In the Public Domain
Journal ofGerontology: MEDICAL SCIENCES
1999, Vol. 54A, No.2, M83-M88
Use of an Ambulation Assistive Device Predicts
Functional Decline Associated With Hospitalization
Jane E. Mahoney," Mark A. Sager,':" and Muhammad Jalaluddirr'
'Geriatric Research, Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.
Departments of' Medicine, 3Preventive Medicine, and 4Biostatistics, The University of Wisconsin-Madison.
Background. Loss of functional independence occurs frequently with hospitalization. In community-dwelling
elders, lower extremity disability is an important predictor of functional loss. Ambulation assistive devices (canes,
walkers), as markers of lower extremity disability, may predict functional decline associated with hospitalization, but
this has not been evaluated previously. We sought to determine the association of mobility impairment, as indicated by
cane or walker use prehospitalization, with adverse outcomes at hospital discharge and 3 months post discharge.
Methods. Subjects were community-dwelling adults (N = 1212) aged 70 and older, hospitalized for acute medical
illness. The study was a secondary analysis of the Hospital Outcomes Project for the Elderly, a prospective randomized
trial at three university and two private acute-care hospitals, which randomized patients to usual care or an intervention
group designed to maintain functional abilities.
Results. After controlling for demographic and illness-related characteristics and prehospital function, mobility
impairment was significantly associated with functional decline. Use of a walker was associated with 2.8 times
increased risk for decline in ADL function by hospital discharge (p = .0002). Three months after discharge, patients
who used assistive devices prior to hospitalization were more likely to have declined in both ADLs (p = .02) and
IADLs (p = .003).
Conclusions. Hospitalized patients with mobility impairment, as indicated by use of a cane or a walker, are at high
risk for functional decline. Such patients may benefit from more intensive in-hospital and post-hospital rehabilitative
therapy to maintain function .
.ALMOST one third of older adults decline in ability to
~ perform basic activities of daily living (ADLs)
related to hospitalization and acute medical illness (1-3). If
function is lost related to acute medical illness, it often is
not reversed (3). The ability to predict patients at risk for
decline is important for targeting preventive and rehabilitative therapies during and after hospitalization. Risk factors
for functional decline with hospitalization include cognitive
impairment, pressure sores, low social activity levels, older
age, preexisting instrumental ADL impairment, delirium,
and specific diseases (3-7). These risk factors indicate that,
in general, patients with preexisting impairments are more
likely to lose function in the setting of acute illness and
hospitalization.
In community populations, the presence of lower
extremity disability predicts development of new functional
dependency (8). Measures of lower extremity disability
include objective measures of balance, gait, and chair rise
ability (8,9). Use of an ambulation assistive device may
also serve as a marker of lower extremity disability. Consistent with this, previous studies have shown that patients
who use ambulation aids have poorer performance on
objective tests of balance, gait, and mobility (10-12). We
hypothesized that use of an ambulation assistive device, as
a marker of lower extremity impairment, would predict
development of new functional dependency in the setting
of acute hospitalization.
We have previously shown that patients who use ambulation aids prior to hospitalization are at increased risk for
decline in walking with hospitalization, and for falls after
hospital discharge (13,14). However, the association of
assistive device use with loss of ADL independence has not
been evaluated. The specific objectives of this study were
to determine (a) if use of an assistive device prior to hospitalization is associated with increased risk for functional
decline during the hospitalization period, independent of
decline in walking during the same period; and (b) if
degree of risk for decline varies according to type of assistive device (cane vs walker), and (c) if use of an assistive
device continues to predict decline in function, compared
to prehospital baseline, 3 months after discharge.
METHODS
Study populations.-This study is a secondary analysis
of the Hospital Outcomes Project for the Elderly (HOPE), a
prospective randomized trial at three university and two
private acute-care hospitals of distinct but related interventions to prevent functional decline with hospitalization.
