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30 Musculoskeletal & Neurological Rehabilitation KCE reports 57 measures in rehabilitation” delivered a link to the Pro-Esor-study “The use of outcome measures in physical medicine and rehabilitation in Europe” 90 . The aim of the study was to survey the use of outcome measures in rehabilitation within Europe. The survey focused on nine diagnostic groups: hip and knee replacement, low back pain, lower limb amputees, multiple sclerosis, neuromuscular disorders, rheumatoid arthritis, spinal cord lesions, stroke and traumatic brain injury. It identified a relatively small number of dominant outcome assessments for each diagnostic group and some variation in the preference for measures across regions. The five diagnostic groups selected for this project were included although the described methodology can be extended to other pathologies. A comparable study was performed in Australia “Outcome measurement in Australian rehabilitation environment” 91 . For this study the original survey questionnaire of the Pro- Esor study was used. Three of the five diagnostic groups selected for our project were included. 3.2.2 Outcome measures used in rehabilitation 3.2.3 Discussion The results of the Pro-Esor Study and the Australian study for the 5 selected pathologies are included (See Appendix to chapter 3). For each pathology the most frequently applied outcome measures are listed based respectively on a survey of 418 rehabilitation centres across Europe and 440 across Australia. An outcome measure supports by preference clinical decision making as well as resource allocation. This outcome measure must be applicable for most diagnostic groups and must be useful to groups of individuals needing comparable resources. FIM is the only instrument used for outcome measurement in each diagnostic group. Barthel Index is used in nearly each diagnostic group. In literature both outcome measures are considered as competing instruments 92, 93 . Appropriateness and responsiveness of outcome measures such as FIM and BI requires an extensive search of the literature. FIM and BI are tools measuring level of dependence related to activities of daily living. The results of this measurement can be used to estimate workload. But neither FIM nor Barthel Index measure rehabilitation needs. Nevertheless, they are currently used to classify patients into homogeneous groups related to resource consumption during rehabilitation (LOS). 3.3 OUTCOME MODELS 3.3.1 International Classification of Functioning, Disability and Health (ICF) For this project, the concept of an outcome model is used. Several interpretations of this term exist. Within the framework of this project an ‘outcome model’ is considered as a structured compilation of all possible outcomes as a consequence of a health condition. An outcome model is required to identify individuals with different types of disabilities or to examine the effect of interventions. One common classification system for clinical decision making as well as resource allocation could not be found in literature. The reason might be that clinical relevant outcomes can differ from one health condition to another and thus give rise to many subgroups. Within a payment model, subgroups need to be limited, otherwise the model becomes impractical . ICF is an ‘outcome model’. The project team as well as the expert panel agreed on the use of this model because it is a member of the WHO Family of international classifications and it is internationally considered as the most complete set of possible outcomes as a consequence of a health condition. The WHO worked previously with the International Classification of Impairments, disabilities and handicaps (ICIDH) b (= the model preceding ICF), a model proposed by Saad Nagi from the Institute of Medicine and the National Advisory Board on Medical Rehabilitation Research model 94 95 . b http://www.cdc.gov/nchs/about/otheract/icd9/icfhome.htm
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 31 For information on the ICF, the website of the WHO c , the website of the International Classification of Functioning, disability and health d , and the website of ICF Research Branch, WHO FIC Collaborating Center (DIMDI), Institute for Health and Rehabilitation Sciences, Ludwig-Maximilian University in Munich e , were consulted. Publications of Prof. Gerold Stucki, MD, MS, director of the ICF Research Branch of the WHO, were searched on Pubmed. Opinions about the use of the ICF were collected by expert contacts. Expert selection was based on references mentioned in publications or on references of contacted experts. The International Classification of Functioning, Disability and Health is the result of the revision of the ICIDH. ICF is endorsed by the World Health Assembly as a member of the WHO Family of International Classifications in 2001. It is the generally accepted framework to describe functioning in rehabilitation. The joint use of ICF and the International Classification of Diseases ICD-10, needs to be addressed when applying the ICF to rehabilitation medicine. WHO considers the ICF and the ICD-10 to be distinct but complementary classifications. ICF is structured around the following broad components (Figure 3.1): Figure 3.1: ICF model Body function & structure (Impairment) ICF 2001 Interaction of Concepts Health Condition (disorder/disease) Environmental Factors Activities (Limitation) Personal Factors Participation (Restriction) Functioning and disability are viewed as a complex interaction between the health condition of the individual and the contextual factors (environmental an personal). The picture produced by this combination of factors and dimensions is of "the person in his or her world". Within ICF these dimensions are considered as interactive and dynamic rather than linear or static. It allows an assessment of the degree of disability, although it is not a measurement instrument. It rather defines “what to measure”. ICF can contribute to the integration of the results of different outcome measures. ICF must be compatible with these measures. Items of assessment instruments used in rehabilitation should be linked to ICF domains. ICF linking rules 96 are being developed to link technical and clinical measures, health-status measures and interventions to ICF. It will be essential to know how scores from a specific assessment instrument can be mapped to the scores used in the ICF. ICF scores represent ‘performance’ in real life or ‘capacity’ (with or without assistance), typically in a rehabilitation test situation. However, the most widely used instruments in acute and sub-acute rehabilitation, including FIM, measure c http://www.who.int/classifications/icf/en/ d http://www3.who.int/icf/icftemplate.cfm e http://www.icf-research-branch.org/aboutus/history.htm
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35. Etude relative aux coûts poten
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