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Objective
To analyze the content of outcome measures commonly used to assess health in patients with fibromyalgia (FM) by linking the items of the instruments with the International Classification of Functioning, Disability and Health (ICF) in order to evaluate the adequacy of currently used measures.
Methods
Questionnaires used in FM were identified in a structured literature search. All concepts included in the items of the questionnaires were linked to ICF categories, according to previously published linking rules, by 2 independent health professionals. The percentages of linked ICF categories addressing the different ICF components were calculated.
Results
Generic and symptom‐specific instruments were included. From the 296 items contained in all 16 instruments, 447 concepts were extracted and then linked to 52 ICF categories of the component body functions, 1 category of the component body structure, 40 categories of the component activities and participation, and 9 categories of the component environmental factors. More than half of the concepts identified were linked to body function, fewer were linked to activities and participation, and only concepts of 4 instruments were linked to the ICF component environmental factors.
Conclusion
Many concepts were linked to the categories in the ICF component body functions. While linking to the broad category, purportedly similar instruments often covered widely varying areas of function at more fine‐grained levels of detail. Some categories, such as environmental factors, were barely covered by any of the instruments and might constitute an important aspect of health deserving better coverage and future development.
Background: Current health systems are increasingly challenged to meet the needs of a growing number of patients living with chronic and often multiple health conditions. The primary outcome of care, it is argued, is not merely curing disease but also optimizing functioning over a person’s life span. According to the World Health Organization, functioning can serve as foundation for a comprehensive picture of health and augment the biomedical perspective with a broader and more comprehensive picture of health as it plays out in people’s lives. The crucial importance of information about patient’s functioning for a well-performing health system, however, has yet to be sufficiently appreciated.
Methods: This paper argues that functioning information is fundamental in all components of health systems and enhances the capacity of health systems to optimize patients’ health and health-related needs.
Results and conclusion: Beyond making sense of biomedical disease patterns, health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes.
- Implications for rehabilitation
- Functioning is a key health outcome for rehabilitation within health systems.
- Information on restoring, maintaining, and optimizing human functioning can strengthen health system response to patients’ health and rehabilitative needs.
- Functioning information guides health systems to achieve cross-cutting health outcomes that respond to the needs of the growing number of individuals living with chronic and multiple health conditions.
- Accounting for individuals functioning helps to overcome fragmentation of care and to improve interprofessional collaboration across settings
Objectives: To examine metric properties and responsiveness of the International Classification of Functioning, Disability and Health (ICF) Generic Set when used in routine clinical practice to assess functioning.
Design: Prospective multicentre study.
Setting: 50 hospitals from 20 provinces of Mainland China.
Participants: 4510 adult inpatients admitted to the departments of Pulmonology, Cardiology, Neurology, Orthopaedics, Cerebral Surgery or Rehabilitation Medicine.
Main outcome measures: The ICF Generic Set (ICF Generic 6 Set) applied with an 11-point numeric rating scale (0-no problem to 10-complete problem) was fit to the Partial Credit Model (PCM) to create an interval score of functioning.
Results: PCM assumptions were found to be fulfilled after accounting for Differential Item Functioning. With an average improvement by 7.86 points of the metric ICF Generic 6 score (95% CI 7.53 to 8.19), the ICF Generic 6 Set proved sensitive to change (Cohen’s f2=0.41). Ceiling and floor effects on detecting change in functioning were cancelled or reduced by using the metric score.
Conclusion: The ICF Generic 6 Set can be used for the assessment of functioning in routine clinical practice and an interval score can be derived which is sensitive to change.
Background: The International Classification of Functioning, Disability and Health is the international standard for describing and monitoring functioning. While the categories, the units of the classification, were not designed with measurement in mind, the hierarchical structure of the classification lends itself to the possibility of summating categories into some higher order domain. Focusing on the chapters of d4 Mobility, d5 Self-Care and d6 Domestic Life, this study seeks to ascertain if qualifiers rating of categories (0-No problem to 4-Complete problem) within those chapters can be summated, and whether such derived measurement is consistent with estimates obtained from well-known instruments which purport to measure the same constructs.
Methods: The current study applies secondary analysis to data previously collected in the context of validating Core Sets for stroke, rheumatoid arthritis, and osteoarthritis. Data included qualifier-based ratings of the categories in the Core Sets, and the physical functioning sub-scale of the Short-Form 36, and the World Health Organization Disability Assessment Schedule 2.0. To examine qualifier-comparator scale item agreement Kappa statistics were used. To identify whether appropriate gradients of the comparator scales were observed across qualifier levels, an Independent Sample Median Test of the ordinal scores was deployed. To investigate the internal validity of the summated ICF categories, the Rasch model was applied.
