Patrick Gompertz

A postal version of the Barthel Index

The Barthel Index is the best known and most popular activities of daily living (ADL) scale. Many studies have confirmed its validity and it has been validated for many different methods of administration. These include direct observation, interview of patient carer or nurse and telephone. The aim of this study was to devise and test the reliability of a self-completed postal version of the Barthel Index for use in surveys and outcome studies. The items were changed into multiple choice questions, taking into account the published guidelines and knowledge of common areas of confusion when administering the Barthel by interview. The test retest reliability over two weeks of the resulting questionnaire was evaluated using a consecutive series of 21 patients from a stroke register, who had responded without prompting to a postal survey six months after stroke. All the items had κ statistics indicating at least moderate reliability, the toilet and mobility items being the worst. The mean difference in total scores was -0.5 out of 20, standard deviation 2.1. The 95% limits of agreement were -4.6 to 3.6, corresponding to a change in dependence of up to two ADL items. This study demonstrates that the postal self-report questionnaire version of the Barthel is reliable and practical. Further studies are needed to establish its validity in comparison with interview administration.

Stroke patients' views on their admission to hospital

Abstract Objective: To explore which components of care were valued by patients admittedto hospital following a stroke. Design: Qualitative study using in depth interviews 10 months after the stroke. Setting: Two adjacent districts in North Thames Regional Health Authority. Subjects: 82 survivors of stroke taken consecutively from a stroke register, 40of whom agreed to be interviewed. Results: Patients reported that during the acute stage of the stroke they wanted to put their faith in experienced and trusted experts who would help them make sense of the event, take all the actions necessary to ensure survival, and provide comfort and human warmth during the crisis. In addition to being reassured by the clinical tests and practical nursing help they received, patients valued feeling cared about by the staff. In most cases patients reported that their needs were met; however, the institutional natureof the hospital sometimes obstructed the fulfilment of their needs. Conclusion: Patients have important psychosocial needs during the acute stage of the stroke, which are often met by hospital admission. Patients gained benefits from their admission over and above those measurable in terms of morbidity or function. They used a combination of criteria to evaluate their care, focusing on the process as well as the outcome of care. Researchers and clinicians should do likewise.

The reliability of stroke outcome measures

Assessments of outcome in stroke should include measures of the broader aims of rehabilitation, such as handicap, mood and perceived health, and these measures should be reliable. This study compared the test-retest reliability of the Barthel, Nottingham Extended Activities of Daily Living, Geriatric Depression Score (GDS) and the Nottingham Health Profile (NHP) by postal survey of 21 stroke patients six months after their stroke. There was significant variation between test and retest scores in all the scales but the NHP and GDS were much less reliable than the disability measures, perhaps because they measure less objective or more intrinsically variable quantities. Unreliability is important because it adds to the observed variance of any study population, making it more difficult to detect real differences between groups. Analysis of test-retest reliability should be an essential part of the development of questionnaires. Currently recommended outcome measures require further development to improve reliability.

Validity of the extended activities of daily living scale

Scales that measure independence in the basic self-care activities of daily living (ADLs) suffer from ceiling effects when applied to an outpatient population. The instrumental activities of daily living (IADL) measures, which assess the performance of tasks required for independence at home are more appropriate. However, validity evaluation of IADL measures seldom goes beyond content validity and little is known about their sensitivity to change. The aim of this study was to evaluate the construct validity of the extended ADL scale (EADL) and to test its sensitivity to change. Three hundred and sixty-one consecutive acute stroke admissions were recruited and surveyed at one, six and 12 months after stroke, using the EADL. There were the expected correlations with the Barthel Index, Nottingham Health Profile, Geriatric Depression Score and the London Stroke Satisfaction Score. Logistic regression analysis showed that, although men were more mobile, they were less likely to carry out domestic and kitchen tasks. Also, nonwhites were more disabled, owner-occupiers had higher leisure scores and those living alone had higher kitchen scores. Analysis of effect sizes showed that the EADL is sensitive to the changes that occur after stroke and would be sensitive to the effect of an intervention that produced a change in independence of two or more ADLs. The EADL is a valid measure of the performance of instrumental ADLs and is sensitive to clinically important changes.