Estimating the potential impact of behavioral public health interventions nationally while maintaining agreement with global patterns on relative risks.

OBJECTIVE: This paper introduces a novel method to evaluate the local impact of behavioral scenarios on disease prevalence and burden with representative individual level data while ensuring that the model is in agreement with the qualitative patterns of global relative risk (RR) estimates. The method is used to estimate the impact of behavioral scenarios on the burden of disease due to ischemic heart disease (IHD) and diabetes in the Turkish adult population. METHODS: Disease specific Hierarchical Bayes (HB) models estimate the individual disease probability as a function of behaviors, demographics, socio-economics and other controls, where constraints are specified based on the global RR estimates. The simulator combines the counterfactual disease probability estimates with disability adjusted life year (DALY)-per-prevalent-case estimates and rolls up to the targeted population level, thus reflecting the local joint distribution of exposures. The Global Burden of Disease (GBD) 2016 study meta-analysis results guide the analysis of the Turkish National Health Surveys (2008 to 2016) that contain more than 90 thousand observations. FINDINGS: The proposed Qualitative Informative HB models do not sacrifice predictive accuracy versus benchmarks (logistic regression and HB models with non-informative and numerical informative priors) while agreeing with the global patterns. In the Turkish adult population, Increasing Physical Activity reduces the DALYs substantially for both IHD by 8.6% (6.4% 11.2%), and Diabetes by 8.1% (5.8% 10.6%), (90% uncertainty intervals). Eliminating Smoking and Second-hand Smoke predominantly decreases the IHD burden 13.1% (10.4% 15.8%) versus Diabetes 2.8% (1.1% 4.6%). Increasing Fruit and Vegetable Consumption, on the other hand, reduces IHD DALYs by 4.1% (2.8% 5.4%) while not improving the Diabetes burden 0.1% (0% 0.1%). CONCLUSION: While the national RR estimates are in qualitative agreement with the global patterns, the scenario impact estimates are markedly different than the attributable risk estimates from the GBD analysis and allow evaluation of practical scenarios with multiple behaviors.

Enhanced capture of healthcare-related harms and injuries in the 11th revision of the International Classification of Diseases (ICD-11).

The World Health Organization (WHO) plans to submit the 11th revision of the International Classification of Diseases (ICD) to the World Health Assembly in 2018. The WHO is working toward a revised classification system that has an enhanced ability to capture health concepts in a manner that reflects current scientific evidence and that is compatible with contemporary information systems. In this paper, we present recommendations made to the WHO by the ICD revision's Quality and Safety Topic Advisory Group (Q&S TAG) for a new conceptual approach to capturing healthcare-related harms and injuries in ICD-coded data. The Q&S TAG has grouped causes of healthcare-related harm and injuries into four categories that relate to the source of the event: (a) medications and substances, (b) procedures, (c) devices and (d) other aspects of care. Under the proposed multiple coding approach, one of these sources of harm must be coded as part of a cluster of three codes to depict, respectively, a healthcare activity as a 'source' of harm, a 'mode or mechanism' of harm and a consequence of the event summarized by these codes (i.e. injury or harm). Use of this framework depends on the implementation of a new and potentially powerful code-clustering mechanism in ICD-11. This new framework for coding healthcare-related harm has great potential to improve the clinical detail of adverse event descriptions, and the overall quality of coded health data.

Semantic Alignment between ICD-11 and SNOMED CT.

Due to fundamental differences in design and editorial policies, semantic interoperability between two de facto standard terminologies in the healthcare domain--the International Classification of Diseases (ICD) and SNOMED CT (SCT), requires combining two different approaches: (i) axiom-based, which states logically what is universally true, using an ontology language such as OWL; (ii) rule-based, expressed as queries on the axiom-based knowledge. We present the ICD-SCT harmonization process including: a) a new architecture for ICD-11, b) a protocol for the semantic alignment of ICD and SCT, and c) preliminary results of the alignment applied to more than half the domain currently covered by the draft ICD-11.

ICD-11: a comprehensive picture of health, an update on the ICD-ICF joint use initiative.

BACKGROUND: This is a follow-up of the special report Towards the joint use of ICD and ICF: A call for contribution, published by the Journal of Rehabilitation Medicine in 2012, which introduced an initiative of using the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF) in a complementary way in clinical practice. Recognizing the merits of using the ICD and ICF jointly, the World Health Organization (WHO) introduced so-called functioning properties in the ICD-11. The first step in this ICD-ICF joint use initiative revealed 103 rehabilitation-relevant health conditions for which functioning properties were to be identified. Afterwards experts were recruited to identify the functioning properties for the health conditions for which no ICF Core Sets were available and all the functioning properties were integrated in the beta-version of ICD-11. OBJECTIVE: The objective of this special report is to present the outcome of the recruitment and training of the contributing experts, and to provide an update on the current status of identifying functioning properties and their integration in ICD-11. DISCUSSION: Having functioning properties in the ICD-11 achieves a milestone in depicting health information in an integrated and comprehensive manner. Explicitly identifying functioning properties for specific health conditions further reinforces the importance of acquiring a broader and more meaningful picture of a person's health, and can guide clinical decision-making.

