Measuring Functional Health Status in the Chiropractic Office Using Self-Report Questionnaires
 
   

Measuring Functional Health Status in the
Chiropractic Office Using Self-Report Questionnaires

Our thanks to Aspen Publishers and "Topics in Clinical Chiropractic"
for permission to reproduce this article!
 
   

FROM:   Topics in Clinical Chiropractic 1994;   1 (1):   51–59

Christine M.H. Goertz, D.C.

Doctoral Student and Research Assistant Institute for Health Services Research School of Public Health,
University of Minnesota, Minneapolis, Minnesota


Abstract: Patient self-perception of the health care experience is becoming an important component of clinical outcomes assessment. In light of impending change toward more closely managed health care purchasing, chiropractors are being expected to document and quantify clinical progress. Functional health status instruments are an economic and efficient way of accomplishing the task. Two such instruments are presented in detail: the Dartmouth COOP charts and the RAND 36-Item Health Survey 1.0, the latter of which is included in its entirety for use in the office setting. Several other instruments are briefly summarized.

Key words:   chiropractic, functional health status, outcomes assessment


As National Health care reform is becoming a clinical reality, policymakers are forced to contend with the lack of information available regarding what constitutes good and effective health care. In light of the upcoming changes to the health care delivery system, all health care providers need to recognize that many current clinical practices have never been established as efficacious or appropriate. [ 1 ] Traditionally, outcomes of care have been measured according to quantifiable clinical outcomes based on the clinician's perspective or prognosis. [ 2 ] Greater emphasis is now being placed on measuring outcomes such as patient self-perception of the health care experience that may have more immediate value to the patient.

It is currently impossible to predict how national and regional health reform will ultimately affect either the chiropractic practitioner or the chiropractic patient. A new focus on assessment of the quality of care, however, with an emphasis on outcome measures that are important to the patient, [ 3 ] may provide an opportunity for more mainstream acceptance of treatment alternatives that have historically been patient oriented, such as chiropractic. Self-report questionnaires that measure functional health status are one of the patient-oriented outcomes assessment tools now available.


FUNCTIONAL HEALTH STATUS ASSESSMENT

Although the World Health Organization in 1948 defined health to include complete physical, psychologic, and social well-being, [ 4 ] and although the chiropractic profession has traditionally approached clinical problems from an integrated, patient-oriented perspective, it is only in the past decade that patient quality of life issues have been considered an area worthy of scientific or clinical emphasis by mainstream medicine. The scientific community often uses the terms quality of life, outcomes measurement, and functional health status assessment interchangeably, [ 2 ] but there does appear to be somewhat of a consensus regarding the core set of concepts that are important to the patient. These include physical functioning, mental and emotional well-being, social and role functioning, self-perceptions of general health, pain, energy, and vitality. [ 5 ]


ASSESSMENT OF FUNCTIONAL HEALTH STATUS IN THE CHIROPRACTIC OFFICE

Functional health status assessment using self-report questionnaires in the chiropractic office is important for several reasons. First, it allows the physician to quantify the general question "How are you feeling?" in a way that allows the physician, the patient, and third party payors to make comparisons of treatment effectiveness. Second, functional health status assessment improves communication between the physician and patient by focusing not only on location and severity of a specific condition but also on how that condition is affecting the patient both physically and emotionally. It is sometimes difficult to determine from a severity perspective alone the amount of distress the patient may be experiencing as a result of the presenting condition. Furthermore, research has shown that physicians have a tendency to underestimate the level of impairment of physical functioning that a patient perceives himself or herself to be experiencing. [ 6 ] Self-report questionnaires provide an opportunity to manage patient care from a perspective that is important to the patient. Finally, functional health status assessment allows the physician to monitor patient progress over time.

