Institut für Gesundheits- und Rehabilitationswissenschaften. Ludwig-Maximilians-Universität, München

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1 ICF Research Branch of WHO CC FIC (DIMDI) Institut für Gesundheits- und Rehabilitationswissenschaften Ludwig-Maximilians-Universität, München ICF Anwenderkonferenz Roger Hilfiker

2 Themen Konstruktion von Intervallskalen für die Erfassung von Kategorien der ICF aus bestehenden, standardisierten Fragebogen Entwicklung eines ICF basierten klinischen Messinstrumentes für die Funktionsfähigkeit bei Patienten mit Spondylitis ankylosans

3 Konstruktion von Intervallskalen für die Erfassung von Kategorien der Internationalen Klassifikation für Funktionsfähigkeit, Behinderung und Gesundheit. 1,2 Cieza A,, 2 Hilfiker R, 3 Boonen A, 4 Chatterji S, 4 Kostanjsek N, 4 Üstün B, 1,2,5 Stucki G. Institut für Gesundheits- und Rehabilitationswissenschaften ICF Research Branch of WHO Ludwig-Maximilians-Universität, München 1 ICF Research Branch of the WHO Collaborating Center for the Family of Interna-tional Classifications at the German Institute of Medical Documentation and Informa-tion (DIMDI), IHRS, Ludwig-Maximilian University, Munich, Germany 2 Schweizer Paraplegiker-Forschung, Nottwil, Switzerland 3 Department of Internal Medicine, Division of Rheumatology, University Hospital Maastricht, Netherlands 4 Classification, Assessment, Surveys and Terminology Team, World Health Organization, Switzerland 5 Department of Physical Medicine and Rehabilitation, University Hospital Munich, Ludwig-Maximilian University Munich, Germany

4 Möglichkeiten der Anwendung der Qualifier einer ICF Kategorie 2 Möglichkeiten: Semistrukturiertes Interview, um die Informationen der gewünschten ICF-Kategorie zu erhalten, und zu quantifizieren xxx.0 NO problem (none,, absent, negligible, ) 0-44 % xxx.1 MILD problem (slight, low, ) 5-24 % xxx.2 MODERATE problem (medium,, fair,...) % xxx.3 SEVERE problem (high, extreme, ) % xxx.4 COMPLETE problem (total, ) % xxx.8 not specified xxx.9 not applicable Standardisierte Testverfahren, um das Konstrukt der gewünschten ICF-Kategorie zu erfassen und in Qualifier umzuwandeln

5 Anwendung standardisierter Testverfahren am Beispiel der Kategorie b Zu messendes Konstrukt b130 Funktionen der psychischen Energie und des Antriebs 2. Welche Fragen (Items) bestehender Fragebogen erfassen Inhalte dieser ICF Kategorie? 3. Aus 6 Fragebogen wurden 19 Fragen ausgewählt. 4. Patienten mit Rheumatoider Arthritis (n=122) füllten diese Fragebogen aus. 5. Raschanalyse und Transformation auf ICF Qualifier

6 ICF Kategorie Intervallskala RAQoL b1.... b130 b134 b152 b180 b1801 =19 Items HAQ Joint mobility Mobility (general) Muscle power / Strength Pain Joint mobility Stability Mobility of SF-36 joints (general) Emotional Muscle function power / Strength Engergy Pain & Drive functions Gait / Ambulation Stability INSTRUCTIONS: of joints This survey asks for Stiffness Emotional your views function EQ-5D about your health. This MuscleEngergy endurance information & Drive functions will help keep track of how Sexual Gait functions / you Ambulation feel and how well you are able to Sleep Stiffness do your usual activities. Muscle endurance Joint mobility MFI Sexual Answer functions Mobility every question (general) by marking Sleep the answer Muscle as indicated. power / Strength If you ar unsure Pain about Joint how to mobility answer a question, Stability please Mobility of give CES-D joints the (general) best answer you can. Emotional Muscle function power / Strength Engergy Pain & Drive functions Gait / Ambulation Stability INSTRUCTIONS: of joints This survey asks for Stiffness Emotional your views function about your health. This MuscleEngergy endurance information & Drive functions will help keep track of how Sexual Gait functions / you Ambulation feel and how well you are able to Sleep Stiffness do your usual activities. Muscle endurance Sexual Answer functions every question by marking Sleep the answer as indicated. If you ar unsure about how to answer a question, please give the best answer you can. 122 Patienten mit RA s299 s710 s720 s730 s73001 s d170 d230 d360 d410 d415 d430 e110 e115 e120 e125 e135 e ?

