Developing core sets for patients with head and neck cancer based on the International Classification of Functioning, Disability and Health (ICF)

Patient-Reported Outcomes for Spine Oncology: A Narrative Review

Spine tumors, both primary and metastatic, impose significant morbidity and mortality on patients and physicians. Patient-reported outcomes are valuable tools to assess a patient's impression of their health status and enhance communication between physicians and patients. Various spine generic patient-reported outcome tools have traditionally been used but have not been validated in the spine tumor patient population. The Spine Oncology Study Group Outcome Questionnaire, which is disease-specific for the metastatic spine patient population, has been shown to have strong validity, even across multiple languages. Patient-Reported Outcomes Measurement Information System, which has recently been developed, employs computerized adaptive testing to assess multiple health domains. It has been shown to capture information in both generic and specific questionnaires and has the potential to be used as a universal tool in the spine oncology patient population. Further long-term studies, as well as, cross-cultural adaptations, are needed to validate Patient-Reported Outcomes Measurement Information System's applicability and effectiveness.

Measuring oral health-How can the International Classification of Functioning help?

There is a need for a theoretically informed, contextualized approach to measuring oral health from a multidisciplinary perspective that goes beyond the commonly used clinical indices and sociodental measures. This commentary aims to discuss the potential for the WHO's International Classification of Functioning, Disability and Health (ICF) to provide a model for the development of indicators for oral health. It is suggested that the ICF might provide both a theoretical model and an operational classification for indicators of oral health. The ICF model states that human experience of physical, cognitive and social functioning is universal and, thus, can be described and qualified. Human function is given social and environmental context within the model at both an individual and population level. The ICF can not only capture data regarding oral health and function at the physiological level (e.g. chewing) but also at the social level (e.g. sharing meals). It is able not only to capture aspects of preventive behaviour (e.g. caring for teeth) but also aspects of social facilitation (e.g. economic self-sufficiency) or ability to fulfil a social role (e.g. remunerative employment). It also includes aspects of social environment, such as healthcare services or political, economic and legal systems. Case studies are given as examples of the potential use of the ICF in the oral health domain. Examples are also given of the first steps that have been made towards operationalization of the ICF in data collection and oral health research. The challenges of encompassing such a comprehensive model into a practical oral health measure are discussed.

Longitudinal functional outcomes and late effects of radiation following treatment of nasopharyngeal carcinoma: secondary analysis of a prospective cohort study

Background

The study objectives were: provide longitudinal data on upper aerodigestive tract function and late complications following IMRT for nasopharyngeal carcinoma, and elucidate factors that might predict a worse outcome. The hypotheses were: (1) Despite advances such as IMRT, radiation will cause significant functional decline and late complications that often progress or arise years after treatment. (2) Larger radiation volume will be associated with poorer outcomes.

Methods

Longitudinal, observational cohort study of nasopharyngeal carcinoma patients with retrospective analysis of prospectively collected, population-based data. Late sequelae and validated measures of overall performance, speech, and swallowing were documented pre-treatment and 3,6,12, 24, 36 and ≥ 60-months post-treatment.

Results

Forty-two patients treated curatively with radiation (N = 9) or chemoradiation (N = 33) were followed for a median 74 months. Functional outcomes showed an initial nadir at 3 months associated with acute effects of treatment, followed by initial recovery. There was subsequent functional decline years post-treatment with advancing dysphagia/aspiration, trismus, muscle spasm, and hypoglossal nerve palsy. Univariable regression analysis revealed that increasing high-dose radiation volumes (PTV 70 Gy) were associated with increased likelihood of less than solid diet (Performance Status Scale (PSS)—Normalcy of Diet score < 50; p = 0.04), and reduced PSS—Understandability of Speech (p = 0.005). The probability of poor outcome increased with time. Eleven percent of patients were tube feed dependent at ≥ 5 years.

Conclusions

Despite improvements in radiation delivery, late effects of radiation remain common. Higher radiation volumes are associated with poorer outcomes that worsen over time.

