Tina Hansen

Validation of the Danish version of the McGill Ingestive Skills Assessment using classical test theory and the Rasch model

Purpose: The study aimed to validate the Danish version of the Canadian the “McGill Ingestive Skills Assessment” (MISA-DK) for measuring dysphagia in frail elders. Method: One-hundred and ten consecutive older medical patients were recruited to the study. Reliability was assessed by internal consistency (Chronbach’s alpha). External construct validity (convergent and known-groups validity) was evaluated against theoretical constructs assessing the complex concept of ingestive skills. Internal construct validity was tested using Rasch analysis. Results: High internal consistency reliability with Chronbach’s alpha of 0.77–0.95 was evident. External construct validity was supported by expected high correlations with most of the constructs related to ingestive skills (rs = 0.53 to rs = 0.66). The MISA-DK discriminated significantly between known-groups. Fit to the Rasch model (x2 (df) = 12 (12), p = 0.424) and unidimensionality of the MISA-DK was confirmed after resolving disordered thresholds for 11 items and adjustment of local dependency. Conclusion: The psychometric properties of the MISA-DK equal the original Canadian version. Assessment of internal construct validity indicated multidimensionality due to local dependency. Although achieving good fit to the Rasch model after adjustments, additional studies are needed to establish cross-cultural validity. Finally, establishment of the inter- and intra-rater reliability of the MISA-DK is also needed. Implications for Rehabilitation Validity evidence is a prerequisite to verify whether a measurement instrument in fact accomplish what it is supposed to accomplish. Using classical test theory in combination with the Rasch Model provides comprehensive insight of validity evidence. The Danish version of the McGill Ingestive Skills Assessment provides valid estimates of dysphagia patients’ ingestive skill abilities.

Reliability of the Danish version of the McGill Ingestive Skills Assessment for observation-based measures during meals

Abstract Aim: To establish measurement equivalence in terms of reliability of the Danish version of the Canadian McGill Ingestive Skills Assessment (MISA) for use by occupational therapists. Methods: A cross-sectional two-rater and test–retest design was applied. A total of 102 elderly medical patients were included consecutively, and were video-recorded during a meal. Raters were paired randomly for each video-case, which was re-scored within three to eight weeks. Reliability was evaluated with the intra-class correlation coefficients (ICC), the standard error of measurement (SEM), the smallest detectable change (SDC), and limits of agreement (LOA). Results: Inter-rater reliability was good to excellent (ICC 1.1 0.61–0.84) and intra-rater reliability was excellent (ICC 3.1 0.84–0.93). For the total scale, SEM was 7% between raters and 4% in repeated measurement by the same rater. For the absolute total scale range on 86 points, the SDC was 15.8 between raters and 10.3 in repeated measurement by the same rater. Conclusions: The reliability of the Danish MISA equals the original version and is suitable for clinical practice. When extending the evaluation of the reproducibility, weaker precision was evident when measurements are repeated by different raters than by the same rater. Therefore further investigation of rater effects is recommended.

Content validation of a Danish version of "The McGill Ingestive Skills Assessment" for dysphagia management

Abstract This study addresses the first steps in the cross-cultural adaptation of a Danish version of the McGill Ingestive Skills Assessment (MISA), which quantifies eating and drinking abilities by scoring a meal observation. The original Canadian MISA was translated and adapted into Danish (MISA-DK). For content validation of the MISA-DK, a judgemental quantification process was applied using 13 experts. Thereafter, the MISA-DK was pilot tested by 16 occupational therapists. Finally, the MISA-DK was linked to the International Classification of Functioning, Disability and Health (ICF). Content validity of 43 items was found for 93% in terms of adequacy, 67% in terms of clarity of item description, 86% in terms of clarity of score descriptions, and 93% in terms of relevance. Thirteen of 14 sections of the instruction manual and score sheet were content valid. In light of these results, a revised MISA-DK was produced for the pilot test, which then found content validity for all sections and 98% of the items. The ICF linking resulted in 41 ICF-categories, which may reflect the complexity of eating and drinking as well as a multidimensional structure of the MISA-DK. In conclusion, the MISA-DK is prepared for psychometric testing using classical as well as modern test theory.

The effect of rater training on scoring performance and scale-specific expertise amongst occupational therapists participating in a multicentre study: a single-group pre-post-test study.

