Friedbert Kohler

Developing Core Sets for persons following amputation based on the International Classification of Functioning, Disability and Health as a way to specify functioning

Amputation is a common late stage sequel of peripheral vascular disease and diabetes or a sequel of accidental trauma, civil unrest and landmines. The functional impairments affect many facets of life including but not limited to: Mobility; activities of daily living; body image and sexuality. Classification, measurement and comparison of the consequences of amputations has been impeded by the limited availability of internationally, multiculturally standardized instruments in the amputee setting. The introduction of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001 provides a globally accepted framework and classification system to describe, assess and compare function and disability. In order to facilitate the use of the ICF in everyday clinical practice and research, ICF core sets have been developed that focus on specific aspects of function typically associated with a particular disability. The objective of this paper is to outline the development process for the ICF core sets for persons following amputation. The ICF core sets are designed to translate the benefits of the ICF into clinical routine. The ICF core sets will be defined at a Consensus conference which will integrate evidence from preparatory studies, namely: (a) a systematic literature review regarding the outcome measures of clinical trails and observational studies, (b) semi-structured patient interviews, (c) international experts participating in an internet-based survey, and (d) cross-sectional, multi-center studies for clinical applicability. To validate the ICF core sets field-testing will follow. Invitation for participation: The development of ICF Core Sets is an inclusive and open process. Anyone who wishes to actively participate in this process is invited to do so.

Prospective validation study of the International Classification of Functioning, Disability and Health score in Crohn's disease and ulcerative colitis

BACKGROUND AND AIMS Inflammatory bowel diseases (IBD) may result in disability. We aim to validate a novel scoring system for the IBD disability index (IBD-DI), and identify predictors of disability and its correlation with work absenteeism. METHODS This prospective IBD ambulatory clinic cohort study measured IBD-DI, Crohns Disease Activity Index (CDAI) for Crohns disease (CD) or partial Mayo score (pMayo) for ulcerative colitis (UC), IBDQ quality-of-life, and Work Productivity and Activity Impairment. Negative IBD-DI represented greater disability. Validation tests were performed and predictors and extent of work absenteeism were determined. RESULTS 166 consecutive subjects were recruited (75 CD, 41 UC, 50 controls). IBD-DI correlated with CDAI (r=-0.77, P<0.001), pMayo (r=-0.82, P<0.001) and IBDQ (r=0.86, P<0.001). IBD-DI differentiated CD, and UC from controls (medians -7, -4, +10; P<0.001) with a score of >3.5 identifying controls with 94% sensitivity and 83% specificity (area-under-curve 0.92). Stable patients had unchanged IBD-DI (P=ns) but not in those who relapsed (P<0.001). Intraclass correlation was 0.89 and Cronbachs alpha of internal consistency was 0.94. Diagnosis age, sex, phenotype, perianal disease, prior surgery, steroid-use and disease duration did not influence the IBD-DI but active use of biological agents significantly reduced disability (P=0.03). 21.6% of IBD patients had moderate-severe disability equating to missing >25% of work hours in the previous week. Multivariate analysis identified that only IBD-DI to be predictive of unemployment status (OR: 0.94; 95% CI: 0.89-0.99). CONCLUSIONS The IBD-DI is a valid tool measuring disability in both CD and UC and correlates with workforce participation. It is a potential useful tool in the assessment of participation restriction and activity limitation. TRIAL REGISTRATION ACTRN12613000903785.

Can the ICF be used as a rehabilitation outcome measure? A study looking at the inter- and intra-rater reliability of ICF categories derived from an ADL assessment tool.

