Scale‐Banking for Patient Reported Outcome Measures (PROMs) Measuring Functioning in Rheumatoid Arthritis: A Daily Activities Metric

Objective Functioning is an important outcome for rheumatoid arthritis (RA) management. Heterogeneity of respective patient‐reported outcome measures (PROMs) challenges direct comparisons between their results. This study aimed to standardize reporting of such PROMs measuring functioning in RA to facilitate comparability. Methods Common Item Non‐Equivalent Groups Design (NEAT) with the Health Assessment Questionnaire (HAQ) as a common scale across data sets from various countries (incl. UK, Turkey and Germany) to establish a common metric. Other PROMs included are the Physical Function items of the Multidimensional Health Assessment Questionnaire (MDHAQ), Disabilities of Arm, Shoulder and Hand (DASH), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS 2.0), and four short forms (20, 10, 6, and 4 physical function items) from the Patient‐Reported Outcomes Measurement Information System (PROMIS). As the HAQ includes mobility, self‐care and domestic life items, this study focuses on these three domains. PROMs were described using Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD). Rasch Measurement model was used to create the common metric. Results Range of SEM is 0.2 (MDHAQ) to 7.4 (SF36‐PF). SDD revealed a range from 9.7 % (WOMAC‐RAT) to 33.5 % (WHODAS‐PF). PROMs co‐calibration revealed fit to the Rasch measurement model. A transformation table was developed to allow exchange between PROMs scores. Discussion Scores between the Daily Activity PROMs commonly used in RA can now be compared. Factors such as SEM and SDD help determine choice of PROM in clinical practice and research

An initial application of computerized adaptive testing (CAT) for measuring disability in patients with low back pain

<p>Abstract</p> <p>Background</p> <p>Recent approaches to outcome measurement involving Computerized Adaptive Testing (CAT) offer an approach for measuring disability in low back pain (LBP) in a way that can reduce the burden upon patient and professional. The aim of this study was to explore the potential of CAT in LBP for measuring disability as defined in the International Classification of Functioning, Disability and Health (ICF) which includes impairments, activity limitation, and participation restriction.</p> <p>Methods</p> <p>266 patients with low back pain answered questions from a range of widely used questionnaires. An exploratory factor analysis (EFA) was used to identify disability dimensions which were then subjected to Rasch analysis. Reliability was tested by internal consistency and person separation index (PSI). Discriminant validity of disability levels were evaluated by Spearman correlation coefficient (r), intraclass correlation coefficient [ICC(2,1)] and the Bland-Altman approach. A CAT was developed for each dimension, and the results checked against simulated and real applications from a further 133 patients.</p> <p>Results</p> <p>Factor analytic techniques identified two dimensions named "body functions" and "activity-participation". After deletion of some items for failure to fit the Rasch model, the remaining items were mostly free of Differential Item Functioning (DIF) for age and gender. Reliability exceeded 0.90 for both dimensions. The disability levels generated using all items and those obtained from the real CAT application were highly correlated (i.e. > 0.97 for both dimensions). On average, 19 and 14 items were needed to estimate the precise disability levels using the initial CAT for the first and second dimension. However, a marginal increase in the standard error of the estimate across successive iterations substantially reduced the number of items required to make an estimate.</p> <p>Conclusion</p> <p>Using a combination approach of EFA and Rasch analysis this study has shown that it is possible to calibrate items onto a single metric in a way that can be used to provide the basis of a CAT application. Thus there is an opportunity to obtain a wide variety of information to evaluate the biopsychosocial model in its more complex forms, without necessarily increasing the burden of information collection for patients.</p

Reliability, construct validity and measurement potential of the ICF comprehensive core set for osteoarthritis

<p>Abstract</p> <p>Background</p> <p>This study aimed to investigate the reliability and construct validity of the International Classification of Functioning, Disability and Health (ICF) Comprehensive Core Set for osteoarthritis (OA) in order to test its possible use as a measuring tool for functioning.</p> <p>Methods</p> <p>100 patients with OA (84 F, 16 M; mean age 63 yr) completed forms including demographic and clinical information besides the Short Form (36) Health Survey (SF-36^®) and the Western Ontario and McMaster Universities Index of Osteoarthritis (WOMAC). The ICF Comprehensive Core Set for OA was filled by health professionals. The internal construct validities of "Body Functions-Body structures" (BF-BS), "Activity" (A), "Participation" (P) and "Environmental Factors" (EF) domains were tested by Rasch analysis and reliability by internal consistency and person separation index (PSI). External construct validity was evaluated by correlating the Rasch transformed scores with SF-36 and WOMAC.</p> <p>Results</p> <p>In each scale, some items showing disordered thresholds were rescored, testlets were created to overcome the problem of local dependency and items that did not fit to the Rasch model were deleted. The internal construct validity of the four scales (BF-BS 16 items, A 8 items, P 7 items, EF 13 items) were good [mean item fit (SD) 0.138 (0.921), 0.216 (1.237), 0.759 (0.986) and -0.079 (2.200); person item fit (SD) -0.147 (0.652), -0.241 (0.894), -0.310 (1.187) and -0.491 (1.173) respectively], indicating a single underlying construct for each scale. The scales were free of differential item functioning (DIF) for age, gender, years of education and duration of disease. Reliabilities of the BF-BS, A, P, and EF scales were good with Cronbach's alphas of 0.79, 0.86, 0.88, and 0.83 and PSI's of 0.76, 0.86, 0.87, and 0.71, respectively. Rasch scores of BF-BS, A, and P showed moderate correlations with SF-36 and WOMAC scores where the EF had significant but weak correlations only with SF36-Social Functioning and SF36-Mental Health.</p> <p>Conclusion</p> <p>Since the four different scales derived from BF-BS, A, P, and EF components of the ICF core set for OA were shown to be valid and reliable through a combination of Rasch analysis and classical psychometric methods, these might be used as clinical assessment tools.</p

