The international classification for functioning, disability and health

Individual and institutional factors associated with functional disability in nursing home residents: An observational study with multilevel analysis

Background

High prevalence of functional limitations has been previously observed in nursing homes. Disability may depend not only on the characteristics of the residents but also on the facility characteristics. The aims of this study were: 1, to describe the prevalence of functional disability in older people living in Spanish nursing homes; and 2, to analyze the relationships between individual and nursing home characteristics and residents’ functional disability.

Methods

A cross-sectional study with data collected from 895 residents in 34 nursing homes in the province of Albacete (Spain) was conducted. Functional status was assessed by the Barthel Index. Taking into account both levels of data (individual and institutional characteristics) we resorted to a multilevel analysis in order to take different sources of variability in the data.

Results

The prevalence of functional disability of the total sample was 79.8%. The best fitting multilevel model showed that female gender, older age, negative self-perception of health, and living in private nursing homes were factors significantly associated with functional disability. After separating individual and institutional effects, the institutions showed significant differences.

Conclusions

In line with previous findings, our study found high levels of functional dependence among institutionalized elders. Gender, age, self-perception of health, and institution ownership were associated with functional status. Disentangling individual and institutional effects by means of multilevel models can help evaluate the quality of the residences.

Instrumented BASFI (iBASFI) Shows Promising Reliability and Validity in the Assessment of Activity Limitations in Axial Spondyloarthritis

OBJECTIVE

The Bath Ankylosing Spondylitis Functional Index (BASFI) is the most popular method to assess activity capacity in axial spondyloarthritis (axSpA), to our knowledge. It is endorsed by the Assessment of Spondyloarthritis international Society. But it may have recall bias or aberrant self-judgments in individual patients. Therefore, we aimed to (1) develop the instrumented BASFI (iBASFI) by adding a body-worn accelerometer with automated algorithms to performance-based measurements (PBM), (2) study the iBASFI's core psychometric properties, and (3) reduce the number of iBASFI items.

METHODS

Twenty-eight patients with axSpA wore a 2-axial accelerometer while completing 12 PBM derived from the BASFI. A chronometer and both manual and "automated algorithm-based" acceleration segmentation identified movement time. Test-retest trials and methods (algorithm vs manual segmentation/chronometer/BASFI) were compared with ICC, standard error of measurement [percentage of movement time (SEM%)], and Spearman ρ correlation coefficients. Linear regression identified the optimal set of reliable iBASFI PBM.

RESULTS

Good to excellent test-retest reliability was found for 8/12 iBASFI items (ICC range 0.812-0.997, SEM range 0.4-30.4%), typically with repeated and fast movements. Automated algorithms excellently mimicked manual segmentation (ICC range 0.900-0.998) and the chronometer (ICC range 0.878-0.998) for 10/12 iBASFI items. Construct validity compared with the BASFI was confirmed for 7/12 iBASFI items (δ range 0.504-0.755). Together, sit-to-stand speed test (stBeta 0.483), cervical rotation (stBeta -0.392), and height (stBeta -0.375) explained 59% of the variance in the BASFI (p < 0.01).

CONCLUSION

The proof-of-concept iBASFI showed promising reliability and validity in measuring activity capacity. The number of the iBASFI's PBM may be minimized, but further validation in larger axSpA cohorts is needed before its clinical use.

Patients with well-established ankylosing spondylitis show limited deterioration in a ten-year prospective cohort study