Results: Data from 2,927 subjects from Europe, Australasia, Middle East and South America were available for analysis; 36.3% had experienced a stroke, 35.8% osteoarthritis, and 27.9% had rheumatoid arthritis. The items from the Short-Form 36 could not match directly the qualifier categories as the former had only 3 response options. The Kappa between World Health Organization Disability Assessment Schedule 2.0 items and categories was low. For all qualifiers, a significant (<0.001) overall gradient was observed across the comparator scales. Only in few of the World Health Organization Disability Assessment Schedule 2.0 items could no discrete level be detected. The aggregation of the qualifiers at the Chapter and higher order levels mostly revealed fit to the Rasch model. Almost all ICF qualifiers showed ordered thresholds suggesting that the current structure and response options of the qualifiers worked as intended.
Conclusions: The findings of this study provide supporting evidence for the use of the professionally rated categories and associated qualifiers to measure functioning.
Implication for Rehabilitation
- This study provides evidence that functioning data can be collected directly with the International Classification of Functioning, Disability and Health (ICF) by using the ICF categories as items and the ICF qualifiers as rating scale.
- The findings of this study show the aggregated ratings of ICF categories from the chapters d4 Mobility, d5 Self-care, and d6 Domestic life capture a broader spectrum of the construct than the corresponding summated items from the SF36-Physical Function sub-scale and the corresponding items of the World Health Organization Disability Assessment Schedule 2.0.
- This study illustrates the potential of building quantitative measurement by aggregating ICF categories and their qualifier ratings into meaningful domains.
Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers
(2020)
Context: Environmental factors play a key role in the lives of individuals with a spinal cord injury (SCI). This study identifies environmental barriers and their impacts on daily lives as perceived by individuals living with SCI in Mongolia.
Design: A qualitative study with semi-structured interviews was conducted. A topic guide for the interviews was structured around the components of the International Classification of Functioning, Disability, and Health.
Setting: Urban and rural areas of Mongolia.
Participants: A purposive sample of 16 persons with traumatic SCI.
Interventions: Not applicable.
Outcome Measures: Not applicable.
Results: Seven categories of environmental barriers were mentioned, such as poor access to the physical environment, absence of wheelchair-friendly transportation, negative societal attitudes, inadequate health and rehabilitation services, lack of access to assistive devices and medicines, limited financial resources for healthcare, and inaccurate categorization of disabilities in laws. These barriers were claimed to have an impact on physical and psychological health, limit activities, and restrict participation in almost all areas of life.
Conclusion: This study contributes to the identification of targets for interventions aimed at improving the lived experience of persons with SCI in a low-resource context. The findings reveal that while the Mongolian government already has laws and policies in place to improve access to the physical environment, transportation, assistive devices and employment, much more has to be done in terms of enforcement. Specialized SCI care and rehabilitation services are highly demanded in Mongolia.
Abstract
Objective: Since the 1990s the Functional Independence Measure (FIM™) was believed to measure 2 different constructs, represented by its motor and cognitive subscales. The practice of reporting FIM™ total scores, together with recent developments in the understanding of the influence of locally dependent items on fit to the Rasch model, raises the question of whether the FIM™ 18-item version can be reported as a unidimensional interval-scaled metric.
Design: Rasch analysis of the FIM™ using testlet approaches to accommodate local response dependency.
Patients: A calibration sample containing 946 cases of data from 11,103 patients undergoing neurological or musculoskeletal rehabilitation in Switzerland in 2016.
Results: Baseline analysis and the traditional testlet approach showed no fit with the Rasch model. When items were grouped into 2 testlets, fit to the Rasch model was achieved, indicating unidimensionality across all 18 items. A transformation table to convert FIM™ raw ordinal scores to the corresponding Rasch interval scaled values was created.
Conclusion: This study provides evidence that FIM™ total scores represent a unidimensional set of items, supporting their use in clinical practice and outcome reporting when applying the respective transformation table. This provides a basis for standardized reporting of functioning.
Lay Abstract
The aim of this study was to look in detail at the FIM™, an assessment tool often used for patients undergoing rehabilitation. Some users report the FIM™ as 2 scores: one related to motor tasks, the other to cognitive tasks; others recommend reporting it as a single score including both motor and cognitive tasks. This study explored whether it is statistically meaningful to sum all the points into a single FIM™ total score. The results support the current practice of summing the points into a single total score for patients undergoing musculo-skeletal and neurological rehabilitation. The results also allowed an interval scale to be derived from the FIM™, enabling a broad range of calculations to be made using the FIM™ score, such as calculating the change in FIM™ outcomes from the time a patient is admitted to a rehabilitation clinic until their discharge.
Background: The Extended Barthel Index (EBI), consisting of the original Barthel Index plus 6 cognitive items, provides a tool to monitor patients’ outcomes in rehabilitation. Whether the EBI provides a unidimensional metric, thus can be reported as a valid sum-score, remains to be examined.
Objective: To examine whether the EBI can be reported as unidimensional interval-scaled metric for neurological and musculoskeletal rehabilitation.
Methods: Rasch analysis of a calibration sample of 800 cases from neurological or musculoskeletal rehabilitation in 2016 in Switzerland.
Results: In the baseline analysis no fit to the Rasch Model was achieved. When accommodating local dependencies with a testlet approach satisfactory fit to the Rasch Model was achieved, and an interval scale transformation table was created.
