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Editorial Commentary
Measuring case complexity in neurological rehabilitation Derick Wade Healthcare systems need a fair way of measuring the resources a patient needs for specific services, so that the service provider can obtain fair payment, and the payer can obtain a fair return on the payment. This is challenging for several reasons: need (the ability to benefit) is difficult to determine; the specific inputs required to deliver the benefit are imprecise; and the outcome will be influenced by many factors, both patientrelated and contextual. In rehabilitation, the situation is particularly difficult because there are so many variables to take into account. Turner-Stokes et al (see page 146) have developed a measure of complexity in rehabilitation1 to assist in justifying resources used; what is its utility? The scale is supposed to be ‘a measure of case-load complexity’ in rehabilitation. The measure acknowledges three components to that complexity: supportive care, usually provided by nurses; interventions intended to alter outcome (therapy), provided by many professions; and disease management, usually provided by doctors. Their analysis showed that in practice, only two factors are measured: nursing/ medical specialist care and therapy. The study can be criticised on many grounds. The sample was highly selected. Oxford Centre for Enablement, Windmill Road, Oxford, UK Correspondence to Professor Derick Wade, Oxford Centre for Enablement, Windmill Road, Oxford OX3 7LD, UK;
[email protected]
J Neurol Neurosurg Psychiatry February 2010 Vol 81 No 2
The risk of circular reasoning is high, as the same people provided the data for both the new measure and the validating measures, and moreover some data items cover similar constructs such as dependence. The strong correlations with other measures would suggest it is not measuring much new. It relies upon clinical opinion, which may well be correct, but it may not convince purchasers or service managers. The patient needs to be in rehabilitation for at least 2 weeks to obtain the data. There are two other reasons for being concerned about this scale. The first is practical. It cannot help determine ‘complexity’ before patients are admitted, yet this is the primary need of most services, and most data are subjective, which reduces its credibility with purchasers. However, the major concern is philosophical: the scale is not actually a measure of complexity. Complexity concerns the interaction of many variables from many different domains, usually in a non-linear way; this measure covers only one or two domains and is linear. An actual measure of complexity would encompass data from several or many different domains and would have a complicated method for calculating complexity. Many others have recognised that measures of need and complexity are
required,2 3 but so far there has been little progress. However, at least one group has identified that complexity in healthcare requires a multifactorial approach, and has suggested both important domains and a way to calculate overall complexity using vectors.3 This approach seems very appropriate, though I would strongly suggest using the expanded World Health Organization’s International Classification of Functioning model of illness to identify the important domains,4 certainly in rehabilitation. Nonetheless, the Rehabilitation Complexity Scale is a simple, clinical measure of overall resource use by a patient already accepted for rehabilitation. Provided its severe limitations are recognised, it may be useful. Competing interests None. Provenance and peer review Commissioned; not externally peer reviewed. Received 22 July 2009 Revised 22 July 2009 Accepted 26 July 2009 J Neurol Neurosurg Psychiatry 2010;81:127. doi:10.1136/jnnp.2009.178863
REFERENCES 1.
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Turner-Stokes L, Williams H, Siegert RJ. The rehabilitation complexity scale version 2: a clinimetric evaluation in patients with severe complex neurodisability. J Neurol Neurosurg Psychiatry 2009;81:146e53. Johnston MV, Graves D, Greene M. The uniform postacute assessment tool: systematically evaluating the quality of measurement evidence. Arch Phys Med Rehabil 2007;88:1505e12. Safford MM, Allison JJ, Kiefe CI. Patient complexity: more than comorbidity. the vector model of complexity. J Gen Intern Med 2007;22:382e90. Wade T, Halligan PW. Do biomedical models of illness make for good healthcare systems? BMJ 2004;329:1398e401.
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PostScript
Figure 3 Cerebrospinal fluid CXCL13 in neuroborreliosis patients prior to therapy plotted against time since the onset of symptoms (time to lumbar puncture). The straight line is a regression line; the correlation was significant (p¼0.044, R¼0.383).
doi:10.1136/jnnp.2009.173732corr1
K Brantberg. Paroxysmal staccato tinnitus: a carbamazepine responsive hyperactivity dysfunction symptom of the eighth cranial nerve J Neurol Neurosurg Psychiatry 2010;81: 451e455. A number of errors in the author’s manuscript were published uncorrected by JNNP. In the first sentence of the introduction “N VII” should have been deleted. In the same section, fourth paragraph, second to last sentence it should be “fifth and seventh cranial nerves” rather than “fifth and eigth cranial nerves”. In the Discussion, in both the second and fourth paragraph it refers to the fifth and seventh cranial nerves when it should have been the seventh and eigth cranial nerves. JNNP would like to apologise for not correcting
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these errors which occurred during editing and which were also pointed out by the author before publication. doi:10.1136/jnnp.2009.178863corr1
D Wade. Measuring case complexity in neurological rehabilitation. J Neurol Neurosurg Psychiatry 2010;81:127. The commentary by Derick Wade contained several errors that need correction. Column 1, paragraph 2: The RCS has four components (not three). Column 2, paragraphs 1 and 2: The RCS can be completed after a single assessment, and does not require two weeks as an inpatient. It can be completed either prospectively to record rehabilitation ‘needs’
or retrospectively to describe the level of interventions actually provided. In the analysis reported by Turner-Stokes et al (J Neurol Neurosurg Psychiatry 2010;81: 146e153), it was used retrospectively. Professor Wade therefore wishes to withdraw the statement in paragraph 2: “There are two other reasons for being concerned about this scale. The first is practical. It cannot help determine ‘complexity’ before patients are admitted, yet this is the primary need of most services, and most data are subjective, which reduces its credibility with purchasers.” Column 3, last paragraph should be amended to read: “Nonetheless, the Rehabilitation Complexity Scale is a simple, clinical measure of overall resource use. Provided its limitations are recognised, it may prove useful.” In addition, Professor Wade overlooked a potential competing interest; although he was not directly involved in the analysis by Turner-Stokes et al (pp 146e153), he is a member of the same academic department (Department of Palliative Care Policy and Rehabilitation, Kings College, London). He is also a co-investigator in the NIHR-funded Programme under which the RCS and other tools to address complexity of rehabilitation needs and interventions are being developed. In writing this commentary, Professor Wade sought to highlight some of the limitations of a tool that is necessarily simplified for practical utility and to place it in the context of the broader issues involved in assessing case complexity in rehabilitation, which are also being addressed in other sections of the programme. His critical appraisal of the RCS and failure to declare his association should not be taken in any sense to imply disengagement from the programme. He remains fully committed to this important area of work.
J Neurol Neurosurg Psychiatry October 2010 Vol 81 No 10
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Measuring case complexity in neurological rehabilitation Derick Wade J Neurol Neurosurg Psychiatry 2010 81: 127
doi: 10.1136/jnnp.2009.178863
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