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					        Reliability of the ICF-core set for
              rheumatoid arthritis

                          Till Uhlig, dr. med.
                          Senior researcher
                       Dept. of Rheumatology.
                       Diakonhjemmet Hospital
                             Oslo, Norway

Disclosure present work:
Medical Science Manager Rheumatology
Bristol-Myers Squibb Norway Ltd.
              ICF application
 Statistical tool (surveys, management of
  information systems)
 Research tool (outcomes, quality of life,
  environmental factors)
 Clinical tool (assessment of needs, rehabilitation,
 Social policy (planning social security,
  compensation, policy designs/implementation)
 Educational tool (curriculum designs, raise
                          ICF overview
             Functioning and                             Contextual Factors
             Disability (Part I)                         (Part II)
Components Body functions and       Activities and       Environmental       Personal factors
             structures             Participation        factors

Domains      Body functions         Life areas (tasks,   External            Internal
             Body structures        actions)             influences on       influences on
                                                         functioning and     functioning and
                                                         disability          disability
Constructs   Change in body         Capacity             Facilitation or     Impact of
             functions              (standard            hindering impact    attributes of the
             (physiological)        environment)         from physical,      person
                                    Performance          social, and
                                    (current             attitudinal world
Positive     Functional and         Acitivities          Facilitators        Not applicable
aspect       structural integrity   participation

Negative     Impairment             Activity             Barriers/           Not applicable
aspect                              limitation,          Hindrances
Can we develop condition-oriented
        ICF Core-Sets ?

 Condition-specific health status measures
  Link of function to a condition possible
  Relevant categories differ among conditions

 Core Sets from the „medical“ perspective
           ICF Core Sets
  – Chronic conditions
  – Trauma
Condition / Setting
  – Acute hospital
              ICF Core Sets
make the ICF feasible for
   Research
       Clinical and epidemiological studies
       Health reporting and monitoring of functioning and
   Clinical practice
       Diagnosis (Assessment) of patient problems
       Rehabilitation Management
       Follow-up and evaluation after medical, rehabilitation
        and surgical interventions
              ICF core set
Resulting in a list of ICF categories to be
 recorded for a comprehensive,
 multidisciplinary assessment of functioning
 and health in patients with a specific
Development is based on evidence
 (preliminary studies) and consensus process
 (Delphi exercise, international consensus
                        ICF Core Sets

 Lists of ICF categories
 that are relevant to most patients
 with a specific health condition
Stucki G and Cieza A: The ICF for RA: a way to specify functioning, Ann Rheum Dis
2004, 40-45
Cieza A and Stucki G: The ICF in Rheumatology: Ann Rheum Dis 2004, 40-45
         ICF Core Set
Development of disease specific core sets

                     Empiric data
                                             Delphi -
Systematic                                   procedures

                  International consensus

  Core sets                           Intermediate data
              Evaluation in
              clinical practice
      Development of core sets
 Musculoskeletal           Rheumatoid arthritis
                            Osteoarthritis
                            Osteoporosis
                            Back Pain
 Neurology and mental      Stroke
                            Depression
                            Chronic pain
                            Obesity
 Internal medicine         Coronary heart disease
                            COPD/Asthma
                            Diabetes
                            Breast cancer
           Body Functions - RA

b280    Pain
b710    Mobility of joint functions
b730    Muscle power functions
b4555   Exercise tolerance function
b780    Sensations related to muscles and movement functions
b2800   Generalized pain
b2801   Pain in body part
b7102   Mobility of joints generalized
b7800   Sensation of muscle stiffness
b134    Sleep functions
b130    Energy and drive functions
b640    Sexual functions
b715    Stability of joint functions
b152    Emotional functions
b180    Experience of self and time functions
b1801   Body image
b740    Muscle endurance function
b510    Ingestion functions
b770    Gait pattern functions
b430    Haematological system functions
            Body Structures - RA

s750     Structure of lower extremity
s730     Structure of upper extremity
s710     Structure of head and neck region
s720     Structure of shoulder region
s75001   Hip joint
s75011   Knee joint
s7502    Structure of ankle and foot
s73001   Elbow joint
s73011   Wrist joint
s7302    Structure of hand
s73021   Joints of hand and fingers
s73022   Muscles of hand
s760     Structure of trunk
s7600    Structure of vertebral column
s76000   Cervical vertebral column
s770     Additional musculoskeletal structures related to movement
s299     Eye, ear and related structures, unspecified
s810     Structure of areas of skin
             Activities & Participation – RA

d450   Walking
d850   Remunerative employment
d440   Fine hand use
d410   Changing basic body position
d445   Hand and arm use
d230   Carrying out daily routine
d430   Lifting and carrying objects
d470   Using transportation
d620   Acquisition of goods and services
d920   Recreation and leisure
d640   Doing housework
d540   Dressing
d630   Preparing meals
d475   Driving
d530   Toileting
d550   Eating
d859   Work and employment, other specified and unspecified
d170   Writing
d510   Washing oneself
d770   Intimate relationships
                Environmental Factors - RA

