Upload
bedirhan-ustun
View
819
Download
0
Tags:
Embed Size (px)
DESCRIPTION
DSM5 has changed the requirements for describing the clinical significance of a DSM category. Now there it is required that "impairment" criteria is specified in accordance with the ICF ( International Classification of Functioning Disability and Health ) and operationally measured with the WHODAS 2.0;
Citation preview
Dr T. Bedirhan ÜstünClassifications, Terminologies and Standards
World Health Organization
Clinical Significance:ICF and WHODAS 2.0
Clinical Significance:ICF and WHODAS 2.0
Statement of Potential Conflicts of Interest
Clinical Significance:
ICF and WHODAS2.0for measuring Disability
Relating to this presentation, the following relationships could be perceived as potential conflict of interests:
• work at the World Health Organization• Responsible for ICD, ICF
• Significantly involved in WHODAS2.0 development• Believes in Science
ICD-10 B24 HIV disease B24 HIV disease
ICF activity limitations performance restriction in:
Moving around (d455.44) Washing (d510.33) Education (d830.44)
…
Almost fully functional
moderate participation restriction in
Higher education (d830.03)
Separate Classification of Disease and Disability
Separate Classification of Disease and Disability
+ = case
Diagnosis Disability => better formulation of caseness
“Diagnosis” alone fails to predict:“Diagnosis” alone fails to predict:
service needs (National Advisory Mental Health Council 1993)
length of hospitalisation (McCrone and Phelan, 1994)
level of care (Burns, 1991)
outcome of hospitalization (Rabinowitz et al, 1994)
receipt of disability benefits (Massel et al, 1990; Segal and Choi, 1991; Basset
and Regier)
work performance (Gatchel et al, 1994; Massel et al, 1990)
social integration (Ormel et al, 1993)
Dx + “Disability” can predict:Dx + “Disability” can predict:
health service utilization (Hoeper et al 1979; Regier et al, 1985; Basset and Folstein, 1991; Von Korff et al, 1992; Ormel et al, 1993)
Length of Hospitalization (Horn, 1990)
Outcome after hospitalization (Rabinowitz et al, 1994)
return to work (Hlatky et al, 1986)
work performance (Massel et al, 1990)
recovery of social integration (Tate, 1989)
Added Value of Disability InformationPredictive power
13%8%
19%28%
100%100%
150%123%
OR 1
OR 1
OR 1
OR 14
OR 4
OR 15
Functioning Information
Operationalization of DiagnosisOperationalization of Diagnosis
ICDA Specific phenomenology
B Signs and Symptoms
C ….
D Exclusion rules
DSMA Specific phenomenology
B Signs and Symptoms
C DISABILITY & DISTRESS
D Exclusion rules
RecommendationsRecommendations
1. DSM 5 should adopt an unambiguous and internationally harmonious terminology and conceptual approach for functioning and disability.
• Use ICF compatible terminology and definitions.
• Operationalize separate assessments of symptoms, severity and disability.
ICF & WHODAS 2.0 ICF & WHODAS 2.0
What is ICF ? What is ICF ?
What is WHODAS 2.0 ?What is WHODAS 2.0 ?
– A generic assessment instrument for measuring health and disability – in clinical practice– at population level
– captures the level of functioning in six domains of life
1: Cognition understanding and communicating
2: Mobility moving and getting around
3: Self-care hygiene, dressing, eating and staying alone
4: Getting along interacting with other people
5: Life activities domestic responsibilities, leisure, work and school
6: Participation joining in community activities, participating in society
– provides a disability profile and a summary measure • that is reliable • applicable across cultures, in all adult populations
Summing up different dimensions combination of multiple vectors of functioningSumming up different dimensions
combination of multiple vectors of functioning
Vision
Hearing
Mobility
Social Activities
Work
Cognition
Selfcare
Disease Status (ICD - DSM)
Information about Illness, disorder, injury, trauma
Functional Status (ICF)
Information about functioning@ body level: IMPAIRMENTS@ person level: ACTIVITIES@ societal level: PARTICIPATION +
impact of person’s ENVIRONMENT (barriers/facilitators)
Quality of Life
Subjective well-being, satisfaction
Where is WHODAS 2.0
in the context of Health Status information? Where is WHODAS 2.0
in the context of Health Status information?
WHODAS 2.0
WHOQoL
Why use WHODAS 2.0? Why use WHODAS 2.0?