Graphical Abstract

The "Comprehensive ICF Core Set for Head and Neck Cancer": a Delphi consensus survey among German speaking speech and language therapists

The "Comprehensive ICF Core Set for Head and Neck Cancer" (ICF-HNC) is an application of the "International Classification of Functioning, Disability and Health" (ICF), representing the characteristic spectrum of issues in patients with head and neck cancer (HNC). Our primary aim was to evaluate which categories of the ICF-HNC are dealt with by speech and language therapists (SLTs) in Germany, Austria, and Switzerland. The secondary aim was to identify outcome measures used by SLTs to measure the categories of the ICF-HNC in clinical practice. SLTs experienced in the treatment of HNC patients evaluated the categories of the ICF-HNC in a three-round Delphi survey. They were asked whether the listed categories represented issues treated by SLTs in HNC patients, and what outcome measures were used to assess them. Altogether, 31 SLTs completed the survey. 47 of 108 previously selected categories of the ICF-HNC achieved the cut-off value. Out of these, 40.4% were derived from the component "Body Functions", 36.2% from "Body Structures", 12.8% from "Environmental Factors", and 10.6% from "Activities and Participation". Altogether, 82 of the mentioned outcome measures were considered as reasonable from the perspective of SLTs. Of these, only 37 achieved more than 50% approval. This study emphasises the importance of "Body Structures" and "Body Functions" for SLTs in Germany and Switzerland in treating patients with HNC. Moreover, the results highlighted the need to agree on evidence-based outcome measures in speech and language therapy.

A Global Oral Health Survey of professional opinion using the International Classification of Functioning, Disability and Health

OBJECTIVES

The concept of oral health is frequently reduced to the absence of disease, despite existing conceptual models exploring the wider determinants of oral health and quality of life. The International Classification of Functioning, Disability and Health (ICF) (WHO) is designed to qualify functional, social and environmental aspects of health. This survey aimed to reach a consensual description of adult oral health, derived from the ICF using international professional opinion.

METHODS

The Global Oral Health Survey involved a two-round, online survey concerning factors related to oral health including functioning, participation and social environment. Four hundred eighty-six oral health professionals from 74 countries registered online. Professionals were pooled into 18 groups of six WHO world regions and three professional groups. In a randomised stratification process, eight professionals from each pool (n=144) completed the survey. The first round consisted of eight open-ended questions. Open expression replies were analysed for meaningful concepts and linked using established rules to the ICF. In Round 2, items were rated for their relevance to oral health (88% response rate).

RESULTS

Eighty-nine ICF items and 30 other factors were considered relevant by at least 80% of participants. International professionals reached consensus on a holistic description of oral health, which could be qualified and quantified using the ICF.

CONCLUSIONS

These results represent the first step towards developing an ICF Core Set in Oral Health, which would provide a practical tool for reporting outcome measures in clinical practice, for research and epidemiology, and for the improvement of interdisciplinary communication regarding oral health.

CLINICAL SIGNIFICANCE

Professional consensus reached in this survey is the foundation stone for developing an ICF Core Set in Oral Health, allowing the holistic aspects of oral health to be qualified and quantified. This tool is necessary to widen our approach to clinical decision making, measurement of clinical outcomes, research and epidemiology.

Assessment of functional outcomes in patients with head and neck cancer according to the International Classification of Functioning, Disability and Health Core Sets from the perspective of the multi-professional team: results of 4 Delphi surveys

BACKGROUND

The International Classification of Functioning, Disability and Health Core Set for Head and Neck Cancer (ICF-HNC) covers the typical spectrum of problems in functioning in head and neck cancer. This study is part of a multistep process to develop practical guidelines in Germany. The purpose of this study was to identify instruments for the assessment of functioning using the ICF-HNC as reference.

METHODS

Four Delphi surveys with physicians, physiotherapists, psychologists, and social workers were performed to identify which aspects of the ICF-HNC are being treated and which assessment tools are recommended for the assessment of functioning.

RESULTS

Ninety-seven percent categories of the ICF-HNC were treated by healthcare professionals participating in the current study. Altogether, 33 assessment tools were recommended for therapy monitoring, food intake, pain, further organic problems/laboratory tests, and psychosocial areas.