7 ITEM Questionnaire Response options Collapsing strategy Instructions for the MFI-20: By means of the following statements we would like to get an idea of how you have been feeling lately. There is, for example, the statement I FEE RELAXED. If you think that this is entirely true, that indeed you have been feeling relaxed lately, please, place an X in the extreme left box. The more you disagree with the statement, the more you can place an X in the direction no, that is not true. Please do not miss out a statement and place one X next to each statement. I feel fit. MFI-20 From 0=yes, that is true to 4= no, that is not true I feel very active. MFI I feel tired. MFI I am rested. MFI-20 Physically, I feel only able to do a little. MFI-20 Physically, I can take on a lot. MFI-20 Physically, I feel I am in bad condition. MFI I tire easily. MFI-20 Physically, I feel I am in excellent condition. MFI-20 Instructions of the CES-D: Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week. I did not feel like eating; my appetite was poor. CES-D 0=RARELY or NONE of the time. (Less than 1 day) 1=SOME or a LITTLE of the time. (1-2 days) 2=OCCASIONALLY or a MODERATE amount of the time. (3-4 days) 3=MOST or ALL of the time. (5-7 days) I felt that everything I did was an effort. CES-D I could not get going. CES-D Instructions for the SF-36: These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks - (circle one number on each line) Did you have a lot of energy? SF-36 1=All of the Time 2=Most of the Time 3=A Good Bit of the Time 4=Some of the Time 5=A Little of the Time 6=None of the Time Did you feel worn out? SF-36 Did you feel tired? SF Instructions for the RAQoL: Below you will find some statements which have xxx.0 been made NO by people problem who have (none, rheumatoid, absent, arthritis. Please negligible, read each statement ) carefully. 0-4 We 4 would % like you to tick "yes" if you feel the statement applies to you, and tick "no" if it does not. I have to go to bed earlier than I would like to. xxx.1 MILD RAQOL problem 0=No (slight, low, ) 5-24 % 1=Yes It s too much effort to go out and see people. xxx.2 MODERATE RAQOL problem (medium,, fair,...) % I have to keep stopping what I am doing, to rest. RAQOL I feel tired whatever I do. xxx.3 SEVERE RAQOL problem (high, extreme, ) % xxx.4 COMPLETE problem (total, ) % xxx.8 not specified xxx.9 not applicable

8 Rasch Model Rasch Analyse

9 Kürzesteinführung in Rasch Das Rasch Model gibt vor, dass die Fähigkeit der Personen und die Schwierigkeiten der Fragen auf einer Skala von wenig Ausprägung bis starke Ausprägung liegen. Mit der Rasch Analyse wird evaluiert, zu welchem Grade die Daten dem Modell entsprechen. Low Functioning High Functioning

10 Fähigkeit der Person Gut ausgeprägte Fähigkeit Logit = +5.0 Schwierigkeit des Items Schwieriges Item Logit = +4.0 Logit = +3.0 Logit = Log of the odds = Item passt nicht Item 5 ITEM 1 Niedrige Fähigkeit Negativer Misfit Logit = +2.0 Logit = +1.0 Logit = 0.0 Logit = -1.0 Logit = -2.0 Logit = -3.0 Logit = -4.0 Logit = -5.0 ITEM 4 Person Person Einfaches Item Item 3 Person Positiver Misfit Item passt nicht zum Rasch Modell (und diskriminiert nicht) Log Log = 0 ( = Probability of succes Probability of failure Ability Difficulty ( ) Ability Difficulty 2-2=0 )

11 b130 Funktionen der psychischen Energie und des Antriebs MFI-20 I feel fit. I feel very active. I feel tired. I am rested. Physically, I feel only able to do a little. Physically, I can take on a lot. Physically, I feel I am in bad condition. I tire easily. Physically, I feel I am in excellent condition. CES-D I did not feel like eating; my appetite was poor. I felt that everything I did was an effort. I could not get going. SF-36 Did you have a lot of energy? Did you feel worn out? Did you feel tired? RAQOL I have to go to bed earlier than I would like to. It s too much effort to go out and see people. I have to keep stopping what I am doing, to rest. I feel tired whatever I do. Rasch Model: 16 von 19 Items passten zum Rasch Modell X² df=32 = 38.25, p=0.21 Z Mean =0.451 Z SD =1.085 Z Mean = , Z SD =1.132 R β =0.93.

