheelchair devices allow individuals with impaired mobility to engage in personal, professional and social activities with greater ease [1,2].In the United States, a subsection of wheelchair devices has been classified as complex rehabilitation technology (CRT) which includes medically necessary, individually configured devices such as custom manual and power wheelchairs, designed to meet the specific and unique medical, physical and functional needs of people with disabilities [3].For example, when a person with mobility impairment needs independent pressure relief, postural support and gravity-assisted positioning for improved digestion and respiration, an individually configured tilt-in-space/recline wheelchair with postural supports could be prescribed.As the complexity of CRT equipment design and provision has increased over the years, so has the number of breakdowns and the need for repairs.
Research studies conducted over the last decade indicate that the rate of wheelchair breakdowns and repairs reported over a 6month period has doubled from 44 to 88% [4-8].Of those who received at least one repair, 27.6% faced an adverse consequence such as being stranded, missing a medical appointment, or missing work as a result of the breakdown [6].A secondary data analysis study of 65,000þ wheelchair repairs showed that more complex manual and power wheelchairs typically fitted with seat functions such as tilt in space and recline are at twice the risk of experiencing a wheelchair breakdown and subsequent potential adverse consequences to the user compared to ultralight manual wheelchairs and power wheelchairs with no seat functions [9,10].
Between wheelchair types, power wheelchairs experience significantly higher number of repairs than manual wheelchair and scooters [5].Specifically, repairs completed on the wheels and casters were the most frequent repair to manual wheelchairs [6,11], whereas repairs to the electrical and power and control systems were the most frequent type of repair on power wheelchairs [12].Repairs take anywhere between two weeks to 6 months for completion [8,13].Until the repair happens, individuals who do not have a backup device, may be confined to a bed and completely dependent on others for the completion of activities of daily living.This could be the primary reason for breakdowns being associated with pressure injury and rehospitalization [7].Thus, frequent wheelchair breakdowns and longer repair times negatively impact users of CRT wheelchairs and increase healthcare burden.
In the United States, CRT wheelchairs are classified as durable medical equipment (DME) by the Centers for Medicare and Medicaid Services (CMS), the largest payer of DME.CMS has the following guidelines with respect to reimbursement for the repair and replacement of medical equipment that includes CRT: 1.The treating physician must document that that the DME, prosthetics, orthotics and supplies (DMEPOS) item being repaired continues to be reasonable and necessary; and 2. Either the treating physician or the supplier must document that the repair itself is reasonable and necessary [14].
Therefore, a repair cannot be initiated until a physician confirms the wheelchair is still medically necessary, the supplier documents the scope of the repair, and the repair is approved by the insurance provider which can be a lengthy and burdensome process.
Reimbursement for the labour to perform a repair can only be claimed through the use of a single generic Healthcare Common Procedure Code (HCPCS) K0739 regardless of the complexity of the repair [15].Labour can only be billed to insurance in the case of a repair or replacement, while general maintenance is considered the responsibility of the beneficiary, i.e., the user [16].Private insurance companies maintain similar policies to those adopted by CMS and offer similar or less reimbursement and labour compensation.Competitive bidding for certain DME has also created lower reimbursements for devices and replacement parts [15].Although the need for CRT has increased, a slow consolidation or acquisition of suppliers is occurring within the wheelchair industry.The total number of CRT suppliers in the United States decreased from 1340 companies in 2011 to 804 companies in 2014 potentially reducing access to qualified suppliers to perform repairs [17].
Although the literature demonstrates the prevalence of wheelchair repairs and breakdowns across wheelchair devices, insurance plans and specific populations who use mobility devices, there is no published research on the repair process from the point of view of CRT suppliers who perform the repairs.This cross-sectional research study with CRT suppliers aims to evaluate this perspective on barriers and facilitators for wheelchair repairs and identify opportunities for appropriate CRT provision.The specific questions investigated included: 1. Which areas of the repair industry are performing inefficiently? 2. Which areas of the repair industry are performing well? 3. Which opportunities exist to improve the efficiency and quality of CRT repairs?