Functional health status is generally measured with the use of a carefully constructed self-report questionnaire that addresses at least some of the dimensions described above. A great deal of interest and energy has been put into the development, validation, and, more recently, the clinical implementation of health status assessment tools. The best approach to health status assessment is thought to involve the use of generic measures supplemented as necessary with problem-specific instruments. [ 5 ] Two such generic measures that are becoming more and more widely used by the traditional medical community and the chiropractic profession are the Dartmouth COOP charts and the RAND 36-Item Health Survey 1.0. These are short versions of more complex health status questionnaires, and each has generally been shown to address some patient problems as effectively as questionnaires that are longer and often more difficult for the patient to fill out. [ 7, 8 ] These instruments are presented in detail in Figs 1 through 9 and Appendix F. A brief description of other generic and specific instruments of possible use in chiropractic practice is presented as well.


THE DARTMOUTH COOP CHARTS

The Dartmouth COOP charts, developed in 1987, have been shown to be useful in assessing functional health status in patients with a variety of conditions. An overview of nine quality of life measures assessed by the charts has been presented previously in the chiropractic literature. [ 9 ] These measures are physical functioning, emotional functioning, daily activities/role functioning, social functioning/activities, pain, overall health, health change, quality of life, and social support/resources. A conceptual outline illustrating the instrument can be found in Figs 1 through 9 . The COOP charts are as capable of detecting the association between disease and functioning as longer measures that are considered more standard. The charts use a single item to capture an entire dimension of health status and are the shortest validated instrument available for clinical assessment of general health status.

The COOP charts are easily scored because each section has only one question that is evaluated on an ordinal scale from 1 to 5, with 1 representing no limitation and 5 representing the severest degree of limitation. They can be used to monitor patient progress, but their main strength is in assisting in physician-patient communication by giving the patient an opportunity to reveal functioning limitations that otherwise may not be mentioned. [ 10 ] The charts can be administered by a doctor of chiropractic or a trained staff person, or they can be self-administered by the patient. Because they are pictorial, they require little explanation and can generally be understood and completed even when a language barrier exists. [ 11 ] They take an average of 5 minutes for the patient to complete and can be easily integrated into the chiropractic office patient flow protocol.

The COOP charts have been demonstrated to be practical, reliable, valid, sensitive to the effects of disease, and useful for quickly measuring patient function. Furthermore, most health care providers and patients studied feel that the charts are easy to understand and to use. [ 6 ]   Permission to use the Dartmouth COOP charts must be obtained by both practitioners and researchers. This permission can be obtained by calling or writing Debbie Johnson, Dartmouth COOP Project, Dartmouth Medical School, Hanover, New Hampshire 03756, (603) 650-1974.


DOWNLOAD the RAND 36-Item Health Survey 1.0 as a Word document

The Medical Outcomes Study Short Form, developed in 1988 by RAND, became the parent of the now widely used RAND 36-Item Health Survey 1.0, also known as the SF 36. The questions in both the RAND Health Survey and the SF 36 are identical, but the way in which the questions are scored is different. When the questionnaire is scored in the manner described in this article, it should be referred to as the RAND 36-Item Health Survey 1.0. The RAND Health Survey measures physical functioning, social functioning, role limitations due to physical problems, role limitations due to emotional problems, emotional well-being, energy/fatigue, pain, general health perception, and health change. The questions focus on areas of clinical complaint that many patients are experiencing upon presentation to the chiropractic office.

With the exception of perceived change in health status, which is on a single-item scale, the questionnaire contains several questions regarding each of the areas listed above allowing the patient to evaluate his or her total health condition on a multidimensional scale. The 36-Item Health Survey has been tested and found to be reliable and valid. [ 7 ] It is designed to be self-administered, administered by phone, or administered by personal interview. The RAND 36-Item Health Survey takes approximately 10 minutes to fill out, and complicated explanations are not required to complete the questionnaire. It is sensitive enough to detect low levels of ill health in patients [ 7 ] and has been used to measure the progress of chiropractic patients in several studies. [ 12, 13 ]

A copy of the entire RAND 36-Item Health Survey 1.0 is provided in Appendix F. The questionnaire can also be revised or reformatted to meet individual physician or patient needs. Any publication that refers to the questionnaire must reference RAND, however, and changes from the original document must be clearly specified.