CONCLUSION

Although the ICF-HNC is being currently implemented by the head and neck cancer experts, several areas are not covered regularly. Additionally, validated tools were rarely recommended.

Content comparison of self-reported disability measures for the elderly according to the international classification of functioning, disability and health

PURPOSE

To identify self-reported disability measures developed for older adults by performing a systematic literature review and to compare the contents of all identified measures based on the International Classification of Functioning, Disability and Health (ICF).

METHOD

A broad systematic literature search was performed in March 2012 in the following databases: MEDLINE, EMBASE, CINAHL, PsycINFO and PROQOLID. Each item in the identified measures was extracted and linked to the ICF categories. A content comparison between measures was performed. The content density and diversity of each measure were assessed by calculating the content density ratio (the number of meaningful concepts divided by the number of items in each questionnaire) and content diversity ratio (the number of different ICF categories divided by the number of linked meaningful concepts), respectively.

RESULTS

We reviewed 5622 published articles and identified 13 eligible measures. In total, 293 meaningful concepts from 265 items were extracted, of which, 270 concepts were linked to the ICF. A total of 62 different ICF categories were addressed. EARRS, FHS and SF-LLFDI had the highest content density ratio, while FHS and KI had the highest content diversity ratio. Different measures differed considerably in content.

CONCLUSIONS

The ICF can be used as a conceptual framework not only for assessing measures but also for developing new measures. According to this ICF-based content comparison, the contents of currently available measures for disability in older adults vary significantly from one another. Our study may provide useful information for the selection of suitable measures for a particular purpose, as well as the development of new measures.

Using the International Classification of Functioning, Disability and Health (ICF) to describe children referred to special care or paediatric dental services

Children in dentistry are traditionally described in terms of medical diagnosis and prevalence of oral disease. This approach gives little information regarding a child’s capacity to maintain oral health or regarding the social determinants of oral health. The biopsychosocial approach, embodied in the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) (WHO), provides a wider picture of a child’s real-life experience, but practical tools for the application of this model are lacking. This article describes the preliminary empirical study necessary for development of such a tool - an ICF-CY Core Set for Oral Health. An ICF-CY questionnaire was used to identify the medical, functional, social and environmental context of 218 children and adolescents referred to special care or paediatric dental services in France, Sweden, Argentina and Ireland (mean age 8 years ±3.6yrs). International Classification of Disease (ICD-10) diagnoses included disorders of the nervous system (26.1%), Down syndrome (22.0%), mental retardation (17.0%), autistic disorders (16.1%), and dental anxiety alone (11.0%). The most frequently impaired items in the ICF Body functions domain were ‘Intellectual functions’, ‘High-level cognitive functions’, and ‘Attention functions’. In the Activities and Participation domain, participation restriction was frequently reported for 25 items including ‘Handling stress’, ‘Caring for body parts’, ‘Looking after one’s health’ and ‘Speaking’. In the Environment domain, facilitating items included ‘Support of friends’, ‘Attitude of friends’ and ‘Support of immediate family’. One item was reported as an environmental barrier – ‘Societal attitudes’. The ICF-CY can be used to highlight common profiles of functioning, activities, participation and environment shared by children in relation to oral health, despite widely differing medical, social and geographical contexts. The results of this empirical study might be used to develop an ICF-CY Core Set for Oral Health - a holistic but practical tool for clinical and epidemiological use.

Priorities of head and neck cancer patients: a patient survey based on the brief ICF core set for HNC

The International Classification of Functioning, Disability and Health Core Set for Head and Neck Cancer (ICF-HNC) covers the typical spectrum of problems in functioning experienced by patients with head and neck cancer (HNC). The major goal of the present work was to evaluate patients' priorities using the brief ICF-HNC as a starting point. A priorities assessment checklist consisting of 15 statements was created based on the 14 validated categories of the brief ICF-HNC. In a cross-sectional study, patients were requested to select up to 5 items that were especially important to them. The checklist was sent by mail to 465 patients at different time points of cancer follow-up and handed out to 56 patients with recent HNC diagnosis. Altogether 300 (64.51 %) patients returned the checklist. The top priority of our sample was "I want to survive the cancer", followed by "I want that all the expenses for cancer treatment, cancer care and any additional follow-up treatments be covered by my health insurance or by the welfare system", "I want to be able to continue performing all daily life tasks well", "I want to have trusting relationships with my doctors, nurses and therapists" and "I want to be able to speak clearly". Although survival was, as expected, the top priority for patients enrolled in the study, we show that the weight given to survival and further symptoms or daily life activities meaningfully changes when the biopsychosocial perspective proposed in the ICF is adopted.

