CONTEXT For decades now, wheelchairs have been powered by either a rear-wheel or a front-wheel drive system. In 1996, however, a new drive configuration appeared on the scene, giving us mid -wheel drive powered wheelchairs (MWDs). The main drive wheels of these chairs are positioned in line with or near their centre of gravity. RAMQ'S QUESTIONS RAMQ asked whether it would be advisable to add MWDs to its list of insured mobility products and, if so, which eligibility requirements should apply. ASSESSMENT

METHOD:

With these questions in mind, AETMIS began by determining which laws, regula-tions and standards govern the manufacture, distribution and sale of powered wheel-chairs. The next step involved searching for controlled studies on the effectiveness, safety and cost of the different models of powered wheelchairs available on the market. The first study, conducted at the University of Pittsburgh, examined five different brands of FWDs, RWDs or MWDs. These brands were selected because they appeared on the list of wheelchairs covered by the U.S. Department of Veterans Affairs. Three types of powered chairs from each brand were tested, that is, 15 wheelchairs purchased from different retailers by an anonymous third party. Tests were performed according to nearly half of the international and American wheelchair standards in effect when the study was published in February 2002. The aim of the study was to check whether these standards could be used to evaluate different types of powered wheelchairs. The second study was conducted in British Columbia during the winter of 1999­2000 on powered wheelchairs with different types of drives. The aim of the study was to test the performance of these wheelchairs in real winter conditions.

RESULTS:

LAWS, REGULATIONS AND STANDARDS Powered wheelchairs are classified as medical devices in both the United States and Canada. Certain laws and regulations spell out minimum requirements for some of their characteristics. Compliance with wheelchair standards is voluntary for manufacturers in both countries; however, this system of voluntary compliance led to a particular legal situation in the United States. In the early 1990s, over 38 states were obliged to enact what are known as wheel-chair lemon laws in order to protect individual consumers as well as public or private payers against the frequent break-downs and lengthy downtimes of powered wheelchairs. In 1998, a federal law applicable to all 56 states, territories and dependencies was enacted to cover all assistive technology, not only powered wheelchairs as do the laws of the individual states.

RESULTS:

COMPARATIVE STUDIES A literature search of conventional bibliographic databases, such as Medline, did not yield any controlled studies useful for our purposes. The Web, on the other hand, provides a plethora of information on all the different types of powered wheel-chairs. Most of this information comes from manufacturers but some is provided by wheelchair-user groups and rehabilitation centres. Despite this abundance of informa-tion, there are very few well-designed studies comparing the performance of the different types of available wheelchair drives. As a result, we retained only two studies. A final point must be added to our conclu-sions Of the 15 FWDs, RWDs or MWDs tested for standards compliance, 9 wheel-chairs failed at least 1 test out of the 11 selected for the study (from a total of 23 applicable tests) . If, on the one hand, this observation can no doubt be viewed as an a posteriori justification for the American lemon laws, on the other hand, it raises questions about the quality of the mobility products currently available in Canada. Nonetheless, in Québec, the contracts between RAMQ and its suppliers are explicit regarding the warranties to be fulfilled and may help counter some of the evident shortcomings.

CONCLUSIONS:

Although limited, the data we collected provided enough information for us to conclude that MWDs do not seem inferior to other powered wheelchairs. Most of the characteristics of the tested MWDs are equally good and their turning radius is superior, giving them better manoeuvrability in tight spaces. Despite the paucity of data, we can assert that they are reasonably priced. We were unable to find any specific eligibi-lity requirements for potential users of MWDs. Given the lack of data on the parameters to be considered in prescribing these wheelchairs, the present procedure based on the clinical judgment of health-care practitioners, backed by current multidisci-plinary interventions, must remain the method for allocating these wheelchairs.

RECOMMENDATIONS:

Given that this review is favourable overall, AETMIS recommends that RAMQ add mid-wheel drive powered wheelchairs to its list of devices that compensate for physical deficiencies, on the same basis as other currently insured powered wheelchairs. Nevertheless, RAMQ must be able to assure itself of the quality of these chairs by means of compliance tests performed on more than one chair of the same brand. The same requirement applies to all types of powered wheelchairs. Considering the means required to imple-ment this recommendation, it would seem advisable either to provide for both operational and financial partnership or collaborative agreements among all the parties concerned, or to review existing terms and conditions in order to wield greater control over the reliability of the products. Such parties include manufactur-ers, public or private standards-testing organizations, and public or private payers.(AU)