e310   Immediate family
e580   Health services, systems and policies
e355   Health professionals
e115   Products and technology for personal use in daily living
e570   Social security services, systems and policies
e155   Design, construction and building products and technology of buildings for private use
e110   Products or substances for personal           consumption
e450   Individual attitudes of health professionals
e150   Design, construction and building products and technology of buildings for public use
e135   Products and technology for employment
e425   Individual attitudes of aquaintances, peers, colleagues, neighbors and community
e410   Individual attitudes of immediate family members
e420   Individual attitudes of friends
e540   Transportation services, systems and policies
e340   Personal care providers and personal assistants
e360   Other professionals
e320   Friends
e120   Products and technology for personal indoor and outdoor mobility and transportation
e460   Societal attitudes
e125   Products and technology for communication
e225   Climate
    After defining a core set…
Test the preliminary core set for specific
  – Feasibility
  – Reliability
  – Validity (Sensitivity to change)
Continueous process: Revision of core sets?
 National Resource Center for Rehabilitation in
  Rheumatology, Dept. of Rheumatology,
  Diakonhjemmet Hospital, Oslo, Norway
 Department of Internal Medicine III, Division of
  Rheumatology, Vienna Medical University, Austria
 Physical Medicine and Rehabilitation, University of
  Munich, Germany,
 Dept. of Rheumatology, University Hospital,
  Maastricht, Netherlands
         Reliability study in RA
 25 patients recruited from outpatient department
   – Classsification of rheumatoid arthritis (RA)
 Examined with ICF core set for RA
   – Day 1: occupationanl therapist and physiotherapist
     independently from each other
   (= interrater reliability)
   – After one week (day 6-10) again by one of the two
   (= intrarater reliability)
   – Self- reported health status (SF-36, MHAQ, pain,
     fatigue) at both time points
          How to measure ?
ICF Qualifier, based on
  – history
  – clinical exam
  – clinical test
.0   No problem         (intet, fraværende, ubetydelig…)    0-4%

.1   Mild problem       (lett, lavgradig…)                  5-24%

.2   Moderate problem   (middels uttalt)                    25-49%

.3   Severe problem     (omfattende, ekstremt, subtotalt)   50-95%

.4   Total problem      (fullstendig, helt manglende …)     96-100%

.8   Not specified

.9   Not applicible
              Body structures: Intrarater
                 ICF Category Title              Intra-rater agreement   Kappa   Missing** (%)

         Ear and related structures, specified

s299                                                      48             0.54         0
          Structure of head and neck region

s710                                                      88             0.86         4
            Structure of shoulder region
s720                                                      64             0.60         0
            Structure of upper extremity
s730                                                      52             0.31         0
                     Elbow joint
s73001                                                    76             0.80         0
                     Wrist joint
s73011                                                    52             0.56         0
                  Structure of hand
s7302                                                     48             0.33         0
              Joints of hand and fingers
s73021                                                    60             0.57         0
                  Muscles of hand
s73022                                                    64             0.50         0
            Structure of lower extremity
s750                                                      50             0.48         4
         Body structures: Interrater
                  ICF Category Title              Inter-rater agreement * (%)   Kappa   Missing** (%)

          Ear and related structures, specified

s299                                                          46                0.32         4
           Structure of head and neck region

s710                                                          52                0.32         8
             Structure of shoulder region
s720                                                          42                0.47         4
             Structure of upper extremity
s730                                                          38                0.22         4
                      Elbow joint
s73001                                                        44                0.48         0
                      Wrist joint
s73011                                                        56                0.61         0
                   Structure of hand
s7302                                                         59                0.49         12
               Joints of hand and fingers
s73021                                                        48                0.42         8
                   Muscles of hand
s73022                                                        50                0.39         12
             Structure of lower extremity
s750                                                          50                0.25         12
      Observer agreement: all categories

                           All categories (n=95)

Observed agreement         Intra                   Inter

Higher than 80 %           4                       0

51-80 %                    67                      44
21-50 %                    24                      43
20 % and lower             0                       8

Categories with kappa      82/95 (86%)             41/95 (43%)
values 0.4 or higher (%)
                     Observer agreement
             Body             Body            Activities and   Environmental
             Functions        Structures      Participation    Factors (n=21)
             (n=24)           (n=18)          (n=32)
Observed     Intra    Inter   Intra   Inter   Intra    Inter   Intra   Inter
Higher than 1         0       2       0       1        0       0       0
80 %
51-80 %      20       17      12      6       24       17      11      4
21-50 %      3        7       4       11      7        13      10      12
20 % and     0        0       0       1       0        2       0       5
N kappa      18/24    14/24 14/18 10/18 25/32          13/32   15/21 4/21
0.4 or       (75%)    (58) (78%) (56%) (71%)           (41%)   (71%) (19%)
higher (%)
.0   No problem         (intet, fraværende, ubetydelig…)    0-4%

.1   Mild problem       (lett, lavgradig…)                  5-24%

.2   Moderate problem   (middels uttalt)                    25-49%

.3   Severe problem     (omfattende, ekstremt, subtotalt)   50-95%

.4   Total problem      (fullstendig, helt manglende …)     96-100%

.8   Not specified

.9   Not applicable
        Collapsing of qualifiers
 Rasch analyses suggested that reduction of the
  number of qualifiers from five to three (and from
  nine to three for Environmental Factors) improved
  both inter-rater and intra-rater agreement.
 Qualifiers were thus collapsed for Body
  Functions, Body Structures, and Activities and
  Participation with the collapsing strategy 0 11 22.
  Environmental Factors were collapsed
  -1-1-1-1 0 1111.
Mean time for assessments with the ICF
 Core Set for RA was 34 (SD 9, range 20-
 75) minutes.
  Summary: Reliability study in RA

 Inter-rater and intra-rater reliability of the ICF
  Core Set of RA was low to moderate.
 Mean intra-rater (inter-rater) complete agreement
  for all categories was seen in 59% (47%) of the
 Reliability (kappa >0.4) was observed in 86% of
  categories within raters, and in 43% of categories
  between raters.
 The metric of the qualitiers’ scale may be
  improved by reducing the number of qualifiers to
  three for all components.