Do measures used in studies of anxiety disorders reflect activities and participation as defined in the WHO International Classification of Functioning, Disability and Health?

Background: Besides the measurement of symptoms, information on functioning and disability in daily routines expands the description of impairments in patients with anxiety disorders. Therefore, the measurement of activities and participation, as theoretically included in the International Classification of Functioning, Disability and Health (ICF) is of increasing importance. The objective of this study is to give an overview over the implementation of the concept ‘activities and participation’ in outcome measurements of patients with anxiety disorders.

Methods: Based on a literature review in PubMed and PsycInfo databases and including 200 papers, this study analyses 65 outcome instruments used in randomized controlled trials in anxiety disorders according to their content related to the ICF domain of ‘Activities and participation’.

Results: Instruments used in trials evaluating outcome in patients with anxiety disorder only partially address activities and participation. Over all 65 instruments, the chapters on ‘Interpersonal interactions and relationships’ and ‘Mobility’ were most frequently included in measurements.

Conclusions: The identification of relevant ICF categories (core sets) according to activities and participation and especially interpersonal interactions and relationships as well as mobility, can be a basis for describing functioning and evaluating treatment in anxiety disorders, helping to improve outcome assessment in clinical practice.

Situating primary health care within the international classification of functioning, disability and health: enabling the Canadian Family Health Team Initiative

Primary health care (PHC) mandates the provision of services delivered by a collaborative team of providers, ultimately to improve quality of care and health status. Considering the challenges related to interprofessional collaboration within novel PHC models, we explored how the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) could facilitate the enactment of PHC teams. The Canadian Family Health Team (FHT) initiative is used as an example. This paper will explore how the ICF could inform the development of a practice model to enable PHC. Three potential barriers to the envisioned enactment of PHC within the espoused Canadian FHT initiative are identified through a critical gaps analysis; lack of (i) philosophical grounding, (ii) developmental and operational directives, and (iii) evaluation methods. An ICF-informed practice model is proposed to overcome these potential barriers. It is argued that the proposed ICF-informed practice model has international implications as a unifying conceptual framework ideally situated to facilitate the provision of comprehensive evidence-based person-centered care by interprofessional collaborative teams within diverse PHC models.

Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalisation

PURPOSE

To present a systematic literature review on the state of the art of the utilisation of the International Classification of Functioning, Disability and Health (ICF) since its release in 2001.

METHOD

The search was conducted through EMBASE, MEDLINE and PsychInfo covering the period between 2001 and December 2009. Papers were included if ICF was mentioned in title or abstract. Papers focussing on the ICF-CY and clinical research on children and youth only were excluded. Papers were assigned to six different groups covering the wide scenario of ICF application.

RESULTS

A total of 672 papers, coming from 34 countries and 211 different journals, were included in the analysis. The majority of publications (30.8%) were conceptual papers or papers reporting clinical and rehabilitation studies (25.9%). One-third of the papers were published in 2008 and 2009.

CONCLUSIONS

The ICF contributed to the development of research on functioning and on disability in clinical, rehabilitation as well as in several other contexts, such as disability eligibility and employment. Diffusion of ICF research and use in a great variety of fields and scientific journals is a proof that a cultural change and a new conceptualisation of functioning and disability is happening.

Intensity modulated radiotherapy (IMRT) in the management of locally advanced oropharyngeal squamous cell carcinomata (SCC): disease control and functional outcome using the therapy outcome measure (TOM) score--report from a single U.K. institution

Introduction

This paper evaluates tumour control and toxicity especially in relation to swallowing dysfunction in those patients with locally advanced oropharyngeal squamous cell carcinoma who have undergone either primary chemo-radiation or post-operative parotid sparing IMRT. The TOM scoring system was used to assess dysphagia.