Subjects eligible to participate in the HOPE study were age
70 or older and hospitalized for a medical illness between
1989 and 1992 at one of five hospitals: Cedars Sinai Medical Center, Los Angeles, CA; University Hospitals of
Cleveland, OH; St Mary's Hospital Medical Center, MadiM83
M84
MAHONEYETAL.
son, WI; Stanford University Hospital, Palo Alto, CA; and
Yale-New Haven Hospital, New Haven, CT. At each hospital site, patients were randomized to usual care or an
intervention designed to maintain functional abilities of
hospitalized older persons. The study design, site-specific
interventions, and inclusion and exclusion criteria were previously described (3,4,15-.19). Exclusion criteria common
to all sites included terminal illness, severe cognitive impairment, inability to give informed consent, admission to
the intensive care unit, and residence in a nursing home
prior to hospitalization. Informed consent was obtained in
accordance with appropriate institutional review boards.
A total of 1,486 patients met these eligibility criteria and
were enrolled in the study between 1989 and 1992. From
this sample, 207 were excluded from analysis for the following reasons: 64 died, and 143 had either absent (87) or
incomplete (56) data regarding ADLs at admission or discharge. The remaining 1,279 represented 86% of the eligible study population (90% of survivors). Patients excluded
because of absent or incomplete functional information did
not differ from the study sample in age, gender, living site,
race, marital status, or length of hospital stay.
Of the sample of 1,279 subjects, 59 patients reported
they used a wheelchair prior to hospitalization and 9 reported use of another mobility aid (non-cane, non-walker).
Because these groups were too small to permit meaningful
analysis, patients using wheelchairs and other non-cane,
non-walker assistive devices were excluded from the analysis. Thus, the population for this study comprised 1,212
subjects who used no assistive device, or a cane or a walker
prior to hospitalization.
MeQsurements.-Patients were assessed at three time
intervals: within 48 hours of admission, at hospital discharge, and 3 months after discharge. The admission assessment included baseline demographic information (age,
gender, race, living arrangement [alone or with others], and
marital status), and retrospective self-report of use and type
of ambulation assistive device, ability to walk across a
small room, and need for help from another person to perform seven IADLs (Lawton scale) and five ADLs (Katz
scale) 2 weeks before hospitalization (20,21). Patients were
considered independent in walking if they were able to
walk across a small room without the assistance of another
person. Patients were considered independent in an ADL or
IADL if they were able to perform the activity without help
from another person. At the Madison site, the Katz scale of
discharge ADL function was validated against the Functional Independence Measure (FIM), an objective, performance-based assessment of ADL function (22,23). Overall
agreement between the two measures was 78% (17). An
abbreviated Mini-Mental State Examination (MMSE),
excludirig the 9 items composing the language portion of
the test, was also conducted (24). The language items were
excluded because of concerns about the ability of acutely ill
patients to perform tasks such as writing and copying.
Spearman's rank order correlation between the 21-item and
standard 30-item MMSE was .90 (p < .001) in the cohort at
the Madison site.
At discharge, patients were assessed by the same meth-
odology as on admission regarding ability to perform
the five ADLs and independently walk across a room.
Discharge diagnoses (ICD-9-CM classification), hospital
length of stay, and discharge destination (community vs
nursing home) were obtained from hospital records. Three
months after discharge, patients and/or families were contacted by telephone to determine current ADL, IADL, and
walking function, living arrangement, rehospitalization, and
mortality.
Data collection.-All data were obtained from participants or proxies by trained interviewers using predetermined protocols and data collection instruments standardized across sites. After informed consent was signed, the
participant was identified a priori as the primary source of
data, and proxies were used only if the patient was too ill to
respond. Participant self-reports accounted for 90% of
admission and 85% of discharge information, and 90% of
3-month follow-ups. The same reporter was used for all
three phases of data collection in 77% of cases.
Analysis.-Type of assistive device used prior to hospitalization was classified as cane or walker. Patients using
more than one type-were considered to use the type indicating the greatest degree of impairment, with a walker representing greater impairment than a cane. A summary ADL
functional score from 0 to 5 was calculated as the number
of ADLs;that a subject could independently perform (out of
five basic AD's-bathing, dressing, toileting, transferring
and eating). A summary score for IADLs from 0 to 7 was
similarly constructed.
