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