Abstract Purpose: In order to enhance the quality of the data collected in a multicentre validation study of a revised Danish version of the McGill Ingestive Skills Assessment (MISA), the authors developed a rater training programme. The purpose of the present study was to evaluate the effect of the training on scoring performance and scale-specific expertise amongst raters. Method: During 2 days of rater training, 81 occupational therapists (OTs) were qualified to observe and score dysphagic clients’ mealtime performance according to the criteria of 36 MISA-items. The training effects were evaluated pre- to post-training using percentage exact agreement (PA) of scored MISA items of a case-vignette and a Likert scale self-report of scale-specific expertise. Results: PA increased significantly from pre- to post-training (Z = −4.404, p < 0.001), although items for which the case-vignette reflected deficient mealtime performance appeared most difficult to score. The OTs scale-specific expertise improved significantly (knowledge: Z = −7.857, p < 0.001 and confidence: Z = −7.838, p < 0.001). Conclusion: Rater training improved OTs scoring performance when using the Danish MISA as well as their perceived scale-specific expertise. Future rater training should emphasis the items identified as those most difficult to score. Additionally, further studies addressing different training approaches and durations are warranted. Implications for Rehabilitation When occupational therapists (OTs) use the McGill Ingestive Skills Assessment (MISA) they observe, interpret and record occupational performance of dysphagic clients participating in a meal. This is a highly complex task, which might introduce unwanted variability in measurement scores. A 2-day rater training programme was developed and this builds on the findings of several studies. These suggest that combinations of different training methods tend to yield the most effective results. Participation in the newly developed training programme on how to administer the MISA significantly reduces unwanted variability in measurement scores and improves OTs’ competency. The training programme could be used in undergraduate and postgraduate dysphagia education initiatives to help OTs understanding of the content and the scoring criteria for each aspect of occupational performance during a meal, thus developing observation skills as well as recognizing and avoiding the most common errors in measurement scores.

Translating the Canadian Occupational Performance Measure to Danish, addressing face and content validity

Abstract Background: The Canadian Occupational Performance Measure (COPM) is a recognized assessment tool within Danish occupational therapy (OT), and translated versions of the COPM have been implemented in Danish OT practice. However, a rigorous translation and cross-cultural validation process has not been applied to these versions. Aims: To produce a new Danish translation of the COPM evaluating its semantic, conceptual, operational and item equivalence while addressing its face and content validity. Methods: An iterative, multistage translation process was undertaken with (1) forward translation involving professional translators and bilingual OTs, (2) pilot testing and cognitive debriefing interviews with 15 OTs and 37 clients which were analyzed quantitatively and qualitatively, and (3) finalization with adaptations, back translation and approval. Results: Content validity of COPM in terms of appropriateness, acceptability, intelligibility and comprehensiveness was found in 78–100% of the cases, and its ability to ensure a client-centred focus in the assessment process was confirmed. However, issues concerning the administration and content of the COPM were identified. Subsequently, two recommendations regarding the administration of the COPM were added to the Danish version. Conclusion: Semantic, conceptual, operational and aspects of item equivalence of the COPM into Danish were achieved and supported by face and content validity.

Validation of the Dutch version of the Swallowing Quality-of-Life Questionnaire (DSWAL-QoL) and the adjusted DSWAL-QoL (aDSWAL-QoL) using item analysis with the Rasch model: a pilot study

BackgroundThe Swallowing Quality-of-Life Questionnaire (SWAL-QoL) is considered the gold standard for assessing health-related QoL in oropharyngeal dysphagia. The Dutch translation (DSWAL-QoL) and its adjusted version (aDSWAL-QoL) have been validated using classical test theory (CTT). However, these scales have not been tested against the Rasch measurement model, which is required to establish the structural validity and objectivity of the total scale and subscale scores. Thus, the purpose of this study was to examine the psychometric properties of these scales using item analysis according to the Rasch model.MethodsItem analysis with the Rasch model was performed using RUMM2030 software with previously collected data from a validation study of 108 patients. The assessment included evaluations of overall model fit, reliability, unidimensionality, threshold ordering, individual item and person fits, differential item functioning (DIF), local item dependency (LID) and targeting.ResultsThe analysis could not establish the psychometric properties of either of the scales or their subscales because they did not fit the Rasch model, and multidimensionality, disordered thresholds, DIF, and/or LID were found. The reliability and power of fit were high for the total scales (PSI = 0.93) but low for most of the subscales (PSI < 0.70). The targeting of persons and items was suboptimal. The main source of misfit was disordered thresholds for both the total scales and subscales. Based on the results of the analysis, adjustments to improve the scales were implemented as follows: disordered thresholds were rescaled, misfit items were removed and items were split for DIF. However, the multidimensionality and LID could not be resolved. The reliability and power of fit remained low for most of the subscales.ConclusionsThis study represents the first analyses of the DSWAL-QoL and aDSWAL-QoL with the Rasch model. Relying on the DSWAL-QoL and aDSWAL-QoL total and subscale scores to make conclusions regarding dysphagia-related HRQoL should be treated with caution before the structural validity and objectivity of both scales have been established. A larger and well-targeted sample is recommended to derive definitive conclusions about the items and scales. Solutions for the psychometric weaknesses suggested by the model and practical implications are discussed.