Logistic regression was performed to identify factors
predictive of functional and health utilization outcomes at
discharge and at 3 months post discharge. For these analyses, functional outcomes were treated as binary variables,
comparing decline in ADL score or decline in IADL score
(scored as 1) to no decline in ADL or IADL score (scored
as 0). All outcome models tested the independent contributions of demographic characteristics (age, race, gender, living arrangement), prehospitalization ADL and IADL functional status and mobility [use of ambulation assistive
device vs no device]), cognitive status (abbreviated MMSE),
diagnostic category of principal diagnosis (cancer, circulatory, respiratory, gastrointestinal, and other), and number of
comorbid illnesses, controlling for site of hospitalization,
treatment group (experimental vs control), and source of
data (patient vs other). Loss of walking independence during hospitalization was included as a control variable, to
determine if use of an assistive device predicted decline in
ADL function independent of change in walking. Loss of
walking independence was defined to have occurred if a
patient could ambulate across a small room independent of
another person prior to hospitalization, but required personal assistance by discharge. To determine the difference
in risk associated with cane or walker versus no assistive
device, logistic models were repeated using prehospital use
of cane and walker as indicator variables, with no assistive
device being the reference category.
Outcomes of interest at hospital discharge included
decline in ADL function compared to baseline two weeks
ASSISTIVE DEVICES AND FUNCTIONAL DECLINE
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prior to hospitalization, and discharge to a nursing home.
For analysis of decline in function, prehospital ADL function was included in the regression using dummy variables
for each level of ADL function prior to hospitalization.
Patients with a prehospital ADL level of 0 (n = 29) were
excluded because they could not decline.
Outcomes of interest at 3 months post discharge included
mortality, decline in ADL and IADL function compared to
two weeks prior to hospitalization, location of residence
(nursing home vs community), and rehospitalization in the
interim. For the analysis of decline in ADL function, prehospital ADL function was included as described above,
excluding those with a level of 0 (n = 21). Decline in IADL
function was analyzed similarly, using indicator variables
for prehospital levels of IADL function, and excluding 58
people with a prehospital IADL level of O.
Chi-square analysis was performed on the subset of
patients who had declined in ADL function by discharge, to
compare frequency of subsequent recovery in cane users
versus those with no assistive device. Similarly, chi-square
testing was performed on the subset of patients who had not
declined by hospital discharge, to compare frequency of
subsequent ADL decline in cane users versus those with no
assistive device.
All analyses were performed using SAS statistical software, version 6.09 (Statistical Analysis Systems, Cary, NC).
excluded from analysis of follow-up outcomes. Subjects
with complete data at 3 months (n = 1072) did not differ
from those with missing data in demographic characteristics, prehospital ADL or IADL function, assistive device
use, or cognition.
By 3 months post discharge, 17.4% of survivors had
declined in ADL function compared to baseline before hospitalization, and 39.3% had declined in IADL function.
Seven percent were residing in a nursing home at 3-month
follow-up, and 22% had been rehospitalized in the interim.
Table 3 shows the association between use of an assistive
device prehospitalization and 3-month outcomes. Compared to those who did not use an assistive device, patients
who used an ambulation aid were at 1.7 times increased
risk for decline in ADL and IADL function, after controlling for decline in walking during the hospitalization
period. In examining type of assistive device, both cane and
walker were associated with 1.7 times increased risk for
ADL decline, although only cane use was statistically significant. The association of cane use with ADL decline was
likely related to the fact that cane users were less likely to
recover after discharge. Fifty-three percent of cane users
RESULTS
Age (Mean, SD)
79.1 (6.2)
Characteristics of the study sample.-Table 1 shows characteristics of the 1,212 subjects who were admitted to the
hospital from the community for acute medical illness and
used a cane, walker, or no ambulation aid prior to hospitalization. Subjects were largely independent in ADLs prior to
admission, but had substantial impairment in IADLs. One
third of subjects used an assistive device prior to hospitalization, with 21% using a cane and 13% a walker. Almost
half of patients were admitted for primary respiratory or
circulatory conditions; gastrointestinal conditions or cancer
accounted for another 20% of admitting diagnoses.
Discharge outcomes associated with use of an assistive
device.-At hospital discharge, 29.5% of people had declined in one or more of the five ADLs, and 7.8% were discharged to a nursing home. Fifteen percent had become
newly dependent on another person to walk.