What's in a class? Lessons learnt from the ICD - SNOMED CT harmonisation.

The upcoming ICD-11 will be harmonized with SNOMED CT via a common ontological layer (CO). We provide evidence for our hypothesis that this cannot be appropriately done by simple ontology alignment, due to diverging ontological commitment between the two terminology systems. Whereas the common ontology describes clinical situations, ICD-11 linearization codes are best to be interpreted as diagnostic statements. For the binding between ICD codes and classes from the ontological layer, a query-based approach is favoured.

ICD-11 and SNOMED CT Common Ontology: circulatory system.

The improvement of semantic interoperability between data in electronic health records and aggregated data for health statistics requires efforts to carefully align the two domain terminologies ICD and SNOMED CT. Both represent a new generation of ontology-based terminologies and classifications. The proposed alignment of these two systems and, in consequence, the validity of their cross-utilisation, requires a specific resource, named Common Ontology. We present the ICD-11 SNOMED CT Common Ontology building process including: a) the principles proposed for aligning the two systems with the help of a common model of meaning, b) the design of this common ontology, and c) preliminary results of the application to the diseases of the circulatory system.

Revising the WHO verbal autopsy instrument to facilitate routine cause-of-death monitoring.

OBJECTIVE: Verbal autopsy (VA) is a systematic approach for determining causes of death (CoD) in populations without routine medical certification. It has mainly been used in research contexts and involved relatively lengthy interviews. Our objective here is to describe the process used to shorten, simplify, and standardise the VA process to make it feasible for application on a larger scale such as in routine civil registration and vital statistics (CRVS) systems. METHODS: A literature review of existing VA instruments was undertaken. The World Health Organization (WHO) then facilitated an international consultation process to review experiences with existing VA instruments, including those from WHO, the Demographic Evaluation of Populations and their Health in Developing Countries (INDEPTH) Network, InterVA, and the Population Health Metrics Research Consortium (PHMRC). In an expert meeting, consideration was given to formulating a workable VA CoD list [with mapping to the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) CoD] and to the viability and utility of existing VA interview questions, with a view to undertaking systematic simplification. FINDINGS: A revised VA CoD list was compiled enabling mapping of all ICD-10 CoD onto 62 VA cause categories, chosen on the grounds of public health significance as well as potential for ascertainment from VA. A set of 221 indicators for inclusion in the revised VA instrument was developed on the basis of accumulated experience, with appropriate skip patterns for various population sub-groups. The duration of a VA interview was reduced by about 40% with this new approach. CONCLUSIONS: The revised VA instrument resulting from this consultation process is presented here as a means of making it available for widespread use and evaluation. It is envisaged that this will be used in conjunction with automated models for assigning CoD from VA data, rather than involving physicians.

Sharing ontology between ICD 11 and SNOMED CT will enable seamless re-use and semantic interoperability.

In order to support semantic interoperability in eHealth systems, domain terminologies need to be carefully designed. SNOMED CT and the upcoming ICD-11 represent a new generation of ontology-based terminologies and classifications. The proposed alignment of these two systems and, in consequence, the validity of their cross-utilisation requires a thorough analysis of the intended meaning of their representational units. We present the ICD11 SNOMED CT harmonization process including: a) the clarification of the interpretation of codes in both systems as representing situations rather than conditions, b) the principles proposed for aligning the two systems with the help of a common ontology, c) the high level design of this common ontology, and d) further ontology-driven issues that have arisen in the course of this work.

Social network integration of the ICD11 revision platform.

Classification revision and update can be defined as a social experience, with the participating community of experts behaving like a social network. ICD11 is being revised using an innovative web based process, for which we envisioned also tools for social platforms integration. The present poster preliminarily describes the Facebook tools developed for soliciting expert and participation in the ICD11 revision process.

The Personal Factors of the International Classification of Functioning, Disability and Health in the literature - a systematic review and content analysis.

PURPOSE: This review provides an overview of the literature on the conceptualisation of the Personal Factors (PF) component of the International Classification of Functioning, Disability and Health (ICF). METHOD: A systematic literature review was carried out. Electronic searches were performed in Pubmed, Embase, PsycINFO, CINAHL and SSCI. Qualitative content analysis of statements about PF was conducted using inductive coding. RESULTS: The searches yielded 353 citations, 79 papers were eligible for analyses. Five hundred thirty-eight statements about PF were extracted, condensed and coded. Beside conceptual statements, 238 examples of potential PF as well as five attempts at classifying PF were found in the literature. PF were considered in relation to clinical service provision, assessment and intervention, in research and social security contexts. PF were seen to be related to various aspects of health, functioning, disability and the environment. CONCLUSIONS: The analysis of the literature shows that PF is seen as relevant to the application of the ICF in various settings. The review revealed a need for standardisation of PF. The literature points to the potential of PF in enhancing the understanding of functioning, disability and health, in facilitating interventions and services for people with disabilities, and strengthening the perspective of individuals in the ICF.