Methods
A research study was undertaken to survey the CRT suppliers and gather evidence of their perspective on the state of the wheelchair repair industry and processes.The University of Pittsburgh Institutional Review Board determined this study was exempt from formal review as all responses would be voluntary survey data and be de-identified.

Exploratory interviews
Six CRT suppliers and four national subject matter experts were interviewed to develop questions (see Appendix A) to include in the survey.The interviews were conducted at the University of Pittsburgh Medical Center-Center for Assistive Technology located in Pittsburgh, PA or over the phone and followed a basic question and answer format.This outline included some open-ended questions to facilitate a dialogue related to the state of the repair process within the CRT industry.Themes extracted from the interviews were translated into statements for survey purposes.

Survey development
The first section of the survey included demographic questions for the CRT supplier.The supplier's location, years of experience, company category, position in the company and repair tracking system were collected.In addition to demographic questions, participants were asked to estimate the amount of time out of the repair process that was not compensated for.The response may highlight the repair losses incurred by the supplier.To evaluate alternative forms of repair coverage, a question about the number of clients that would choose to have the repairs be self-pay was included in this section as well.
The second section of the survey included a comprehensive list of statements focussed on CRT supplier's level of agreement derived from exploratory interviews.The statements were grouped into specific areas (subcategories).To score these statements a metric was created that would allow participants to rank their agreement with each of the statements using a scale from 1 to 6 with 1 being completely disagree and 6 being completely agree.A six-point scale with no mid-point was used so that a general trend of agreement or disagreement with each statement would emerge.All statements were phrased in a way that if that statement received a higher score, then it would represent a positive aspect of the CRT industry.This process prevented bias based on the wording of the statements and the meaning of each statement to the wheelchair repair industry.An option for comments was also available following each statement; however, these comments were not analysed for the purposes of this report.
The survey was created using the Qualtrics online survey system through the University of Pittsburgh.An initial screening question was created to determine whether the participant who used the link to the survey was eligible to complete it.This question asked whether or not the person worked for a company that provided wheelchair repairs, which was the target population.Questions were asked one at a time with the participant having the option to skip any questions that they preferred not to answer.

Survey deployment
In order to distribute the survey, an anonymous link was created that allowed anyone with the link to access the survey.The survey was disseminated through the National Registry of Rehabilitation Technology Supplier (NRRTS) email listserv and direct email solicitation to leaders in the CRT industry.A press release was also shared whereby announcements were made in Mobility Management magazine and HME News explaining the purpose of the study and included a link to complete the survey.The survey was released on 17 March 2019 and remained open until 27 April 2019.To encourage participation in the survey, a drawing for free continuing education access through the University of Pittsburgh's Rehabilitation Science and Technology Continuing Education (RSTCE) program was offered.The contact information was collected from respondents who wished to enter the drawing after the completion of the survey.There was no ability to connect survey responses to those who chose to enter the drawing.Three winners were randomly selected by a member of the RSTCE team who was not involved with the project.

Data analysis
The quantitative survey data were exported from Qualtrics into a Microsoft Office Excel database.Frequencies and distributions of the demographic data were computed.Average scores and standard deviations were calculated for each of the survey statements.Two-tailed t-tests were conducted at level of significance a � 0.05 to find differences in survey responses across the company categories.

Exploratory interview results
Responses from exploratory interviews with suppliers and experts resulted in a list of 20 statements related to CRT supplier satisfaction under three subcategories of administrative, operational and future opportunities.Administrative factors refer to external items that are required by insurance providers to complete a repair or involves the reimbursement received by the company from the provider.Operational factors refer to the internal workings of the company and how they complete the repair itself.Lastly, future opportunities refer to new ideas that may or may not provide a benefit to the wheelchair repair industry.