Direct conceptual link to the International Classification of Functioning, Disability and Health (ICF)
Cross-cultural comparability
Good Psychometric Properties
Ease of use and availability
WHODAS 2.0Development Centres
WHODAS 2.0Development Centres
Seattle
LimaIbadan
SantanderLuxembourg
LondonAmsterdam
Hamburg
AnkaraAthens
Bangalore
Beijing TokyoVienna
Delhi Madras
Santiago
Mexico City Havana
Michigan
New YorkSt. LouisPitsburg
Moscow
Pnom Peng
Tmisora
TunisiaLebanon
WHO DAS CENTREST. Kugener Austria
K. Hourn Cambodia
G. Yao China
J. Saiz Cuba
V. Mavreas Greece
S. Murthy India
H. Pal India
R. Thara India
U. Nocentini Italy
M. Tazaki Japan
E. Karam Lebanon
C. Pull Luxembourg
H. Hoek Netherlands
B. Odejide Nigeria
J. Segura Garcia Peru
R. Vrasti Romania
D. Veltischev Russia
J.-L. Vazquez-Barquero Spain
N.Glozier UK
P. Doyle USA
D. Hasin USA
TASK FORCE MEMBERS: M. von Korff USA (HSR TF Chair)
C. Pull Luxembourg (AI TF Chair)
E. Badley Canada
K. Ritchie France
D. Wiersma Netherlands
M. Prince U.K.
R. Kessler USA
R. Trotter USA
NIH Staff
D. Regier, C. Kennedy, K. Magruder NIMH
B. Grant NIAAA
J. Blaine NIDA
WHO STAFF
T.B. Ustun , N. Kostansjek
S. Chatterji, J. Rehm
WHODAS 2.0 Development TEAM
Conceptual equivalence of Disability Assessment
– Language
– Norms, Values , beliefs
– Classification differences
– Context differences
Translatability
Usability
Cross-population comparability
Structure of WHODAS 2.0Structure of WHODAS 2.0
Full version (36-item)– provides most detail – allows to compute overall and 6 domain specific functioning scores – available as interviewer-, self- and proxy-administered forms– average interview time: 20 min.
Short version (12-item)– useful for brief assessments of overall functioning in surveys or health-outcome studies – allows to compute overall functioning scores – explains 81% of the variance of the 36-item version– available as interviewer-, self- and proxy-administered forms– average interview time: 5 min.
Hybrid Versions (12+24-item) – uses 12 items to screen for problematic domains of functioning. – Based on positive responses to the initial 12 items, respondents may be given up to
24 additional questions. – can only be administered by interview or computer-adaptive testing (CAT)
WHODAS 2.0 factor structure WHODAS 2.0 factor structure
WHODAS 2.0 reliability: test–retest summary
WHODAS 2.0 reliability: test–retest summary
WHODAS 2.0 Meaningful distinctions among subgroups
WHODAS 2.0 Meaningful distinctions among subgroups
WHODAS 2.0 Concurrent Validity Summary
WHODAS 2.0 Concurrent Validity Summary
SF QOL LHS FIM1 Cognition -.56 -.482 Mobility -.82/-.59 -.60/-.68 -.70 -.80 3 Self Care -.58/-.76 -.47 -.694 Interpersonal -.54 -.36/-.57 -.62 -.375 Work & Home -.54/-.46 -.516 Participation -.69 -.39
WHODAS 2.0 relationship with work disability
WHODAS 2.0 relationship with work disability
WHODAS 2.0 Score
Days with reduced household tasks
Days missed work for half day or more
Cognition .28 .15
Mobility .42 .31
Self Care .48 .40
Interpersonal .33 .28
Work & Household .68 .58
Participation .53 .49 TOTAL
.63
.52
WHODAS 2.0Responsiveness in depressed subjects
WHODAS 2.0Responsiveness in depressed subjects
0.8
1.07
0.44
0.72
0.74
0.81
1.32
0.23
0 0.2 0.4 0.6 0.8 1 1.2 1.4
Outpatient care(Mexico City)
Outpatient care(Ibadan, Nigeria)
Outpatient care ofelderly (London, UK)
Primary health care(Seattle, USA)
WHODAS 2.0 Comparator
Effect size (mean/SD)
LHS
LHS
SF-36 (MCS)
SF-36 (MCS)
N = 100
N = 60
N = 40
N = 73
WHO DAS II Responsiveness in schizophrenia subjects
WHO DAS II Responsiveness in schizophrenia subjects
1.03
1.38
0.65
0.86
0 0.2 0.4 0.6 0.8 1 1.2 1.4
Outpatient care(Cuba)
Outpatient care -newly treated
(Beijing, China)
WHODAS 2.0 Comparator
Effect size (mean/SD)
LHS
SF-12 (MCS)
N = 50
N = 50
WHODAS 2.0 Responsiveness in other conditions
WHODAS 2.0 Responsiveness in other conditions
1.25
0.77
0.59
1.19
0.58
0.42
0 0.2 0.4 0.6 0.8 1 1.2 1.4
Alcohol dependencerehab. (Romania)
Hip / kneearthoplasty
(London, UK)
Primary care of lowback pain (Seattle,
US)
WHODAS 2.0 Comparator
Effect size (mean/SD)
LHS
SF-12 (PCS)
LHS
N = 80
N = 72
N = 76
CLASSIFICATIONS … BUILDING BLOCKS OF HEALTH INFORMATION …
Population distribution of IRT-based scores for WHODAS 2.0 – Full version
Population distribution of IRT-based scores for WHODAS 2.0 – Full version
Mobility VignettesMobility Vignettes
Paul: active athlete who runs long distance races of 20 kilometres
Mary: has no problems with moving around or using her hands, arms and legs. She jogs 4 kilometres twice a week
Rob: is able to walk distances of up to 200 metres without any problems but feels breathless after walking one km.