Table 2 shows the risk of adverse outcomes at discharge,
in relation to any assistive device use and to type of assistive device, after controlling for decline in walking. Use of
a walker prior to hospitalization was associated with 2.8
times increased risk for decline in ADLs (bathing, dressing,
toileting, transferring, and eating), independent of prehospital functional status and decline in walking during hospitalization. Use of a cane was not associated with increased
risk of ADL decline.
Three-month outcomes associated with use of an assistive device.-At 3-month follow-up, 10.3% of subjects had
died. Of patients who survived, 6.4% had incomplete information regarding functional status. These patients. were
Table 1. Characteristics of Subjects
Prior to Hospitalization (N = 1212)
Female (%)
61.6
Race (%)
Caucasian (%)
African American (%)
Asian (%)
Hispanic, American Indian, other (%)
78.8
18.5
2.0
0.2
Living arrangement (%)
Alone (%)
With spouse (%)
With family (%)
With unrelated person (%)
37.5
40.8
17.5
4.2
Abbreviated MMSE (range 0-21) (Mean, SD)*
17.1 (3.9)
No. independent ADLs (range 0-5) (Mean, SD)t
No. independent IADLs (range 0-7) (Mean, SD):j:
4.5 (1.2)
4.6 (2.2)
Need assistive device before hospitalization
Cane (%)
Walker(%)
33.9
20.9
13.0
~4
comorbid illnesses (%)
62.3
Discharge diagnostic category:
Cancer (%)
Gastrointestinal (%)
Respiratory (%)
Circulatory (%)
Other (%)
14.6
19.6
26.2
33.0
6.4
*Abbreviated MMSE = Mini-Mental State Examination, excluding 9
language items.
t ADL =5 activities of daily living (bathing, dressing, transferring, toileting, and eating).
:j:IADL = 7 instrumental activities of daily living (managing finances,
taking medications, telephoning, shopping, using transportation, preparing meals, doing housework).
MAHONEYETAL.
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Table 2. Relationship of Prehospital Use of a Cane or a Walker With Functional Decline and Institutionalization at Hospital Discharge
Discharge Outcomes
Adjusted Odds Ratio
Associated With
Assistive Device*t 95% CI
Adjusted Odds Ratio
Associated With
Cane*t
95% CI
Adjusted Odds Ratio
Associated With
Walker*t
95% CI
Decline in ADL function during
hospitalizationjf
Discharge to nursing home
1.32
0.83
(0.92-1.92)
(0.45-1.52)
0.91
0.62
(0.59-1.4)
(0.30-1.28)
2.77
1.25
(1.63-4.72)
(0.58-2.69)
*Adjusted for age, race, gender, prehospitalliving arrangement, prehospital ADL and IADL function, cognition, diagnostic category, number of comorbid illnesses, site, treatment group, and source of data. All models adjusted for decline in walking during hospitalization (that is, new dependency on
another person to walk across a small room) during index hospitalization.
[Odds ratio equals the probability of functional decline if a person uses an assistive device divided by the probability of functional decline if a person
does not use an assistive device.
tCompared to baseline 2 weeks prior to hospitalization.
§Prehospital ADL function included in logistic model with indicator variable for each level of function; patients with prehospital ADL level of 0 were
excluded (n = 29).
Table 3. Relationship of Prehospital Use of a Cane or a Walker With Functional Decline and Institutionalization at 3 Months
3-Month Outcomes
Adjusted Odds Ratio
Associated With
Assistive Device*t 95%CI
Adjusted Odds Ratio
Associated With
95%CI
Cane*t
Adjusted Odds Ratio
Associated With
95%CI
Walker*t
Mortality
1.58
(0.95-2.63)
1.54
(0.86-2.75)
1.70
(0.87-3.33)
Among Survivors (n = 1072):
Decline in ADL functiontj
Decline in IADL functiont**
In nursing home
Rehospitalized in interim
1.71
1.71
1.19
1.08
(1.10-2.65)
(1.19-2.44)
(0.59-2.39)
(0.73-1.61)
1.72
1.63
0.79
1.20
(1.06-2.81)
(1.10-2.42)
(0.33-1.87)
(0.78-1.85) .