Demographic data findings
A total of 127 participants completed the survey.Table 1 displays the demographic characteristics of survey respondents.Results showed the diversity in participants based on years of experience and company category.The majority of respondents were people with extensive experience in the field with 66.1% having worked in the field for at least 16 years.Of those who filled out the survey, 22% had been working in the field for over 30 years compared to only 7.9% that were new to the field with only 1-5 years of experience.Less variety was observed in the type of position held by respondents with 51.2% being assistive technology professionals (ATPs) and another 26.8% being in a management role such as an owner or branch manager.Majority of respondents (93.6%) indicated that some type of electronic system was used in the tracking of repairs for their company with only 6.4% not using any type of electronic recordkeeping.Responses to the type of company displayed a wide variety of different sizes.The majority of respondents were from small independent suppliers with their responses making up 42.5% of the total.National suppliers on the other hand only made up 15.7% of the total responses to the survey.There was a skewed result for those that answered the question about self-pay for repairs with 81.9% of respondents stating that less than 20% of their customers would choose this option as an alternative for the traditional insurance process.Chi-square testing showed that only years of experience is normally distributed (p > 0.05).

Opinion survey results
A breakdown of the average scores and standard deviations for each survey statement are included in Table 2. Eleven (55%) of the 20 statements received scores that represented general disagreement among suppliers receiving an average score of less than 3.The statements were combined into subcategories and analysed to determine the average scores for each of the subcategories (see Table 3).Operations received a slightly higher score of 3.19 but still represented a general disagreement with the 10 statements that were contained within that subcategory.The highest scoring subcategory was future opportunities that had a general agreement with all the statements contained within it.

Discussion
The wheelchair repair industry provides an essential service to people with disabilities using CRT that enables participation in the community, independence and a better quality of life.Without access to repair services from suppliers, CRT users would find it difficult, if not impossible, to maintain their mobility and protect the value of their device.This research study highlights the inconsistencies in the repair service provision process and dissatisfaction among the CRT suppliers.This may contribute to the limited levels of repair services and a higher rate of breakdowns and repairs leading to adverse consequences and secondary health complications to CRT users.

Which areas of the repair industry are performing inefficiently?
Data from the supplier survey section demonstrated an overall lack of satisfaction with the current state of the wheelchair repair industry with a number of different areas performing inefficiently.Companies are likely providing repairs at a loss as 58% of respondents reported they are being compensated for less than half of the time of total repair.Technician travel time compensation was one of the lowest scoring questions of the entire survey.This uncompensated travel time consumes many resources for the company and can heavily affect revenue.The reimbursement for the parts themselves had an average value of 1.78.All suppliers interviewed for the survey development reported that repairs were a financial loss within their companies.However, they continue to provide this service to support and retain the customer.
If providing repairs is a loss, companies are perhaps less likely to allocate resources or efforts to improve the situation.
According to the survey, the delays in providing a repair are likely due to the documentation requirements for providing a repair.Documentation must be obtained from both the supplier and the physician to begin the approval process for a repair which can result in delays based on communication between these two entities.Majority of the statements included in the administration subcategory received negative feedback suggesting that it is a primary area of concern for suppliers.Federal government policies such as Medicare, guide many of the policies enacted by private insurers where it can have a direct effect on the ability of the supplier to provide quality continued care with respect to repairs.It was also reported that less than 20% of CRT users have the financial resources to bypass the insurance process and pay out of pocket for their repairs.

Which areas of the repair industry are performing well?
Under administration subcategory, suppliers acknowledged that simple repairs were approved faster than complex repairs.This may be attributed to lower cost of repairing simple items like arm pads that are treated as consumables by the insurance and CRT industry.Suppliers are also known to stock such parts and conduct the repair sooner.Respondents tended to somewhat agree/ disagree they were able to respond to repairs in a timely manner however other research has documented that repair can take between two weeks and six months [8,13].Repair scheduling and tracking systems have improved the CRT repair operations and tracking of repair and replacement parts.Existing and emerging electronic documentation systems likely improve process efficiency.Training technicians well and ensuring that they have all necessary competencies to perform the job were statements that generally received more agreement and positive feedback even though the process for hiring and retaining technicians scored low.From an operational perspective, the independent suppliers were slightly better off than the national suppliers.