Methods

All patients with locally advanced (stage 3/4) squamous cell oropharyngeal cancer and who required either primary or post-operative RT were identified. Toxicity was recorded prospectively. The TOM score (0-5 where 5 indicates that the patient is able to eat a normal diet and 0-2 varying degrees of enteral feeding dependency), weights and trismus was recorded immediately prior to and following radiotherapy.

Results

24 patients were identified between 1/2003 and 11/2007. Median weight loss during radiotherapy was 9 kg. All but one patient had a gastrostomy (RIG) tube inserted prophylactically. With a mean follow-up of 37.1 months, 62.5% of pts had a TOM score of 5, 12.5% scored 3, 8% scored and 17% scored 0-2.. For those patients whose swallowing function did recover, it took on average 8.7 months. 15% patients experienced trismus secondary to radiotherapy. 2 year overall survival was 92% and disease specific survival 96%.

Conclusion

Excellent disease control with intensified schedules of radiotherapy with IMRT has been achieved in this patient population. Intermediate toxicity is significant but with longer follow-up, dysphagia continues to improve with 75% of patients not requiring any form of enteral or oral supplementation.

Introducing a new health-related quality of life outcome tool for metastatic disease of the spine: content validation using the International Classification of Functioning, Disability, and Health; on behalf of the Spine Oncology Study Group

STUDY DESIGN

A systematic review of Health Related-Quality of Life Outcomes (HRQOL) in metastatic disease of the spine and content validation of a new Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ).

OBJECTIVE

To identify HRQOL questionnaires previously reported for spinal metastases and to validate the content of the new SOSGOQ based on the International Classification of Function and Disability (ICF).

SUMMARY OF BACKGROUND DATA

Literature on metastatic tumors of the spine and clinical outcomes is limited and generally of poor quality. The SOSG has developed a "quality of life" outcome tool specific for patients with metastatic of the spine. The ICF is a universal framework allowing content exploration, comparison, and validation of all questionnaires relating to HRQOL.

METHODS

A systematic review identified 141 studies. Reported outcome tools were enumerated. The most commonly used (ESAS, Karnofsky Scale, and Oswestry Disability Index) and the SOSGOQ were linked to the ICF. Descriptive statistics examined the frequency and specificity of the ICF linkage. Linkage reliability was evaluated by interinvestigator percentage agreement.

RESULTS

The SOSGOQ contains 56 concepts, with all 4 domains of the ICF represented. Four concepts could not be linked. There was 100% interobserver agreement (IOA) for total number of concepts and for those "not covered." Hundred percent of concepts had "First and Second" level linkage. Hundred percent IOA exists at both "Component" and "First Level" linkage. There was 96.1% IOA at "Second Level". Thirty-three concepts linked to Third Level with 96.9% IOA. Ten concepts linked at the Fourth Level with 100% IOA.

CONCLUSION

The SOSGOQ includes all domains relevant for measurement of function and disability and its content validity is confirmed by linkage with the ICF. This new questionnaire has superior content capacity to measure disease burden of patients with metastatic disease of the spine than any instruments previously identified in the literature.

Development of ICF core sets for head and neck cancer

BACKGROUND

Based on the International Classification of Functioning (ICF)-Disability and Health, participants from different professional and cultural backgrounds were invited to achieve consensus on a first version of ICF Core Set for head and neck cancer (HNC). It was designed to set standards for the assessment of functioning in HNC.

METHODS

The ICF was adopted by the World Health Organization (WHO) in 2001 and was used as the frame of reference. Preselection of potential ICF categories was based on 4 different preparatory studies: patient interviews, health professional surveys, literature review, and multicenter study applying ICF-nomenclature. After training on the ICF, the results of preparatory studies were presented to 21 invited participants to vote in a formal consensus process on both the Brief and Comprehensive ICF Core Set for HNC. Participants came from all 6 WHO world regions, covering 12 different countries. Professional backgrounds included otorhinolaryngologists, maxillofacial surgeons, medical/radiation oncologists, psychologists, physiotherapists, nurses, and social workers.