Conclusion: The results support the reporting of adapted EBI total scores for both rehabilitation groups by applying the interval scaled transformation table presented in this study.
BACKGROUND: In clinical practice and research a variety of clinical data collection tools are used to collect information on people’s functioning for clinical practice and research and national health information systems. Reporting on ICF-based common metrics enables standardized documentation of functioning information in national health information systems. The objective of this methodological note on applying the ICF in rehabilitation is to demonstrate how to report functioning information collected with a data collection tool on ICF-based common metrics. We first specify the requirements for the standardized reporting of functioning information. Secondly, we introduce the methods needed for transforming functioning data to ICF-based common metrics. Finally, we provide an example.
METHODS: The requirements for standardized reporting are as follows: 1) having a common conceptual framework to enable content comparability between any health information; and 2) a measurement framework so that scores between two or more clinical data collection tools can be directly compared. The methods needed to achieve these requirements are the ICF Linking Rules and the Rasch measurement model. Using data collected incorporating the 36-item Short Form Health Survey (SF-36), the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), and the Stroke Impact Scale 3.0 (SIS 3.0), the application of the standardized reporting based on common metrics is demonstrated.
RESULTS: A subset of items from the three tools linked to common chapters of the ICF (d4 Mobility, d5 Self-care and d6 Domestic life), were entered as “super items” into the Rasch model. Good fit was achieved with no residual local dependency and a unidimensional metric. A transformation table allows for comparison between scales, and between a scale and the reporting common metric.
CONCLUSIONS: Being able to report functioning information collected with commonly used clinical data collection tools with ICF-based common metrics enables clinicians and researchers to continue using their tools while still being able to compare and aggregate the information within and across tools.
Background
The World Health Organization developed the International Classification of Functioning, Disability, and Health (ICF) in 2001 and has been in the process of implementing it in clinics since then. Current international efforts to implement ICF in rehabilitation clinics include the implementation of ICF Core Sets and the development of simple, intuitive descriptions for the ICF Generic-30 Set (also called Rehabilitation Set). The present study was designed to operationalize these ICF tools for clinical practice in Japan. This work included 1) the development of the Japanese version of the simple, intuitive descriptions for the ICF Generic-30 Set, 2) the development of a rating reference guide for Activity and Participation categories, and 3) the examination of the interrater reliability of rating Activity and Participation categories.
Methods
The Japanese version of the simple, intuitive descriptions for the ICF Generic-30 Set was developed following the process employed to develop the Chinese and Italian versions.
For further operationalization of this ICF Set in practice, a rating reference guide was developed. The development of the rating reference guide involved the following steps: 1) a trial of rating patients by several raters, 2) cognitive interviewing of the raters to analyse the thinking process involved in rating, 3) drafting of the rating reference guide, and 4) review by ICF specialists to confirm consistency with the original ICF concepts.
After the rating reference guide was developed, interrater reliability of the rating with the reference guide was determined. Interrater reliability was examined using weighted kappa statistics with linear weight.
Results
Through the pre-defined process, the Japanese version of the simple, intuitive descriptions for 30 categories of the ICF Generic-30 Set and the rating reference guides for 21 Activity and Participation categories were successfully developed. The weighted kappa statistics ranged from 0.61 to 0.85, showing substantial to excellent agreement of the ratings between raters.
Conclusions
The present study demonstrates that ICF categories can be translated into clinical practice. Collaboration between clinicians and researchers would further enhance the implementation of the ICF in Japan.
Objective
To demonstrate the influence and added value of a Standardized Assessment and Reporting System (StARS) upon the reporting of functioning outcomes for national rehabilitation quality reports. A StARS builds upon an ICF-based (International Classification of Functioning, Disability and Health) and interval-scaled common metric.
Design
Comparison of current ordinal-scaled Swiss national rehabilitation outcome reports including an expert-consensus-based transformation scale with StARS-based reports through descriptive statistical methods and content exploration of further development areas of the reports with relevant ICF Core Sets.
Setting
Swiss national public rehabilitation outcome quality reports on the clinic level.
Participants
A total of 29 Swiss rehabilitation clinics provided their quality report datasets including 18 047 patients.
Interventions
Neurological or musculoskeletal rehabilitation.
Main outcome measures
Functional Independence Measure™ or Extended Barthel Index.
Results
Outcomes reported with a StARS tended to be smaller but more precise than in the current ordinal-scaled reports, indicating an overestimation of achieved outcomes in the latter. The comparison of the common metric’s content with ICF Core Sets suggests to include ‘energy and drive functions’ or ‘maintaining a basic body position’ to enhance the content of functioning as an indicator.
Conclusions
A StARS supports the comparison of outcomes assessed with different measures on the same interval-scaled ICF-based common metric. Careful consideration is needed whether an ordinal-scaled or interval-scaled reporting system is applied as the magnitude and precision of reported outcomes is influenced. The StARS’ ICF basis brings an added value by informing further development of functioning as a relevant indicator for national outcome quality reports in rehabilitation.