This study aims to describe the deterioration of well-established ankylosing spondylitis (AS) over a 10-year period. Patients with well-established AS under secondary care review were assessed at baseline and re-assessed after a 10-year period. Data on patient characteristics, spinal mobility and self-reported health status (AS Quality of Life, Bath AS Disease Activity Index, EuroQoL, Revised Leeds Disability Questionnaire and Short Form-12) were compared between the two time points. One hundred fifty-nine patients took part in the initial assessment. After 10 years, 69/117 patients still under secondary care follow-up attended a second assessment. At the second assessment, this cohort was predominately male (92.8 %), mean age of 48.7 years (SD 9.7) and mean disease and symptom duration of 14.9 (SD 9.0) and 21.9 years (SD 13.3), respectively. Amongst the physical and patient-reported measures, only tragus to wall (p < 0.001), cervical rotation (p = 0.001) and disability (p = 0.02) had significantly deteriorated over time. The percentage of patients who had withdrawn from the workforce before normal retirement age increased from 37 to 53 % over the 10-year period. Many of the measures used in the assessment of AS do not generally deteriorate over time in those with well-established disease. This suggests that deterioration may plateau in established disease. However, AS has a long-term social impact with levels of employment in this cohort 30 % lower than the general population. Interventions directed at preventing deterioration may be more effective earlier in their disease course, before this plateau is reached.

Work participation and work transition in patients with systemic sclerosis: a cross-sectional study

OBJECTIVES

To describe work participation and work transition due to health in patients with SSc. Associations are assessed between having made a work transition or not and factors possibly influencing that transition.

METHODS

This study included patients visiting the Scleroderma Clinic of the Ghent University Hospital, who regularly undergo an extensive evaluation. For this study, a questionnaire was used to collect work participation and work transition data.

RESULTS

Eighty-four patients in the adult working-age population were included. Thirty-eight (45%) out of 84 patients participated in the labour force. Forty-six (55%) out of 84 were not engaged in a paid job; in 34 (74%) out of 46 patients this was attributed to health issues. Seventy-six (90%) out of 84 patients made a work transition. Forty-seven (62%) out of 76 made that transition due to health reasons. The group that made a health-related work transition (47/84, 56%) was compared with the remaining group (37/84, 44%) that made no work transition or a work transition for reasons other than health. There was a significant difference in educational level, skin score, lung disease severity, disease activity, disease duration, scleroderma Health Assessment Questionnaire (sHAQ), visual analogue scale (VAS) for RP, VAS for intestinal disease, VAS for overall disease, VAS for pain, Medical Outcomes Study short form 36 (SF-36), work statute and willingness to participate in training. The multivariate analysis retained sHAQ, SF-36 and disease duration as associating variables.

CONCLUSIONS

Work participation is limited in patients with SSc and a majority make a work transition because of health problems. Demographic, disease- and work-related variables, as well as willingness to participate in training are associated with (the occurrence of) work transition.

The rheumatoid foot: a systematic literature review of patient-reported outcome measures

BACKGROUND

The foot is often the first area of the body to be systematically affected by rheumatoid arthritis. The multidimensional consequences of foot problems for patients can be subjectively evaluated using patient-reported outcome measures (PROMs). However, there is currently no systematic review which has focused specifically upon the PROMs available for the foot with rheumatoid arthritis. The aim of this systematic review was to appraise the foot-specific PROMs available for the assessment and/or evaluation of the foot affected with rheumatoid arthritis.

METHODS

A systematic search of databases was conducted according to pre-defined inclusion/exclusion criteria. PROMs identified were reviewed in terms of: conceptual bases, quality of construction, measurement aims and evidence to support their measurement properties.

RESULTS

A total of 11 PROMs were identified and 5 papers that provided evidence for the measurement properties of some of the PROMs. Only one of the PROMs was found to be RA disease-specific. The quality of construction, pretesting and presence of evidence for their measurement properties was found to be highly variable. Conceptual bases of many of the PROMs was either restricted or based on reductionist biomedical models. All of the PROMs were found to consist of fixed scales.

CONCLUSIONS

There is a need to develop an RA-disease and foot-specific PROM with a greater emphasis on a biopsychosocial conceptual basis, cognitive pre-testing methods, patient preference-based qualities and evidence to support the full complement of measurement properties.