The role of Interdisciplinary Teams in Physical and Rehabilitation Medicine

The increasing complexity of healthcare provision and medical interventions requires collaboration between large numbers of health professionals. The nature of the interactions between team members determines whether the pattern of working is described as multi-, inter- or trans-disciplinary. Such team-working is an important part of the specialty of Physical and Rehabilitation Medicine. Grounded in group behaviour theory, team-working demonstrates that joint aims, trust and willingness to share knowledge, can improve patient outcomes, including mortality. The synthesis of individual skills and knowledge and working to common patient goals, has shown benefit in many conditions. This evidence base is perhaps best in stroke, but has been demonstrated in many other conditions, including acquired brain injury, back pain, mental health, cardiopulmonary conditions, chronic pain and hip fracture. There are also considerable benefits to staff and health organizations in terms of outcome and staff morale. This review paper examines the evidence for the benefit of such team-working and for the recommendations of team-working in rehabilitation services

Rehabilitasyon alanında sonuç değerlendirim ve izleminin Avrupa düzeyinde standardizasyonu

Bu projenin amacı, Türkiye'de tıbbi rehabilitasyon alanında sonuç değerlendirim ve izleminin ulusal ve uluslararası düzeyde standardizasyonunu sağlamaktır. Bu amaçla romatolojik rehabilitasyon alanında kullanılmak üzere iki, nörolojik rehabilitasyon alanında ise üç ölçeğin standardizasyonu hedeflenmiştir. Bu ölçekler, romatoid artritte (RA) fiziksel disabilite değerlendiren Sağlık Değerlendirme Sorgulaması (HAQ) ve yaşam kalitesi değerlendiren Romatoid Artrit Yaşam Kalitesi Ölçeği (RAQoL) ile beyin hasarlılarda bilişsel durum değerlendiren Mini Mental Durum İncelemesi (MMSE), Middlesex Mental Durum Değerlendirimi (MEAMS) ve Rivermead Davranışsal Bellek Testi (RBMT) dir. Ölçeklerin önce toplumumuza adaptasyonları yapılmış, daha sonra hem klasik psikometrik yöntemlerle hem de Rasch ölçüm yöntemiyle güvenilirlik ve geçerlilikleri incelenmiştir. Güvenilirlik, içsel tutarlılıkla (Cronbach $\alpha$ ), internal yapısal geçerlilik ve kültürler arası geçerlilik Rasch ölçüm yöntemiyle, eksternal yapısal geçerlilik ise ölçeğin disabilite, bozukluk gibi çeşitli parametrelerle ilişkisi (Spearman korelasyon analizi, Kruskal Wallis analizi) araştırılarak test edilmiştir. Çalışmaya HAQ için 75, RAQoL için 71 RA'lı hasta alınmış, kognitif değerlendirme ölçeklerinden MMSE için 207, MEAMS için 155, RBMT için ise 171 beyin hasarlı hasta değerlendirilmiştir. Çalışmaya alman tüm hastalar Ankara Üniversitesi Tıp Fakültesi Fiziksel Tıp ve Rehabilitasyon Kliniğinde tedavi gören hastalardır. Bilişsel durum değerlendirme ölçekleri yaş ve eğitim düzeyine göre norm belirlenmesini gerektirdiğinden, bu ölçeklerin, geçerlilik/güvenilirlik çalışmalarından önce normatif değerleri belirlenmiştir. Normatif skor belirlemek amacıyla MMSE için 406, MEAMS için 350, RBMT için 266 normal erişkin birey bu testlerle değerlendirilmişlerdir. Bu normal bireyler hastane personeli, hastane personeli yakınları ve hasta yakınları arasından seçilmiştir. Bulgular, HAQ ve RAQoL'in Türkçe versiyonlarının, romatoid artritte kullanılmak üzere güvenilir ve geçerli olduğunu göstermiştir. HAQ ve RAQoL için Cronbach $\alpha$ değerleri 0.97 ve 0.95 olup içsel tutarlılıkları yüksektir. Her iki ölçeğin de Rasch modeline uyumlarının çok iyi olması internal yapısal geçerliliklerini desteklemektedir (ortalama madde uyumu HAQ için 0.205, RAQoL için 0.236). Her iki ölçek de bozukluk ve disabilite parametreleriyle beklenen düzeyde ilişki göstererek eksternal yapısal geçerlikleri saptanmıştır. İngiliz verileriyle karşılaştırılan analizlerde Rasch uyum istatistikleri HAQ ve RAQoL için her iki kültürde de benzer bulunmuş, HAQ için 1, RAQol için 4 maddede hafif bir