PURPOSE The categories of the International Classification of Functioning , Disability and Health (ICF) could potentially be used as components of outcome measures. Literature demonstrating the psychometric properties of ICF categories is limited. OBJECTIVE Determine the agreement and reliability of ICF activities of daily living category scores and compare these to agreement and reliability of the Functional Independence Measure (FIM) item scores. METHOD Two investigators independently reviewed the clinical notes to score the ICF activities of daily living cate-gories, of 100 patients using ICF qualifiers with additional scoring guidelines. The percentage agreement, interrater and intrarater reliability were compared with the matched FIM items scored by a separate set of two investigators using the same methodology. Kappa Statistic was calculated using Med Calc. RESULTS ICF interrater reliability as indicated by Kappa values ranging from 0.42 to 0.81 was moderate or better for the eleven self care and mobility categories. The language ICF categories and problem solving generally have fair agreement, with Kappa values ranging from 0.21 for receiving verbal messages to 0.44 for basic social interactions. Absolute agreement was above 72% for all categories. Reliability and agreement of the FIM items was generally lower than the corresponding ICF categories. CONCLUSION The inter-rater and intra-rater reliability and agreement of the ICF activities of daily living categories were comparable or better than the corresponding FIM items. The results of this study provide an indication that the ICF categories could be used as components of rehabilitation outcome measures.

Feasibility of using a checklist based on the international classification of functioning, disability and health as an outcome measure in individuals following lower limb amputation:

Background: The International Classification of Function, Disability and Health (ICF) has been promoted for use in clinical practice but few articles have demonstrated that it can be used as a sensitive outcome measure, and there has been no published evidence that it can be used for individuals following a lower limb amputation. We developed an ICF-based checklist for individuals who had an amputation. Objective: To evaluate the feasibility of this checklist in detecting meaningful changes of function and quality of life in persons following an amputation using the ICF qualifiers as an outcome measure. Study Design: Time series study. Methods: Twenty patients were rated on the ICF checklist items for four time points; preadmission status, one week post-amputation, on discharge from the acute hospital and three months post-amputation. Results: Seventeen patients completed the full study, having data collected at each of the four time points. Using the ICF checklist, we could demonstrate a significant functional deterioration immediately after amputation with a gradual improvement in function over the following three weeks consistent with our direct observations of these patients. Conclusions: The ICF checklist has the potential to be used as an outcome instrument as it appears to have content validity and sensitivity as a measure of changes in patients following an amputation. Clinical relevance Clinical outcome measures based on the ICF potentially improve the ability to record, monitor and benchmark patient and treatment outcomes nationally and internationally. This paper addresses the feasibility of ICF categories and qualifiers when used as an outcome measure and indicates that further development and analysis of the psychometric properties of such measures is warranted.

Incidence of lower limb amputation in Australian hospitals from 2000 to 2010

Background: Contemporary literature reports that the incidence of lower limb amputation has declined in many countries. This impression may be misleading given that many publications only describe the incidence of lower limb amputations above the ankle and fail to include lower limb amputations below the ankle. Objectives: To describe trends in the incidence of different levels of lower limb amputation in Australian hospitals over a 10-year period. Study design: Descriptive. Method: Data describing the age-standardised incidence of lower limb amputation were calculated from the Australian National Hospital Morbidity database and analysed for trends over a 10-year period. Results: The age-standardised incidence of lower limb amputation remained unchanged over time (p = 0.786). A significant increase in the incidence of partial foot amputations (p = 0.001) and a decline in the incidence of transfemoral (p = 0.00) and transtibial amputations (p = 0.00) were observed. There are now three lower limb amputations below the ankle for every lower limb amputation above the ankle. Conclusion: While the age-standardised incidence of all lower limb amputation has not changed, a shift in the proportion of lower limb amputations above the ankle and lower limb amputations below the ankle may be the result of improved management of precursor disease that makes partial foot amputation a more commonly utilised alternative to lower limb amputations above the ankle. Clinical relevance This article highlights that although the incidence of lower limb amputation has remained steady, the proportion of amputations above the ankle and below the ankle has changed dramatically over the last decade. This has implications for how we judge the success of efforts to reduce the incidence of lower limb amputation and the services required to meet the increasing proportion of persons with amputation below the ankle.