Evaluation of quality of life in relation to anxiety and depression in primary Sjögren's syndrome

The aim of this study was to evaluate health-related quality of life (HR-QOL) in patients with primary Sjögren's syndrome (pSS) using both Short-Form 36 (SF-36) and World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF) questionnaires and to determine the effects of anxiety and depression on HR-QOL using the Hospital Anxiety-Depression Scale (HADS). In this cross-sectional study, 107 female patients with pSS (mean age 54.10 ± 10.2 years), fulfilling US-European Consensus Criteria and 109 female controls (mean age 53.4 ± 10.9 years) were included. Student's t test, Mann-Whitney U test, and analysis of variance (ANOVA) were used for statistical analysis. P values > 0.05 were accepted as significant. All domains of the SF-36, with the exception of "Vitality", and all domains of the WHOQOL-BREF with the exception of "Environment", were significantly lower in pSS patients compared with healthy controls. In pSS patients having anxiety according to HADS, the scores of all domains of WHOQOL-BREF were significantly lower, and in patients having depression according to HADS, three of four domains of WHOQOL-BREF were significantly lower compared with the rest of the group. However, the scores of two domains of the SF-36, namely "Role-Physical" and "Role-Emotional" domains, were significantly higher in pSS patients having depression according to HADS. We confirmed the presence of impaired HR-QOL in pSS. Whereas the presence of anxiety and/or depression generally showed a negative affect on HR-QOL, interestingly, depression seemed to improve the scores of "Role-Physical" and "Role-Emotional" domains of the SF-36. This surprising finding might be related to adaptation to changing health. Social support based upon cultural traditions might also have contributed.

Which aspects of functioning are relevant for patients with ankylosing spondylitis: results of focus group interviews

OBJECTIVE

To investigate whether concepts important to patients with ankylosing spondylitis (AS) are covered by disease-specific self-report health status instruments.

METHODS

A qualitative focus group study was conducted with AS patients on problems in daily functioning. Group sessions with 4 to 5 patients each were organized up to the point that no new information was brought forward. Group sessions were tape-recorded, transcribed, and divided into meaning units. Concepts contained in the meaning units were extracted. Self-report instruments on health status specific for AS were identified in a literature search. Using the International Classification of Functioning, Disability and Health (ICF) as a common reference, it was determined whether the concepts identified in the focus groups were covered by the instruments.

RESULTS

Nineteen patients participated in 4 focus group interviews. In total, 332 unique meaning units were linked to 90 second-level ICF categories, of which 25 referred to body functions, 10 to body structures, 35 to activities and participation and 30 to environmental factors. In addition, several concepts relating to personal factors were identified. Only 47 categories were also covered by one of the self-report instruments in AS. Only a minority of concepts addressed by the AS-specific questionnaires were not revealed as relevant in the interviews.

CONCLUSION

Relevant aspects of the influence of AS are not covered by the classic disease-specific instruments. In particular, the influence of AS on socializing and leisure and the relevance of environmental and personal factors are not adequately assessed by available instruments.

Health-related quality of life, employment and disability in patients with Sjogren's syndrome

OBJECTIVE

To compare health-related quality of life (HR-QOL), employment and disability of primary and secondary SS (pSS and sSS, respectively) patients with the general Dutch population.

METHODS

HR-QOL, employment and disability were assessed in SS patients regularly attending the University Medical Center Groningen (n = 235). HR-QOL, employment and disability were evaluated with the Short Form-36 questionnaire (SF-36) and an employment and disability questionnaire. Results were compared with Dutch population data (matched for sex and age). Demographical and clinical data associated with HR-QOL, employment and disability were assessed.

RESULTS

Response rate was 83%. SS patients scored lower on HR-QOL than the general Dutch population. sSS patients scored lower on physical functioning, bodily pain and general health than pSS patients. Predictors for reduced HR-QOL were fatigue, tendomyalgia, articular involvement, use of artificial saliva, use of anti-depressants, comorbidity, male sex and eligibility for disability compensation (DC). Employment was lower and DC rates were higher in SS patients compared with the Dutch population.

CONCLUSION

SS has a large impact on HR-QOL, employment and disability.

OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

PURPOSE

To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

METHODS

Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale.

RESULTS

Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided.

CONCLUSION

Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.