1.72
2.05
1.85
0.91
(0.94-3.14)
(1.19-3.52)
(0.81-4.21 )
(0.51-1.62)
*Adjusted for age, race, gender, prehospitalliving arrangement, prehospital ADL and IADL function, cognition, diagnostic category, number of comorbid illnesses, site, treatment group, and source of data. All models adjusted for decline in walking (that is, new dependency on another person to walk
across a small room) during index hospitalization.
tOdds ratio equals the probability of functional decline if a person uses an assistive device divided by the probability of functional decline if a person
does not use an assistive device.
tCompared to baseline 2 weeks prior to hospitalization.
§Prehospital ADL function included in model with indicator variable for each level of function, patients with prehospital ADL level of 0 were excluded
from the model (n = 21).
**Prehospital IADL function included in model with indicator variable for each level of function, patients with prehospital IADL level of 0 were
excluded from the model (n =58).
recovered versus 67% of those who used no ambulation
device (p = .04). In addition, compared to those who used
no assistive device, cane users were more likely to have
new decline in ADL function subsequent to discharge (16%
of cane users declined vs 7% of those with no assistive
device, p = .001).
Prehospital assistive device use also predicted decline in
IADL function by 3 months post discharge, with risk being
greater for a walker (OR = 2.0, p = .01) than for a cane (OR
= 1.6, p = .015). Use of an assistive device prior to hospitalization was not associated with 3-month mortality, nursing
home utilization, or rehospitalization.
DISCUSSION
In this multicenter study of older adults hospitalized for a
medical illness, use of a walker prior to hospitalization was
strongly associated with increased risk of functional decline
during the hospitalization period. Loss of function was
often, but not always, accompanied by loss of walking ability. After controlling for simultaneous loss of walking function, use of a walker continued to be an independent predic-
tor of loss of ADL function. Three months after discharge,
use of an assistive device was significantly associated with
decline in both ADL and IADL function compared to prehospitalization. Both cane and walker were predictive, with
risk in general being higher for a walker than for a cane.
Previous studies have shown that older age, impaired
cognition, preexisting ADL and IADL impairment, pressure
sores, and low social support are risk factors for adverse
functional outcomes after hospitalization (3,4,6). The significance of this study is that it demonstrates that specific
indicators of mobility impairment are important, additional
predictors of functional decline. Our findings suggest that,
independent of functional level, preexisting mobility impairment places a patient closer to the threshold of loss of
independence in ADLs. The fact that functional decline at
discharge was associated with use of a walker but not a
cane suggests that the more severe the mobility impairment
before hospitalization, the closer the threshold of functional
decline. For clinicians, simple questions regarding the use
and type of assistive device before admission may permit
identification of patients who are at high risk for loss of
ASSISTIVE DEVICES AND FUNCTIONAL DECLINE
ADL independence, and who might benefit from preventive
and rehabilitative efforts designed to maintain mobility and
ADL function during hospitalization.
We have previously shown that use of an assistive device
is a significant predictor of loss of walking independence
associated with hospitalization for acute medical illness
(13). Importantly, in this study, development of new functional dependency related to assistive device use was not
just due to loss of walking independence. Use of a walker
remained a significant predictor of functional decline even
after controlling for loss of walking function. If a patient
used a walker prior to hospitalization, he or she remained at
risk for loss of independence in other basic ADLs even if
walking independence was maintained.
Ambulation assistive devices can improve mobility and
allow independent performance of mobility-related tasks
for people who would otherwise be dependent on others. In
one study, half of people using mobility aids reported they
could not perform mobility-related activities without the aid
(25). In a study by Sonn and Grimby (26), 43% of those
who used assistive devices for indoor mobility activities
said that the device increased independence, 74% reported
that it increased safety, and 79% reported that it was necessary for performance of the activity. In another study, older
adult cane users reported that use of a cane improved both
functional ability and confidence. (27).
Although assistive devices may permit continued independent functioning for patients who would otherwise be
dependent on others, at the same time they indicate the
presence of substantial impairment in lower extremity function. Use of an assistive device has been associated with
decreased balance, strength, mobility, and stair-climbing
power, slowed gait speed, and increased risk for falls
(10,11,14,28). Fried et al. (12) found that older adults who
were independent in ADLs and IADLs, but who modified
tasks by use of an assistive device or by other methods,
were more impaired on objective tests of physical performance. Use of an assistive device, therefore, would appear
to be a marker for a greater degree of physiologic impairment for a given level of ADL or IADL function. As our
data suggest, it also serves as a marker for those more
likely to become further dependent on others for performance of ADLs.