RAND recommends the following straightforward approach to scoring the RAND 36-Item Health Survey and has developed forms to assist in the scoring process. These can be found in Table 1 and Table 2. All questions are scored on a scale from a 0 to 100, with 100 representing the highest level of functioning possible. Aggregate scores are compiled as a percentage of the total points possible using the RAND scoring table (Table 1). The scores from those questions that address each specific area of functional health status (e.g., pain, physical functioning, etc, as listed above) are then averaged together (Table 2) for a final score within each dimension. Items left blank by the patient are omitted, and the total score should reflect the average of only those questions that were answered.

For example, a patient may answer question 23 by circling 4, question 27 by circling 3, and question 29 by circling 3 and may leave question 31 blank. Recode these answers on a scale of 0 to 100 (as indicated in Table 1). An answer of 4 to question 23 is recoded as 40, an answer of 3 to question 27 is recoded as 60, an answer of 3 to question 29 is recoded as 40, and question 31 is omitted. Table 2 shows that, when you average questions 23, 27, 29, and 31 together, the total score for energy/fatigue is obtained. In this case, the total score is 40 + 60 + 40 + 0 = 140. The number 140 is divided by the number of questions answered, in this case 3, giving a total score of 46.7. A score of 100 would represent high energy with no fatigue; a lower score reflects that the patient is experiencing some loss of energy and some fatigue.

The RAND 36- Item Health Survey 1.0 can be readministered throughout the patient care experience so that comparisons can be made in order to assess improvement in patient-perceived functional health status.


RECOMMENDED PROCEDURES FOR ADMINISTRATION OF THE QUESTIONNAIRES

Both the RAND Health Survey and the COOP charts should be filled out by the patient before treatment begins. Both questionnaires can be used as an initial assessment tool only. If either questionnaire is used to monitor patient progress, it should be readministered. A suggested time for follow-up is approximately 6 weeks. The first questionnaire may be included with the patient's initial intake paperwork. This will add 5 to 10 minutes to the intake process, and the patient should be scheduled accordingly.

Readministration of the questionnaire must be tailored to the individual chiropractic office. The main challenge is to develop a system that allows the physician and his or her staff to determine when the survey being used should be readministered. This can be done routinely using a tickler system or whenever the patient's treatment plan changes, after reexaminations, after discharge from active care, every 15th visit, or on prespecified dates approximately 6 weeks apart. The questionnaire can be readministered in the office (which tends to lead to greater patient compliance) or else mailed to the patient with a stamped return envelope and a cover letter from the physician.


OTHER INSTRUMENTS

A variety of other outcome assessment tools are also available and serve both general and specific interests. Although these are not presented in detail here, the reader may wish to look into any of the following selected instruments. The references can be used as an additional source of information.

Oswestry Low Back Pain Disability Questionnaire   The Oswestry has been presented previously in the chiropractic literature [ 14 ] and has been used to evaluate the progress of patients receiving chiropractic care in at least one published research study. [ 15 ] It is compromised of 10 brief sections, each of which focuses on an activity of daily living (pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling). The patient is asked to rate how affected each of these areas of his or her life has been as a result of low back pain. The Oswestry is generally presented as a one-page questionnaire and takes only a few minutes to complete.


Roland Morris Disability Questionnaire   The Roland Morris is a low back—specific functional health status questionnaire that is based on the Sickness Impact Profile. It comprises 24 questions that address limitations a person may experience as a result of low back pain. The Roland Morris is also generally presented as a one-page questionnaire and takes only a few minutes to complete. Although substantially shorter than the parent instrument, it has been found to be reliable and valid for measuring disability due to low back pain. [ 16 ]


Group Health Association of America Consumer Satisfaction Questionnaire   Patient satisfaction can be measured to identify problems within the delivery of health care services by evaluating provider services and facilities as well as to predict consumer behavior, such as how often patients can be expected to make use of a given service. [ 17 ] Eight major dimensions of care have been identified as necessary components of a reliable and valid patient satisfaction questionnaire: accessibility and availability of services and providers, choice and continuity, communication, financial arrangements, interpersonal aspects of care, outcomes of care, technical quality of care, and time spent with providers. [ 18 ]