Systematic review of concepts measured in individuals with lower limb amputation using the International Classification of Functioning, Disability and Health as a reference:

Background: The International Classification of Functioning, Disability and Health (ICF) is comprehensive but difficult to use in clinical practice. ICF Core Sets are one method of increasing the use of the ICF in clinical practice. To develop a condition-specific core set requires identification of the concepts measured in current clinical practice. Objective: To identify and quantify concepts contained in functional measurements used in published clinical studies utilising the ICF as a reference, for individuals with an amputation of the lower limb. Study Design: Systematic literature review. Methods: The concepts of published clinical and outcome measures used in individuals with a lower limb amputation were extracted and linked to the categories of ICF. Results: The 113 outcome measures identified in the literature search contained 2210 functional concepts. Of the identified concepts, nearly 90% could be linked to ICF categories. The identified concepts linked to 44 categories in the domain of body functions and structures, 56 categories in the domain of activities and participation and 30 categories in the domain of environment. Conclusions: Using the ICF as a reference, we could identify and quantify the majority of concepts in the outcome measures used in published clinical studies. The ICF categories identified will assist in the development of ICF Core Sets for persons with an amputation. Clinical relevance The ICF is available in over 25 languages. Improving the usefulness of the classification for clinicians will assist in standardising clinical practice and in comparison of outcomes nationally and internationally. ICF Core Sets are designed to use a manageable number of categories from the ICF to allow application in day-to-day clinical practice.

Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty: The HIHO Randomized Clinical Trial

Importance Formal rehabilitation programs, including inpatient programs, are often assumed to optimize recovery among patients after undergoing total knee arthroplasty. However, these programs have not been compared with any outpatient or home-based programs. Objective To determine whether 10 days of inpatient rehabilitation followed by a monitored home-based program after total knee arthroplasty provided greater improvements than a monitored home-based program alone in mobility, function, and quality of life. Design, Setting, and Participants In this 2-group, parallel, randomized clinical trial, including a nonrandomized observational group, conducted at 2 public, high-volume arthroplasty hospitals in Sydney, Australia (July 2012-December 2015), 940 patients with osteoarthritis undergoing primary total knee arthroplasty were screened for eligibility. Of the 525 eligible patients consecutively invited to participate, 165 were randomized either to receive inpatient hospital rehabilitation and home-based rehabilitation or to receive home-based rehabilitation alone, and 87 patients enrolled in the observation group. Interventions Eighty-one patients were randomized to receive 10 days of hospital inpatient rehabilitation followed by an 8-week clinician-monitored home-based program, 84 were randomized to receive the home-based program alone, and 87 agreed to be in the observational group, which included only the home-based program. Main Outcomes and Measures Mobility at 26 weeks after surgery, measured with the 6-minute walk test. Secondary outcomes included the Oxford Knee Score, which ranges from 0 (worst) to 48 (best) and has a minimal clinically important difference of 5 points; and EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) visual analog scale, which ranges from 0 (worst) to 100 (best), and has a minimal clinically important difference of 23 points. Results Among the 165 randomized participants, 68% were women, and the cohort had a mean age, 66.9 years (SD, 8.4 years). There was no significant difference in the 6-minute walk test between the inpatient rehabilitation and either of the 2 home program groups (mean difference, −1.01; 95% CI, −25.56 to 23.55), nor in patient-reported pain and function (knee score mean difference, 2.06; 95% CI, −0.59 to 4.71), or quality of life (EQ-5D visual analog scale mean difference, 1.41; 95% CI, −6.42 to 3.60). The number of postdischarge complications for the inpatient group was 12 vs 9 among the home group, and there were no adverse events reported that were a result of trial participation. Conclusions and Relevance Among adults undergoing uncomplicated total knee arthroplasty, the use of inpatient rehabilitation compared with a monitored home-based program did not improve mobility at 26 weeks after surgery. These findings do not support inpatient rehabilitation for this group of patients. Trial Registration clinicaltrials.gov Identifier: NCT01583153

ICD-11: A COMPREHENSIvE PICTURE OF HEAlTH, AN UPDATE ON THE ICD-ICF JOINT USE INITIATIvE

BACKGROUND This is a follow-up of the special report Towards the joint use of ICD and ICF: A call for contribution, published by the Journal of Rehabilitation Medicine in 2012, which introduced an initiative of using the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF) in a complementary way in clinical practice. Recognizing the merits of using the ICD and ICF jointly, the World Health Organization (WHO) introduced so-called functioning properties in the ICD-11. The first step in this ICD-ICF joint use initiative revealed 103 rehabilitation-relevant health conditions for which functioning properties were to be identified. Afterwards experts were recruited to identify the functioning properties for the health conditions for which no ICF Core Sets were available and all the functioning properties were integrated in the beta-version of ICD-11. OBJECTIVE The objective of this special report is to present the outcome of the recruitment and training of the contributing experts, and to provide an update on the current status of identifying functioning properties and their integration in ICD-11. DISCUSSION Having functioning properties in the ICD-11 achieves a milestone in depicting health information in an integrated and comprehensive manner. Explicitly identifying functioning properties for specific health conditions further reinforces the importance of acquiring a broader and more meaningful picture of a persons health, and can guide clinical decision-making.