Use of an assistive device before hospitalization also predicted functional decline 3 months later. Patients who used
assistive devices were at risk for loss of IADL as well as
ADL functions. Reasons for persistent or new decline 3
months after hospitalization are many. Prolonged bedrest,
decreased mobility, recurrent illness, and falls may prevent
recovery of function after hospitalization. New or recurrent
illness may engender new functional dependence over the
subsequent 3 months. Further study is needed to determine
(a) specific factors that mediate loss of function, or failure
to recover function, after hospitalization, and (b) if these
factors serve as greater impediments to recovery in patients
with preexisting mobility impairment.
Use of a cane did not predict decline in ADL function at
hospital discharge, relative to no assistive device, but did
predict decline 3 months later. Our data suggest two explanations for this. First, use of a cane may be a marker for
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decreased ability to recover. Consistent with this, cane users
were significantly less likely to recover compared to those
who used no assistive device. Second, our data also suggest
that use of a cane may be associated with increased risk for
new decline in ADL function subsequent to hospitalization
among those who had not lost function previously.
There are a number of limitations to this analysis. First,
determination of functional status was based on subjective
report. A previous study (17) has documented that patient
self-report may overestimate ADL function compared to
objective performance. However, the agreement of our findings at discharge and 3 months later argues for their validity. Second, we could not determine to what extent functional dependence at the time of hospital discharge was
related to lack of an assistive device that may have been
used at home. However, the continued association of assistive device use with functional decline 3 months later
suggests that functional decline at discharge was not due
merely to lack of a preexisting assistive device, but to a
more severe physiologic decline.
In summary, this study suggests that use of an assistive
device is an important independent predictor of decline in
function around the hospitalization period. Such patients
may be easily identified for specific hospital and post-hospital interventions to prevent ADL and IADL dependence.
Further study is needed to determine if therapies such as
progressive-resistance training, specific balance training, or
more intensive use of physical therapy during hospitalization can ameliorate functional decline in this high-risk
group (10,29). Further study is also needed to determine if
changes in practice style, including more widespread provision of acute care units for the elderly (16), may prevent or
reverse functional loss in patients whose preexisting mobility impairment places them at risk.
ACKNOWLEDGMENTS
Financial support for this study was provided by Grant 92312-G from
the John A. Hartford Foundation, New York, NY. Dr. Mahoney is supported by NIA Academic Award 1 K08 AGOO623-01. This work was also
supported in part by the Department of Veterans Affairs. This is Madison
VA GRECC publication 97-10.
Address correspondence and reprint requests to Dr. Jane Mahoney,
GRECC, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison WI 53705. E-mail: [email protected]
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Received July 23, 1997
Accepted April 23, 1998
Be a Part of the New VA-VA Central Iowa Health Care System.Knoxville Division
The VA Central Iowa Health Care System, a two-division enterprise, is seeking a physician, board certified in Internal
Medicine or board certified/board eligible in Geriatric Medicine, for its Knoxville, Iowa, division. This division is a
long-term facility accredited by JCAHO that includes an acute psychiatry and CARP-accredited subacute rehabilitation. The incumbent will provide leadership for a 230-bed nursing home, supervision of mid-level practitioners, assist
with primary care, and provide consultative services for veterans with medical and/or psychiatric diagnoses.
Knoxville, Iowa, is located in a rural setting, 35 miles from Des Moines, and offers all the conveniences of a small town,
including a day care center on the medical center grounds, excellent schools, a recreation center, and affordable housing. VA offers a generous benefits package, including 10 paid holidays, federal retirement including a 401k plan, 30
vacation days, and paid sick leave. U.S. citizenship and possession of an active and current license to practice medicine
are required.
Applicants may forward a current curriculum vitae and letter of intent to VA Central Iowa Health Care System, Knoxville
Division, 1515 W. Pleasant, Knoxville, IA 50138. Or contact Usha Jaipaul, MD! Chief, Physical Medicine &
Rehabilitation Service at (515) 828-5015. Selectee may be subject to drug testing. VA is an Equal Opportunity Employer.