It is on the above dimensions that the Group Health Association of America (GHAA) Consumer Satisfaction Questionnaire is based. Pilot tests of this instrument have shown it to be reliable and valid with high acceptance rates among users and low missing data rates. The average time it takes to complete the questionnaire is approximately 13 minutes. [ 19 ] A chiropractic version of the GHAA has been developed. It closely follows the format of the second edition of the GHAA and is currently in use in a research study in a chiropractic setting. [ 20 ] Using the GHAA as a template should allow patient satisfaction data collected in a chiropractic setting to be compared with that from other types of treatments.


Nottingham Health Profile   The Nottingham Health Profile (NHP) was developed in 1985. It has been widely used in Britain to study many aspects of health, including rheumatoid arthritis, migraine, hypertension, and heart transplantation. It has also been used successfully in other countries. The NHP consists of a 45-item scale in a two-part questionnaire with dimensions that include energy, pain, emotional reactions, sleep, social isolation, and physical mobility. It has proved to be valid, reliable, and sensitive to changes over a wide range of health status. [ 20 ] It has also been criticized for focusing on the extreme end of ill health, however, and is considered by some unsuitable for examining subtle improvements in health within the general population. [ 7 ]


CONCLUSIONS

Although there are a number of ways of assessing health status that have been shown to be reliable and valid, they tend to be underused in clinical settings, particularly in chiropractic offices. The field of health status assessment is becoming a greater force in health care decision making, but this technology remains to be widely adopted in clinical practice. [ 5 ] Collecting information regarding the functional health status of the chiropractic patient presents the opportunity to assess patient progress in a manner that can be broadly understood by third party payors and policymakers and allows comparison of outcomes among various types of health care providers. Such clinical procedures can also lead to improved communication between physician and patient. Questionnaires such as the RAND 36-Item Health Survey 1.0 and the Dartmouth COOP charts specifically address patient quality of life issues that the chiropractic physician has traditionally considered when managing patient care. The information gained this way is useful to patient, provider, payor, and profession alike.


REFERENCES:

  1. Thier SO.
    Forces motivating the use of health status assessment measures in clinical settings and related clinical research
    Med Care 1992;   30 (5)(suppl):   15-22

  2. Guyatt G.
    Issues in quality-of-life measurement in clinical trials.
    Controlled Clin Trials 1991 (Aug);   12:   81S-90S

  3. Ginzberg E.
    Health Services Research: Key to Health Policy.
    Cambridge, MA: Harvard University Press; 1991

  4. Greenfield S, Nelson EC.
    Recent developments and future issues in the use of health status assessment measures in clinical settings
    Med Care 1992 (May);   30 (5)(suppl):   23-41

  5. Lohr KN.
    Applications of health status assessment measures in clinical practice
    Med Care 1992 (May);   30 (5) (supp1):   1-14

  6. Nelson EC, Landgraf J, Hays R, Wasson J, Kirk J.
    The functional status of patients: how can it be measured in physician offices?
    Med Care 1990 (Dec);   28;   1,111-1,126

  7. Brazier J, Harper R, Jones SN.
    Validating the SF-36 Health Survey Questionnaire: new outcome measure for primary care
    Br Med J. 1992 (Jul 18 );   305 (6846):   160-164

  8. McHomey CA, Ware IE, Rogers W, Raczek A, Lu JF.
    The validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts. Results from the Medical Outcomes Study
    Med Care. 1992 (May);   30 (5 Suppl):   MS253-MS265

  9. Jose WS.
    Outcome measures for chiropractic health care.
    Spinal Manipulat. July 1991:1-5

  10. Bass MJ.
    Assessing functional status in family practice
    Fam Med 1992 (Feb);   24 (2):   134-135

  11. Kraus N.
    The Dartmouth Primary Care Cooperative ("COOP") Information Project.
    lnterstudy Qual Edge. 1991; 1 :33-39

