A comparative study on assessment procedures and metric properties of two scoring systems of the Coma Recovery Scale-Revised items: standard and modified scores.

OBJECTIVE: The study compared the metric characteristics (discriminant capacity and factorial structure) of two different methods for scoring the items of the Coma Recovery Scale-Revised and it analysed scale scores collected using the standard assessment procedure and a new proposed method. DESIGN: Cross sectional design/methodological study. SETTING: Inpatient, neurological unit. PARTICIPANTS: A total of 153 patients with disorders of consciousness were consecutively enrolled between 2011 and 2013. INTERVENTION: All patients were assessed with the Coma Recovery Scale-Revised using standard (rater 1) and inverted (rater 2) procedures. MAIN OUTCOME MEASURES: Coma Recovery Scale-Revised score, number of cognitive and reflex behaviours and diagnosis. RESULTS: Regarding patient assessment, rater 1 using standard and rater 2 using inverted procedures obtained the same best scores for each subscale of the Coma Recovery Scale-Revised for all patients, so no clinical (and statistical) difference was found between the two procedures. In 11 patients (7.7%), rater 2 noted that some Coma Recovery Scale-Revised codified behavioural responses were not found during assessment, although higher response categories were present. A total of 51 (36%) patients presented the same Coma Recovery Scale-Revised scores of 7 or 8 using a standard score, whereas no overlap was found using the modified score. Unidimensionality was confirmed for both score systems. CONCLUSION: The Coma Recovery Scale Modified Score showed a higher discriminant capacity than the standard score and a monofactorial structure was also supported. The inverted assessment procedure could be a useful evaluation method for the assessment of patients with disorder of consciousness diagnosis.

Does community care work? A model to evaluate the effectiveness of mental health services.

The aim of this paper is to evaluate the effectiveness of community Mental Health Departments in Lombardy (Italy), and analyse the eventual differences in outcome produced by different packages of care. The survey was conducted in 2000 on 4,712 patients treated in ten Mental Health Departments. Patients were assessed at least twice in a year with HoNOS (Health of the Nation Outcome Scales). Data on treatment packages were drawn from the regional mental health information system, which includes all outpatient and day-care contacts, as well as general hospital and inpatient admissions provided by Mental Health Departments. Multilevel growth models were used for outcomes statistical analysis, expressed in terms of change of the total HoNOS score. On the whole, Mental Health Departments were effective in reducing HoNOS scores. The main predictor of improvement was treatment, while length of care, gender and diagnosis were weaker predictors. After severity adjustment, some packages of care proved more effective than others. Appropriate statistical methods, comprehensive treatment descriptions and routine outcome assessment tools are needed to evaluate the effectiveness of community mental health services in clinical settings.