12 ICF Qualifier 0 NO problem (none, absent, negligible,...) 0-4% 1 MILD problem (slight, low,...) 5-24% 2 MODERATE problem (medium, fair...) 25-49% 3 SEVERE problem (high, extreme,...) 50-95% 4 COMPLETE problem (total,...) %

13 Umwandlungstabelle MFI-20 I feel fit. I feel very active. I feel tired. I am rested. Physically, I feel only able to do a little. Physically, I can take on a lot. Physically, I feel I am in bad condition. I tire easily. Physically, I feel I am in excellent condition. CES-D I did not feel like eating; my appetite was poor. I felt that everything I did was an effort. I could not get going. SF-36 Did you have a lot of energy? Did you feel worn out? Did you feel tired? RAQOL I have to go to bed earlier than I would like to. It s too much effort to go out and see people. I have to keep stopping what I am doing, to rest. I feel tired whatever I do. R a w S c o re (1 6 Ite m s ) L o g it s c a le IC F c a te g o ry in te rv a l s c a le (0 to ) IC F Q u a lifie r

14 Entwicklung eines ICF basierten klinischen Messinstrumentes für die Funktionsfähigkeit bei Patienten mit Spondylitis ankylosans 1,2 Dr. Alarcos Cieza, MPH;, 1,2 Roger Hilfiker MPTSc., 3 Boonen A, 4 van der Heijde D, 5 Braun J, 1,2,6 Stucki G. Institut für Gesundheits- und Rehabilitationswissenschaften ICF Research Branch of WHO Ludwig-Maximilians-Universität, München 1 ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), IHRS, Ludwig-Maximilian University, Munich, Germany 2 Schweizer Paraplegiker-Forschung, Nottwil, Switzerland 3 Department of Internal Medicine, Division of Rheumatology, University Hospital Maastricht, Netherlands 4 Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands 5 Rheumazentrum Ruhrgebiet, Herne, Germany 6 Department of Physical Medicine and Rehabilitation, University Hospital Munich, Ludwig Maximilian University Munich, Germany

15 ICF categories b260 Proprioceptive function b265 Touch function b279 Sensory functions related to temperature and other stimuli b28013 Pain in back b415 Blood vessel functions - at risk b420 Blood pressure functions b525 Defecation functions b620 Urination functions b640 Sexual functions b7101 Mobility of several joints b7303 Muscle power functions in lower half of the body b735 Muscle tone functions b750 Motor reflex functions b755 Involuntary movement reaction functions b7603 Supportive functions of the arms - resource b7800 Sensation of muscle stiffness (M. ischiocurale) s810 Structure of areas of the skin - at risk d410 Changing a basic body position d4153 Maintaining a sitting position d4200 Transferring oneself while sitting d450 Walking d465 Moving around using equipment d4751 Driving a car d510 Washing oneself d520 Caring for body parts d5300 Regulating urination d5301 Regulating defecation d540 Dressing d9201 Sport e1101 Drugs e1151 Assistive product: Chair cushion e1201 Assistive product mobility: wheelchair, car e155 Design and construction of private building e1602 Ramps and stairways e310 Immediate family e320 Friends e355 Health professionals e5700 Social security services e5750 General social support services pf Sportive person pf Knowledge pf Acceptance of disease ICF Qualifier* problem facilitator barrier Profil Intervallskalierter Summenscore

16 Vorteil Summenscore Ein Summenscore hätte folgende Vorteile: ergänzt die Informationen eines Profils Zusammenfassung Falls Summenscore Intervallskaliert: Erlaubt Berechnung von Differenzen

17 Summenscore Wir können dann einen sinnvollen Summenscore bilden, wenn wir durch die Benutzung des Scores nicht für uns relevante Informationen verlieren Im Idealfall verlieren wir gar keine Informationen: Kennen wir den Summenscore, so kennen wir die Antwort in jedem einzelnen Item ( erschöpfende Auskunft über die getestete Person, sofern das Modell gilt (siehe z.b. Jürgen Rost, Lehrbuch Testtheorie Testkonstruktion, Verlag Hans Huber).