RESULTS

The Comprehensive ICF Core Set for HNC included 112 categories (8% of entire ICF) and the Brief ICF Core Set for HNC included 19 categories (1% of ICF).

CONCLUSION

A first version of ICF Core Sets for HNC was defined. Further validation is in process.

Disability in inflammatory bowel diseases: developing ICF Core Sets for patients with inflammatory bowel diseases based on the International Classification of Functioning, Disability, and Health

The inflammatory bowel diseases (IBDs) are associated with a reduced quality of life. The impact of IBD on disability remains largely unknown. With the International Classification of Functioning, Disability, and Health (ICF) of the World Health Organization (WHO), we can now rely on a globally agreed-upon framework and system for classifying the typical spectrum of problems in the functioning of persons with a specific disease given the environmental context in which they live. The aim of this article is to outline the methods to be utilized to develop ICF Core Sets for IBD. The project is a cooperation between the ICF Research Branch of the WHO, the IPNIC group, the International Society of Physical Rehabilitation Medicine (ISPRM), and the International Organization on Inflammatory Bowel Disease (IOIBD). Four worldwide studies will be conducted from 2009 to 2010. ICF categories relevant for IBD will be identified by systematic literature review of outcomes and measures used in IBD research, semistructured patient interviews, Internet-based expert survey, and cross-sectional study for clinical applicability. The final definition of ICF Core Sets for IBD will be determined at a Consensus Conference. Field testing will then be used to validate the ICF Core Sets. ICF Core Sets are being designed to provide useful standards for research and clinical practice. This tool will enable research that improves understanding of functioning, disability, and health in IBD, and may lead to interventions to improve and maintain functioning and minimize disability among IBD patients throughout the world.

How to apply the ICF and ICF core sets for low back pain

OBJECTIVE

To introduce the International Classification of Functioning, Disability and Health (ICF) as conceptual model and classification and the ICF Core Sets as a way to specify functioning for a specific health condition such as Low Back Pain, and to illustrate the application of the ICF and ICF Core Sets in the context of clinical practice, the planning and reporting of studies and the comparison of health status measures.

METHODS

A decision-making and consensus process was performed to develop the ICF Core Sets for Low Back Pain, the linking procedure was applied as basis for the content comparison of health-status measures and the Rehab-Cycle was used to exemplify the application of the ICE and ICF Core Sets in clinical practice.

RESULTS

Two different ICF Core Sets, namely, a comprehensive and a brief, are presented, three different health-status measures were linked to the ICF and compared and a case example of a patient with Low back Pain was described based on the Rehab-Cycle.

DISCUSSION

The ICF is a promising new framework and classification to assess the impact of Low Back Pain. The ICF and practical tools, such as the ICF Core Sets for Low Back Pain, are useful for clinical practice, outcome and rehabilitation research, education, health statistics, and regulation.

A framework for assessment in oncology rehabilitation

Although the incidence of cancer in the United States is high, improvements in early diagnosis and treatment have significantly increased survival rates in recent years. Many survivors of cancer experience lasting, adverse effects caused by either their disease or its treatment. Physical therapy interventions, both established and new, often can reverse or ameliorate the impairments (body function and structure) found in these patients, improving their ability to carry out daily tasks and actions (activity) and to participate in life situations (participation). Measuring the efficacy of physical therapy interventions in each of these dimensions is challenging but essential for developing and delivering optimal care for these patients. This article describes the acute and long-term effects of cancer and its treatment and the use of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) as a basis for selection of assessment or outcome tools and diagnostic or screening tools in this population.

Developing core sets for persons with traumatic brain injury based on the international classification of functioning, disability, and health

The authors outline the process for developing the International Classification of Functioning, Disability, and Health (ICF) Core Sets for traumatic brain injury (TBI). ICF Core Sets are selections of categories of the ICF that identify relevant categories of patients affected by specific diseases. Comprehensive and brief ICF Core Sets for TBI should become useful for clinical practice and for research. The final definition of the ICF Core Sets for TBI will be determined at an ICF Core Sets Consensus Conference, which will integrate evidence from preliminary studies. The development of ICF Core Sets is an inclusive and open process and rehabilitation professionals are invited to participate.