  12. Goertz CH, et al.
    General health status assessment: the experience of Northwestern College of Chiropractic.
    In: Proceedings of the 1992 International Conference on Spinal Manipulation.
    Arlington, Va: FCER; 1992

  13. Bronfort G.
    Chiropractic spinal adjustive therapy and exercise versus pharmacological treatment and exercise for chronic low back pain.
    In: Proceedings of the 1992 International Conference on Spinal Manipulation.
    Arlington, Va: FCER; 1992

  14. Hansen DT, Ayres JR.
    Chiropractic outcome measures.
    Chirop Tech. 1991;3(1):53-54

  15. Meade TW, Dyer S, Browne W, Townsend J, Frank AG.
    Low Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment
    Br Med J 1990 (Jun 2);   300 (6737):   1431–1437

  16. Deyo RA.
    Comparative validity of the sickness impact profile and shorter scales for functional assessment in low-back pain
    Spine 1986 (Nov);   11 (9):   951-954

  17. Ware J, Davies A, Stewart A.
    The measurement and meaning of patient satisfaction
    Health Med Care Serv Rev 1978;   1 (1):   1-15

  18. Ware J , Davies AR.
    Defining and measuring patient satisfaction with medical care
    Eval Program Plan 1983;   6 (3-4):   247-263

  19. Davies AR, Ware IE.
    GHAA's Consumer Satisfaction Survey and User's Manual. 2nd ed.
    Washington, DC: GHAA; 1991

  20. McLaughlin C, Goertz CH, Blatz C.
    Measuring patient satisfaction and functional health statugs of the 1993 International Conference on Spinal Manipulation.
    Arlington, Va: FCER; 1993

  21. Deyo RA.
    Measuring the functional status of patients with low back pain.
    Chiro Tech. 1990;2(3): 127-137.



Table I, or  
The Scoring Method as a Word Document


STEP 1:   RECODING (or Scoring) ITEMS:

ITEM NUMBERS

ORIGINAL

RESPONSE *

RECORDED

VALUE

1, 2, 20, 22, 34, 36

1

100

 

2

75

 

3

50

 

4

25

 

5

0

     

3, 4, 5, 6, 7, 8, 9, 10, 11, 12

1

0

 

2

50

 

3

100

     

13, 14, 15, 16, 17, 18, 19

1

0

 

2

100

     

21, 23, 26, 27, 30

1

100

 

2

80

 

3

60

 

4

40

 

5

20

 

6

0

     

24, 25, 28, 29, 31

1

0

 

2

20

 

3

40

 

4

60

 

5

80

 

6

100

     

32, 33, 35

1

0

 

2

25

 

3

50

 

4

75

 

5

100


* Precoded response as printed in the questionnaire.

Reprinted with permission from RAND. Rand 36-Item Health Survey 1.0, RAND Health Sciences Program, Santa Monica, CA. © 1986-1992 (Developed as part of the Medical Outcomes Study)




Table II

STEP 2:   AVERAGING ITEMS TO FORM 8 SCALES:

SCALE

NUMBER

OF ITEMS

AFTER RECORDING SCORES PER TABLE 1, AVERAGE THE FOLLOWING ITEMS

Physical functioning

10

3, 4, 5, 6, 7, 8, 9, 10, 11, 12

Role limitations due to physical health

4

13, 14, 15, 16

Role limitations due to emotional problems

3

17, 18, 19

Energy/ fatigue

4

23, 27, 29, 31

Emotional well being

5

24, 25, 26, 28, 30

Social functioning

2

20, 32

Pain

2

21, 22

General health

5

1, 33, 34, 35, 36


Reprinted with permission from RAND. Rand 36-Item Health Survey 1.0, RAND Health Sciences Program, Santa Monica, CA. © 1986-1992 (Developed as part of the Medical Outcomes Study)


Figure 1

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Figure 2

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Figure 3

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Figure 4

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Figure 5

[Figure 5]


Figure 6

[Figure 6]


Figure 7

[Figure 7]


Figure 8

[Figure 8]


Figure 9

[Figure 9]



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