18 ICF categories b260 Proprioceptive function b265 Touch function b279 Sensory functions related to temperature and other stimuli b28013 Pain in back b415 Blood vessel functions - at risk b420 Blood pressure functions b525 Defecation functions b620 Urination functions b640 Sexual functions b7101 Mobility of several joints b7303 Muscle power functions in lower half of the body b735 Muscle tone functions b750 Motor reflex functions b755 Involuntary movement reaction functions b7603 Supportive functions of the arms - resource b7800 Sensation of muscle stiffness (M. ischiocurale) s810 Structure of areas of the skin - at risk d410 Changing a basic body position d4153 Maintaining a sitting position d4200 Transferring oneself while sitting d450 Walking d465 Moving around using equipment d4751 Driving a car d510 Washing oneself d520 Caring for body parts d5300 Regulating urination d5301 Regulating defecation d540 Dressing d9201 Sport e1101 Drugs e1151 Assistive product: Chair cushion e1201 Assistive product mobility: wheelchair, car e155 Design and construction of private building e1602 Ramps and stairways e310 Immediate family e320 Friends e355 Health professionals e5700 Social security services e5750 General social support services pf Sportive person pf Knowledge pf Acceptance of disease ICF Qualifier* problem Hypothese facilitator barrier Profil Es ist möglich, ein eindimensionales klinisches Messverfahren für die Komponenten Körperfunktion, Körperstruktur, Aktivität und Partizipation zu bilden. Intervallskalierter Summenscore

19 Unidimensionalität at some level of precision, no construct is unidimensional, while at some levels of precision, any construct is (Ab einem bestimmten Grad der Präzision ist kein Konstrukt unidimensional, während bei einem bestimmten Grad der Präzision alle Konstrukte unidimensional sind). Health Condition (disorder/disease) Body function&structure (Impairment) Activities (Limitation) Participation (Restriction) Environmental Factors Personal Factors Funktionsfähigkeit bei Patienten mit einer best. HC. Andrich, D. Rasch models for measurement. Newbury Park, CA: Sage, 1988

20 Ziel Ziel war es, zu untersuchen, ob es möglich ist, ein klinisches Messinstrument aus den ICF Kategorien für Körperstruktur, Körperfunktion, Aktivität und Partizipation für Ankylosing Spondylitis zu bilden.

21 Methode Health professionals evaluierten 111 Patienten und Patientinnen basiert auf 165 ICF Kategorien die als potentiell relevant für AS angesehen wurde. Zentren in den Niederlanden und Deutschland.

22 Auswahl der Kategorien 125 Kategorien der ICF Checkliste Version 2.1a entwickelt von der WHO. 39 Kategorien wurden zusätzlich identifiziert durch Linking von vier AS spezifischen Messinstrumenten zu den entsprechenden ICF Kategorien.

23 Reduktion der ICF Kategorien Von den 165 Kategorien gehörten 130 zu den ICF Komponenten Körperstruktur, Körperfunktion und Aktivität und Partiziaption. 35 Kategorien gehörten zu den Umweltfaktoren.

24 Analysen Rasch Model. Andrich D, de Jong JHAL, Sheridan BE. Diagnostic opportunities with the Rasch model for ordered response categories. In: Rost J, Langeheine R, editors. Applications of Latent Trait and Latent Class Models in the Social Sciences. Munster/ New York: Waxmann; p

25 Fähigkeit der Person Gut ausgeprägte Fähigkeit Logit = +5.0 Schwierigkeit des Items Schwieriges Item Item passt nicht ICF Category ICF Category Niedrige Fähigkeit Negativer Misfit Logit = +4.0 Logit = +3.0 Logit = +2.0 Logit = +1.0 ICF Category Logit = 0.0 Logit = -1.0 Logit = -2.0 Person Logit = -3.0 Logit = -4.0 Logit = -5.0 Person Person ICF Category Person Einfaches Item ICF Category Positiver Misfit Item passt nicht zum Rasch Modell (und diskriminiert nicht) Logit = Log of the odds = Log Log = 0 ( ) = Probability of succes Probability of failure Ability Difficulty ( ) Ability Difficulty 2-2=0

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27 Resultate: folgende ICF Kategorien passen nicht in das Rasch Model d850 Bezahlte Tätigkeit d560 Trinken d6200 Einkaufen d830 Höhere Bildung und Ausbildung

28 Nicht passendes Item d850 Bezahlte Tätigkeit Die Punkte stellen gruppierte Personen mit ähnlicher Funktionsfähigkeit dar. Erwarteter Wert Personen mit unterschiedlicher Funktionsfähigkeit haben ähnliche Werte in b850

29 Summenscore Es kann ein Summenscore über 64 Kategorien gebildet werden. Vier Items passen nicht, das heisst jedoch nicht, dass diese Items nicht relevant sind. Sie müssen separat dokumentiert werden.

30 Diskussion Das ICF Core Set für AS wird die Wahl der ICF Kategorien vereinfachen. Mit dem ICF Core Set könnten die gleichen Analysen durchgeführt werden. Herausforderungen: Reliabilität der ICF Kategorien Qualifier Skala

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