Abstract
Objective
The aim of the conference was to derive the Brief and the Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions from the subset of ICF categories selected on the basis of the preparatory phase research.
Methods
Following a multistage decision process, the experts agreed on the ICF categories to be included in the ICF Core Sets for Hand Conditions. The development of the ICF Core Sets for Hand Conditions involved a formal decision-making and consensus process, integrating evidence gathered from preparatory studies including a qualitative study, a systematic literature review, an expert survey and an empirical multicentre study.
Results
Twenty-three experts selected a total of 117 categories for the Comprehensive Core Set and 23 categories for the Brief Core Set. The largest number of categories was selected from the ICF component ‘Activities and Participation’.
Conclusion
The ICF Core Sets for Hand Conditions serve a clinical framework to comprehensively assess patients in acute care hospitals and early postacute rehabilitation facilities. The first versions of the ICF Core Sets will be further tested and validated through empirical studies.
Keywords
Introduction
The World Health Organization (WHO) developed the International Classification of Functioning, Disability and Health (ICF) as a means to address the consequences of the health conditions from a comprehensive perspective. 1 With the ICF we can now rely on a globally accepted language to communicate about functioning in individuals with hand conditions (HC).
The ICF is based on the integrative model of functioning. The model illustrates an individual's functioning as a complex relationship between the health condition and contextual factors (i.e. environmental and personal factors) with dynamic and bidirectional interactions among the entities (Figure 1). The whole classification comprises the components Body Functions and Structures, Activities and Participation and Environmental Factors. The component Personal Factors has not yet been classified (Figure 1 and Box 1). The ICF provides more than 1400 ICF categories, thus enhancing its applicability in clinical practice, and research tools, such as ICF Core Sets, are needed. ICF Core Sets are lists of ICF categories relevant for the description of functioning of individuals with a specific health problem or being treated in specific settings.
The integrative model of functioning, World Health Organization, Geneva, 2001 5
International Classification of Functioning, Disability and Health (ICF) 4
The ICF is a comprehensive classification with 1424 ICF categories. In the ICF, two parts, each with two components, are described.
Part I. Functioning and Disability:
(a) Body Functions and Structures (b) Activities and Participation
‘Activity’ is defined as ‘the execution of a task or action by an individual’ and ‘participation’ is defined as ‘the person's involvement in a life situation’.
Part II. Contextual Factors
(c) Environmental Factors (d) Personal Factors
Within each component, domains are further grouped according to their common characteristics in several categories. These categories contain 1–4 levels.
1
In May 2009 an International ICF Consensus Conference on ‘ICF Core Sets for Hand Conditions’ in collaboration with WHO took place at Nottwil, Switzerland. The aim of the conference was to decide on the first version of the ICF Core Sets for Hand Conditions.
It is envisioned that the ICF Core Sets for Hand Conditions will stimulate research leading to improved understanding of functioning, disability and health in individuals with HC. Additionally, the ICF Core Sets for Hand Conditions may form the basis for studying the content validity of already existing instruments or for the development of new instruments to quantify the severity of HC, to measure change over time and the effectiveness of interventions. 2
The development of the ICF Core Sets for Hand Conditions project started in February 2008 and is a cooperative effort of the German Social Accident Insurance (DGUV), the Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW) (Germany) and the ICF Research Branch of the Collaborating Centre of the Family of International Classifications (DIMDI, Köln, Germany) at the Institute for Health and Rehabilitation Sciences at Ludwig-Maximilian University in Munich (Germany).
The aim of the project was to develop the ICF Core Sets for Hand Conditions to specify functioning and disability of individuals with HC. In this context, HC include conditions of the hand (considered as conditions/health problems located directly at the hand like, e.g. carpal tunnel syndrome or injuries of the hand or osteoarthritis of finger joints or amputations or Dupuytren's disease, etc.) and conditions involving the hand (considered as conditions/health problems originating external to the hand but affecting the hand like, e.g. rheumatoid arthritis or stroke or Parkinson's disease or multiple sclerosis, etc.). 2
There were three phases in the project ‘Development of the ICF Core Sets for Hand Conditions’. Within the first phase four preparatory studies were conducted to address adequately different perspectives:
2
Systematic literature review: A systematic literature review was performed (1) to identify parameters and outcomes reported in studies involving patients with HC and published within the years 2003–2008 and (2) to identify and quantify the concepts contained in these parameters and outcomes using the ICF as a reference. The systematic review was performed, followed by a selection procedure with three steps: step 1, selection of studies; step 2, outcome measures and parameters extraction; and step 3, linkage of the concepts contained within the outcome measures and parameters to the corresponding categories of the ICF. All steps were conducted by two independent reviewers. More information will be published in the future.
Qualitative study: Ten focus groups including 59 individuals with different types of HC were held at five different study centres in Germany.
Expert survey: An Internet-based expert survey was undertaken to gather the opinion of an international pool of 162 experts from 55 countries and of six different health professions (physicians, nurses, physiotherapists, occupational therapists, psychologists and social workers) regarding the most relevant and typical areas to be considered in individuals with HC.
Empirical study: A cross-sectional multicentre study with 210 patients was conducted at five study centres to describe functioning and health of individuals with HC and to identify the most common problems using the classification system of the ICF. A Brief ICF Core Set for Hand Conditions is defined as a list of ICF categories that serves as minimal international standard for the reporting of functioning in persons with HC along the continuum of care (ranging from the acute hospital to rehabilitation facilities and community) and across sectors (health, education, labour and social affairs). A Comprehensive ICF Core Set for Hand Conditions is defined as a list of ICF categories that includes as few categories as possible to be practical, but as many as necessary to describe the aspects of functioning relevant to persons with HC in a comprehensive, multidisciplinary assessment.