Rehospitalisation and mortality after hospitalisation for orapharyngeal dysphagia and community-acquired pneumonia: A 1-year follow-up study

Abstract Research has documented a high prevalence of oropharyngeal dysphagia (OD) in older patients with community-acquired pneumonia (CAP). This study investigated OD as a risk factor for long-term re-hospitalization and mortality in patients hospitalized with CAP. A total of 36 patients (72.2% male, mean age 80.9 years) who were alive 30 days after discharge were included in the follow-up study. Demographic data, CURB65, Charlson Comorbidity Index, Modified Rankin Scale and Barthel-20 score were recorded and OD was assessed with Volume Viscosity Swallow Test. 69.5% of the patients were moderately to severely disabled, and the mean Barthel-20 score was 13.2 and 27.8% lived in nursing homes. In the period from 31 to 180 days 50% of the patients were re-hospitalized and from 181 to 360 days 60.7% were re-hospitalized. Re-hospitalized patients had a significantly higher Barthel-20 score and longer length of stay (LOS) in the hospital. During 31–180 days after discharge 22.2% of the patients died. From 181 to 360 days after discharge 46.4% of the patients died, they had a significantly higher Charlson Comorbidity Index and a significantly weaker handgrip. The one-year mortality was 71.7%. Despite the small sample size, this study confirms a high re-hospitalisation frequency and high mortality. The 1-year mortality is 71.7% for patients hospitalised with CAP and OD.

Revisiting the psychometric properties of a revised Danish version of the McGill ingestive skills assessment

Abstract Background: During a longstanding validation process of the Danish version of the McGill Ingestive Skills Assessment (MISA2-DK) for measuring mealtime performance in dysphagic clients, extensive revisions have been undertaken. Therefore, this study aimed to determine the psychometric properties of this revised version. Methods: In a cross-sectional study, 328 adults referred to occupational therapy for swallowing evaluation were included. MISA2-DK with 36 items distributed into four subscales (positioning for meals, self-feeding skills, liquid ingestion, and solid ingestion) was administered as observation during a meal. Statistical analysis included item analysis by the Rasch model and exploratory factor analysis (EFA). Results: The initial analysis of MISA2-DK presented misfit to the Rasch model, which was resolved by grouping items within subscales into testlets to adjust for local item dependency. However, when testing the items within each subscale, the subscale structure was not supported. The EFA and further item analysis by the Rasch model suggested a different distribution of items—namely, anticipation, bolus preparation, bolus propulsion, and airway protection. Conclusion: The total MISA2-DK score might provide a unidimensional measure of mealtime performance. However, for detailed information of qualitative aspects of dysphagic clients’ mealtime performance, the four EFA-derived subscale domains are recommended.

Is therapeutic judgement influenced by the patient’s socio-economic status? A factorial vignette survey

Abstract Background In Denmark patients are entitled to rehabilitation regardless of socio-economic status (SES). During this process therapists have to balance cost effectiveness with providing equal treatment. Aim To investigate whether occupational therapists and physiotherapists were influenced by the patient’s SES. Material and method An experimental factorial vignette survey was used. Four different vignettes describing fictitious patient cases with different SES variables were randomly allocated to therapists working in somatic hospitals. Thereafter, the therapists judged specific clinical situations and general attitudes in relation to the patient’s SES. Chi-square was used to test the statistical association between the variables. Results No statistically significant associations were found between the specific clinical situations and the patient’s SES. A statistical significant association was found between general attitudes and the patient’s SES. Subgroup analysis revealed a statistically significant association between the therapist’s gender, age, and the therapeutic judgement in relation to SES. Conclusion In the specific clinical situations, Danish therapists seem to maintain their professional ethical principles, although they might face ethical dilemmas during their clinical decision-making. In order to prevent and resolve these dilemmas, they have to be made explicit. However, further research on how SES influences the health care professional’s judgement is warranted.