Towards the joint use of ICD and ICF: a call for contribution.

BACKGROUND To optimize patient functioning, rehabilitation professionals often rely on measurements of functioning as well as on classifications. Although the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF) are used, their joint use has yet to become an established practice. To encourage their joint use in daily practice, the World Health Organization (WHO) has invited all rehabilitation practitioners worldwide to support the ICD-11 revision process by identifying the ICF categories that correspond to specific rehabilitation-relevant health conditions. The first step in completing this task, generating the list of these health conditions, was taken at a February 2012 workshop in São Paulo, Brazil. OBJECTIVES The objectives of this paper are to present the results of the São Paulo workshop, and to invite practitioners to participate in the ICD-ICF joint use initiative. DISCUSSION Alternating plenary and small working group sessions were held and 103 rehabilitation-relevant health conditions were identified. With this list available, WHO together with the International Society of Physical and Rehabilitation Medicine (ISPRM), is reaching out to clinicians of all rehabilitation disciplines to take on the challenge of identifying the ICF categories for at least one of the health conditions listed.

Retrospective Analysis of Telemonitoring (RATE)

Introduction : Telemonitoring may enable early detection of clinical deterioration facilitating early intervention to avoid emergency visits and hospital admissions. Experience of telemonitoring in Australian general practice is limited. The implementation of telemonitoring in South West Sydney is an opportunity to explore how it could be further developed and implemented. In August 2015, 20 telemonitoring devices were introduced to clients in consultation with their general practitioners as a way for delivery of integrated care for distant communities which have restricted access to different levels of health care. This retrospective study analyses the data collected from the telemonitoring project to provide insight into the delivery of telemonitoring, the triage interventions and outcomes from those interventions. Methods : The aim is to analyse the early findings from the telemonitoring data to evaluate and describe the events, as well as to obtain further information to develop an evidence based guide on the model of care and utilization of home telemonitoring. This is a retrospective qualitative and quantitative analysis on the events, interventions and data obtained from the home telemonitoring equipment. Participants were identified as a cohort of COPD patients who had had multiple admissions following discussion with the primary care provider. This study uses de-identified data including a range of information and results on biometrics and chronic condition self-assessment (‘readings’) performed on a routine basis as indicated on the management plan. Data was collected between July 2015 and April 2016. Entry and discharge into and from the programme was staggered. Results : Data was extracted on 18 participants aged 44 to 87. There was equal numbers of males and females. Two participants were discharged due to condition evolving into palliative care needs/facility. 2,932 readings were available for analysis. 55% of readings were of high clinical risk. 25% of readings were within the normal range. 8% of data readings were missed and a further 10% were time delayed as there was no connectivity at the scheduled time. 14 participants had GP escalations. Of the total 93 escalations 23% were related to respiratory conditions. 9 participants had hospitalisations. 51% of hospitalisations were related to respiratory conditions. 1 participant was hospitalised 4 times (only 1 time related to COPD). Overall compliance with the programme was high. Discussion : The analysis demonstrates that selection criteria were generally appropriate but leaves room for further analysis as 4 participants did not need GP intervention at all and 2 participants were discharged to Palliative care. Further analysis would be useful to investigate the actual intervention and outcome when GP intervention was required. Missed data or the loss of connectivity and its interaction with the usefulness and reliability of telemonitoring needs to be explored. The role of technology in integrated models of chronic disease care in primary and hospital care requires further exploration. Conclusion : This project demonstrates a preliminary model for engaging and empowering communities for self-management. It provides a platform for co-designing health service delivery across primary and secondary care. Future research will focus on the model of care, practical barriers and facilitators of telemonitoring in General Practice.