Margaret: feels chest pain and gets breathless after walking distances of up to 200 metres, but is able to do so without assistance. Bending and lifting objects such as groceries produces pain.
Louis: is able to move his arms and legs, but requires assistance in standing up from a chair or walking around the house. Any bending is painful and lifting is impossible.
David: paralysed from the neck down; is confined to bed and must be fed and bathed by somebody else
Calibration Tests Calibration Tests
Mobility: variation of standard PosturoLocomotor Test.
Vision: a standard vision chart (Snellen)
Cognition:
– simple memory: 10 objects given, immediate recall & 20mn
recall
– cancellation test: a combined test of attention, task execution
– fluency: naming as many as animals in 1 minute.
Applications of WHODAS 2.0: Population surveys
Applications of WHODAS 2.0: Population surveys
Multi-country studies/applications– WHO Multi Country Survey Study (MCSS)
– World Mental Health Survey (WMHS)
– Global Study on Aging (SAGE)
– Tsunami Recovery Impact Assessment and Monitoring System (TRIAMS)
– WHO/UNESCAP project on disability statistics
Country studies– Ireland’s National Physical and Sensory Disability Database (NPSDD)
– National Health Performance Assessment Survey (Mexico)
– First National Study on Disability (Chile)
– US VA Twin Registry
Clinical applications of WHODAS 2.0Clinical applications of WHODAS 2.0
Disease specific validation studies / health outcome assessment – inflammatory arthritis – stroke– systemic sclerosis – anxiety disorders – hearing loss– psychotic disorders– schizophrenia – HIV/AIDS– depression – low back pain– ankylosing spondylitis– Injuries– …
Setting specific validation studies / health outcome assessment– General practitioners – Clinical rehabilitation– Community based care for the elderly – …
RecommendationsRecommendations
1. DSM 5 should adopt an unambiguous and internationally harmonious terminology and conceptual approach for functioning and disability.
• Use ICF compatible terminology and definitions.
• Operationalize separate assessments of symptoms, severity and disability.
ICD11 βetaICD11 βetahttp://www.who.int/classifications/icd/revision
Beta – Browser & Print 10 look & feel + descriptions – code structure !
• ICD-11 Beta draft is NOT FINAL
• updated on a daily basis
• NOT TO BE USED for CODING except for agreed FIELD TRIALS
βeta
THE CONTENT MODELAny Category in ICD is represented by:
THE CONTENT MODELAny Category in ICD is represented by:
1. ICD Concept Title1.1. Fully Specified Name
2. Classification Properties2.1. Parents2.2 Type2.3. Use and Linearization(s)
3. Textual Definition(s)
4. Terms4.1. Base Index Terms4.2. Inclusion Terms4.3. Exclusions
5. Body Structure Description 5.1. Body System(s) 5.2. Body Part(s) [Anatomical Site(s)]5.3. Morphological Properties
6. Manifestation Properties6.1. Signs & Symptoms 6.2. Investigation findings
7. Causal Properties7.1. Etiology Type7.2. Causal Properties - Agents7.3. Causal Properties - Causal Mechanisms 7.4. Genomic Linkages7.5. Risk Factors
8. Temporal Properties8.1. Age of Occurrence & Occurrence Frequency8.2. Development Course/Stage
9. Severity of Subtypes Properties
10. Functioning Properties10.1. Impact on Activities and Participation10.2. Contextual factors10.3. Body functions
11. Specific Condition Properties11.1 Biological Sex11.2. Life-Cycle Properties
12.Treatment Properties
13. Diagnostic Criteria
Mental Health and Rest of MedicineMental Health and Rest of Medicine
• Parity
– Common Information Model
– Disease definition: • Dimensions – Categories - Thresholds
– Formulation of Disability
– Use in electronic health records
John NASH: “A Brilliant Mind”1996 WPA Congress
John NASH: “A Brilliant Mind”1996 WPA Congress
My irrational “dreams”, as I call them, and my mathematical thoughts bothcame from the same place, same source …
In time, I kind of created my own thought police in my mind, I then came to recognize my own irrationality
Additional InformationAdditional Information
International Classification of Functioning, Disability and Health
http://www.who.int/classifications/icf/en/
World Health Organization Disability Assessment Schedule 2 http://www.who.int/icf/whodasii/index.html
Developing the World Health Organization Disability Assessment Schedule 2.0 http://www.who.int/bulletin/volumes/88/11/09-067231.pdf