Which opportunities exist to improve the efficiency and quality of CRT repairs?
Although many of the findings from this study highlight the negative aspects of the wheelchair repair industry, there are possible solutions.In particular, the future opportunities subcategory responses demonstrated a positive outlook for the industry as it � p � 0.05 denoted the significant differences in responses between national and independent suppliers.was the only subcategory that received general agreement with all statements.National suppliers agreed more on telehealth opportunity being an efficient strategy compared to independent suppliers.An organization with a large number of resources could also more easily implement a telehealth monitoring service within their organization for clinical service delivery.Statement 20 was the highest scoring statement showing the interest in preventative maintenance coverage.Preventative maintenance reduces the number of high-risk breakdowns that currently are experienced by CRT users [18].Preventative maintenance is possible through education of the consumers who use the mobility devices on how to take care of their equipment and what areas to regularly inspect for continued use.A Wheelchair Maintenance Training Program enables clinicians and technicians to provide education on general maintenance to consumers during the service delivery process [19].Use of active interventions for wheelchair maintenance was shown to be more effective than standard check-ups as most people were unable to recognize if their wheelchair needed maintenance.A recent study showed that wheelchair users are interested in using a smartphone application for preventative maintenance education [20,21].Statement 18 highlighted the possibility of using telehealth systems (including device connectivity) to monitor devices and support more routine maintenance and reduce the necessary travel time of technicians.This was comparable to what Dicianno et al. [22] found in a survey of assistive technology users who showed an interest in "smart technology" and wearable devices for tracking health status and physical activity.The applications of these technologies to CRT can assist with determining the amount of use that a piece of equipment is receiving over its lifetime.

Limitations
First, there is a potential bias related to the convenience sampling method used to obtain responses from CRT suppliers in the field.Those who did not regularly check email announcements from NRRTS or HME news likely did not come across the survey.The survey could also not have been shared with relevant individuals within that organization for their own reasons.Second, the study only looked at a descriptive analysis which laid the groundwork for further analysis on the impact of wheelchair repairs from the CRT supplier perspective.For example, a more statistical approach with additional data can look at a more balanced sample to compare national and independent supplier organizations given respondents primarily represented smaller independent suppliers.
There are some limitations regarding the survey tool and expert sample.The survey tool used in this study was created specifically for this study after an investigation revealed no other tools would capture the intended data from the population of study.This tool was developed exclusively for this study and was not tested for reliability, it can be assumed that it contains only face validity.Consultation with industry experts led to the conclusion that the questions included in the survey would allow for relevant discussion points to be drawn based on the results obtained from the sample population.The sample size of experts was small in this study.Some questions may have appeared leading to suppliers.There is also potential for bias given respondents where more experienced, held management positions and worked for independent suppliers.Lastly, the survey tool and supplier evaluation focussed on the wheelchair provision and repair system in the United States and limits the generalizability of the findings to other countries.

Future work
This initial work presents several opportunities for further investigation.Similar type surveys should be conducted for broader stakeholder group perspectives especially people with disabilities who use CRT, clinicians who prescribe the equipment, and policy makers.Efforts should also investigate opportunities to improve the state of CRT repairs such as the cost-effectiveness and benefits of routine preventative maintenance programs.Suppliers and payers could also benefit financially through programs that incentivize the long-term maintenance of equipment that reduces premature replacements.Reimbursement models used in other industries have been successful and may warrant adoption by the wheelchair repair industry as an alternative to the current prior approval process.A pay for performance model could encourage suppliers to provide quality equipment and maintain the equipment throughout its usable life in order to receive payments from their clients' insurance provider.This model could reduce many of the administrative delays and inefficiencies currently experienced with providing repairs.

Conclusions
The findings of this survey study identified overall supplier reported issues with the state of wheelchair repairs.Administrative issues including policy were most prevalent given lack of coverage for preventative maintenance and limited reimbursement.Future opportunities to improve the process exists including payment models and the application of telehealth, device monitoring and service-based performance incentives to reduce adverse consequences experienced by people who use wheelchairs.Policy and practice opportunities exist and should be further investigated to improve the state of wheelchair repairs in the United States.

Table 1 .
Demographic characteristics of survey respondents.

Table 2 .
Mean scores for statements include in the satisfaction survey.

Table 3 .
Mean score for subcategories of statements.