ayrımsal madde fonksiyonu gözlenmiştir. Bu bulgular, bu iki ölçeğin kültürler arası geçerliliklerini göstermektedir. Analizler, MMSE'nin Türkçe versiyonunun, beyin hasarlı hastalarda geçerli ve güvenilir olduğunu göstermiştir. Ölçeğin içsel tutarlılığı grup düzeyinde yeterli (Cronbach $\alpha$ : 0.75), internal yapısal geçerliliği (ortalama madde uyumu -0.362) kabul edilebilir düzeydedir. Kognitif disabilite ile beklenen düzeyde ilişki (Spearman r: 0.60) saptanmıştır. Rasch analizinde ölçeğin iki maddesi Türkiye ile İtalya arasında ayrımsal madde fonksiyonu göstermiştir; bu iki madde için düzenleme yapılarak İtalya ile ortak çalışmalarda karşılaştırma yapılabilir. MMSE, beyin hasarlılarda kognitif tarama testi olarak kullanılabilir. Ancak, ölçüm özelliklerinin okur-yazar olmayanlarda farklılık göstermesi ve güvenilirliğinin bireysel değerlendirme için sınırda olması, ölçeğin dezavantajlarıdır; ölçekle değerlendirme yapılırken bu dezavantajlarının göz önünde bulundurulması gerekmektedir. Diğer bilişsel ölçekler MEAMS ve RBMT'nin, beyin hasarlı hastalarda geçerli ve güvenilir oldukları belirlenmiştir. Her iki ölçeğin de içsel tutarlılıkları iyidir (Cronbach $\alpha$ değerleri, MEAMS için 0.81, RBMT için 0.84). Her iki ölçeğin de Rasch modeline uyumlarının çok iyi olması internal yapısal geçerliliklerini desteklemektedir (ortalama madde uyumu MEAMS için -0.027, RBMT için -0.219). Her iki ölçek de kognitif disabilite ile beklenen düzeyde ilişkili (Spearman r MEAMS için 0.565, RBMT için 0.670) bulunmuş, bu da ölçeklerin eksternal yapısal geçerliliklerini göstermiştir. MEAMS, genel bilişsel durum, RBMT ise bellek fonksiyonunu değerlendirmek amacıyla güvenle kullanılabilir. Sonuç olarak, bu proje kapsamında kültürümüze adapte edilen sonuç değerlendirim ve izlem ölçekleriyle, Türkiye'de nörolojik ve romatolojik rehabilitasyon alanında kullanılmak üzere standart sonuç değerlendirim ve izlem protokolleri belirlenmiştir ve bu protokollerin bazıları Avrupa düzeyinde standardizasyonları da içermektedir

Osteoporosis. The role of Physical and Rehabilitation Medicine Physicians. The European perspective based on the best evidence

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of PRM interventions. A wide range of health conditions treated by PRM specialists carries the risk of osteoporosis (OP). The consequences of OP may be associated with significant disability. The aim of this paper is: to define the role of PRM physicians in the prevention and management of OP, to describe the needs of people with OP in relation to rehabilitation strategy, and to highlight why and how PRM physicians should be involved in the diagnosis and management of OP. PRM physicians may intervene in the prevention of and risk factor assessment for OP, falls and fractures along with other assessments of functioning and of quality of life. In addition, they are involved in diagnosis and in both pharmacological and nonpharmacological treatment of OP. From a specific PRM perspective based on the International Classification of Functioning, Disability and Health (ICF), there is an important role in optimizing functioning and promoting "activities and participation", including interventions as sociated with environmental factors for people with OP or osteoporotic fractures. Evidence suggests that a large number of interventions within the scope of PRM that range from preventive strategies (including education and self management and most importantly exercise) to pain management strategies and spinal orthoses or hip protectors may be effective in the prevention and/or management of OP and its sequelae. Competencies and aptitudes of PRM specialists, focusing especially on functioning while providing care over the whole course of a health condition from the hospital to the community, may well place them in the management of OP. Evidence-based effective PRM interventions further warrant the role of PRM physicians in the management of OP