The aim of the conference was to derive the Brief and the Comprehensive ICF Core Sets for Hand Conditions from the subset of ICF categories selected on the basis of the preparatory phase research.
Method
A formal decision-making and consensus process was used, integrating evidence gathered from preparatory studies including a qualitative study, a systematic literature review, an expert survey and an empirical multicentre study. The different steps and phases during the consensus conference were defined and described in advance. 3
At the ICF Consensus Conference the results of the preparatory studies were presented by researchers from the Institute for Health and Rehabilitation Sciences. On the basis of this information, three working groups, each of which consisted of participants from different health professions, discussed and determined through a voting mechanism the selection of ICF categories.
Observers were present and they were instructed not to be involved in discussions. The group decisions were presented and discussed at several plenary sessions. The plenary sessions were led by the group leader (Institute for Health and Rehabilitation Sciences) (Box 2).
Consensus procedure 2,3
The ICF Consensus Conference on ‘ICF Core Sets for Hand Conditions’ involved health professionals from different parts of the world. Twenty-three experts were invited to attend the conference and were divided into three different working groups. Each group consisted of different health professionals from different countries who worked actively together for three days in a teamwork technique called the ‘Nominal Group Technique’. The language at the conference was English.
At the beginning of the conference, participants were trained on (1) the structure, principles and nomenclature of the ICF in general; (2) the results from the preparatory studies; and (3) the principles of the consensus process applied during the conference.
The categories to be included in the ICF Core Sets were chosen in two different types of sessions: in working groups and in the plenary. The decision-making process included three consecutive steps: (1) selection of ICF categories for the Comprehensive ICF Core Set on second level; (2) selection of categories that require to be described in more detail at higher ICF-levels, i.e. third and fourth level; and (3) selection of categories out of the Comprehensive ICF Core Set that should be included in the Brief ICF Core Set for HC.
The categories for the Brief ICF Core Set for HC were chosen out of the Comprehensive ICF Core Set by means of a ranking exercise. The cut-off line for the ranking was determined in a separate vote after the ranking.
Results
Twenty-three experts in the field of HC (physicians, physiotherapists, occupational therapists, nurses, psychologists and social workers) from 22 different countries were involved in the formal decision-making and consensus process, which resulted in the selection of ICF categories for the ICF Core Sets for Hand Conditions. Representatives of the World Confederation for Physical Therapy (WCPT), of the World Federation of Occupational Therapists (WFOT) and of the International Federation of Societies for Hand Therapy (IFSHT) were also present.
As a result of the ICF Consensus Conference two ICF Core Sets for Hand Conditions were developed as follows:
A Comprehensive ICF Core Set for Hand Conditions including a selection of 117 ICF categories to be taken into account in a comprehensive, multidisciplinary assessment. A Brief ICF Core Set for Hand Conditions including a selection of 23 ICF categories out of the Comprehensive ICF Core Set for Hand Conditions to be taken into account in any patient with HC irrespective of the health-care setting in which they are treated and when single health-care professionals and not a multidisciplinary team is involved, respectively.
The development of the ICF Core Sets for Hand Conditions within two and a half days was associated with an enormous workload for the participants and a very tight time schedule.
The ICF Core Sets for Hand Conditions are presented on the ICF Research Branch website:
Discussion
The aim of the ICF Consensus Conference on ‘ICF Core Sets for Hand Conditions’ was to derive the Brief and the Comprehensive ICF Core Set for Hand Conditions from the subset of ICF categories selected on the basis of the preparatory phase research. A lot of discussions took place in the working groups and during the plenary sessions. Consensus was achieved by a structured voting procedure.
As in any decision-making and consensus process involving experts, the process has limitations and the results of the voting may have been influenced by several aspects, such as the knowledge of the participants regarding the ICF or decision process itself. This emphasizes the need for testing the first version of ICF Core Sets as well as the need to link this first proposal to assessment instruments and clinical assessment guidelines that are already in use.
Footnotes
Acknowledgement
The project ‘Development of ICF Core Sets for Hand Conditions’ was supported by the German Social Accident Insurance (DGUV) and approved by the Ethics Committee of the Medical Association Hamburg, Germany. We are most grateful for the contributions made by the following experts attending the ICF Consensus Conference (in alphabetical order): Davit Abrahamyan (Armenia), Kevin Chung (USA), Tora Dahl (Denmark), Mohamed Elazhary (Jordan), Patricia Fronek (Australia), Margareta Gustafsson (Sweden), Johanes Hardjono (Indonesia), James January (Zimbabwe), Marie Johnston (Scotland), Hamid Kamarzarin (Iran), Ali Kitis (Turkey), Monique LeBlanc (Qatar), Joy MacDermid (Canada), Kay Maddison (Australia), Christine Meier (Switzerland), Fabian Puepet (Nigeria), U Singh (India), Michael Solomons (South Africa), Catherine Sykes (United Kingdom), Jin Bo Tang (China), Piya Trevittaya (Thailand), Lucelle van de Ven-Stevens (The Netherlands) and Shwu-fen Wang (Taiwan).
We would also like to thank the members of the research group: Heinrich Gall, Andreas Leib, Gertrud Müller and Silvia Neubert.