Developing and validating an index for measuring health in patients with ankylosing spondylitis.

OBJECTIVES: The impact of disease on functioning is the essential information for clinicians when reporting on health problems of individuals. The International Classification of Functioning, Disability and Health (ICF) is a comprehensive and universally accepted model to classify and describe functioning, disability and health in a systematic way. The objective of this article is to outline the development and validation of a health index for patients with AS based on the ICF as a use case. METHODS: The project is a combined effort of the Assessment of SpondyloArthritis International Society, the ICF Research Branch of the World Health Organization (WHO) Collaboration Centre of the Family of International Classifications and the WHO. There are five steps in the development and validation of the health index for patients with AS: (i) development of an item pool; (ii) identification of candidate items; (iii) item selection; (iv) item reduction; and (v) creation of a final version. Consensus about items that have to be part will be reached in a final consensus conference. RESULTS: During a meeting in February 2009, we coordinated the development process of the health index for patients with AS. The results of this investigation will be the health index for patients with AS. CONCLUSION: The goal of developing a health index for patients with AS based on the ICF is very much in line with the broader goal of the WHO to define health indices to ensure the comparability of them within the framework of the ICF.

Integrating research into policy planning: MHADIE policy recommendations.

MHADIE project (Measuring Health and Disability in Europe: Supporting policy development) aimed at developing realistic, evidence-based and effective national policies for persons with disabilities. A preliminary step towards this goal was the demonstration on the feasibility of employing the ICF in clinical, educational and statistical fields, which corresponds to the recognised need to enhance the European Union's capacity of analysis of disability, as highlighted in its Disability Action Plan 2006-2007. The ultimate outcome of the project is the production of 13 policy recommendations, dealing with statistics clinical and educational areas, and four general policy recommendations focusing on: (a) the need of coordinating and integrating disability conceptualization at all policy levels and across sectors; (b) the need of conducting longitudinal cohort studies which include children aged 0-6; (c) the need of reviewing transportation policies in light of the requirements of persons with disabilities; (d) the need of reviewing all disability policies to emphasise and support the role of the family, which is a consistent and substantial environmental facilitator in the lives of persons with disabilities.

Validation of the International Classification of Functioning Disability and Health framework using multidimensional item response modeling.

PURPOSE: To examine the construct validity of the International Classification of Functioning Disability and Health (ICF) framework using multidimensional item response modelling and data collected in different regions from patients with five chronic health conditions. We assume that the ICF components should represent statistically called dimensions that are distinct although related. METHOD: Retrospective validation study using the ICF Core Sets from a convenience sample of patients in an international multicentre, cross-sectional database obtained in different rehabilitation centres. Health professionals working in 89 rehabilitation centres in 32 countries collected data from 3227 rehabilitation patients using the respective ICF Core Sets. Patients included had one of the following health conditions: low back pain (LBP), rheumatoid arthritis (RA), osteoarthritis (OA), obesity (OB) or post-stroke. Data from questions regarding a patient's functioning based on body structures and functions, activities, participation along the ICF Core Sets were analysed with multidimensional item response modelling. RESULTS: The multidimensional models fit the data better than a model with few or no specifications regarding an underlying framework. For example, a model separating four dimensions 'body structures', 'body functions', 'activities' and 'participation' fits the data better than a model differentiating between 'body functions and structures' and 'activities and participation'. The ICF framework with its components represents underlying statistically called dimensions. CONCLUSION: The results of this study support the construct validity of the functioning part of the ICF. The distinct dimensions may facilitate the alignment of ICF components with other measures used clinically and in research. Based on our results it is justifiable to construct instruments integrating ICF categories within components.

What is "functional impairment"? Disentangling disability from clinical significance.

The formulation of disability (or "functional impairment") is currently not operationalized in either the ICD or the DSM. In the DSM system, making a diagnosis depends on a conjoint assessment of symptoms and functioning, whereas the ICD keeps the disability construct separate from the diagnosis of mental disorders. We need an internationally agreed conceptualization between ICD and DSM in terms of better operationalization of disease and disability components. No functioning or disability should appear as part of the threshold of the diagnosis in either system.

The International Classification of Functioning, Disability, and Health could be used to measure functioning.

OBJECTIVE: To explore whether it is possible to construct clinical measures of functioning by integrating information obtained across the categories of the International Classification of Functioning, Disability, and Health (ICF) using the ICF Core Set of osteoarthritis (OA) as a case in point. STUDY DESIGN AND SETTING: Psychometric study using data from 437 patients with OA from Germany, Italy, Hungary, Serbia, and Singapore. The analyses were performed with the ICF categories of the comprehensive ICF Core Set for OA addressing functioning and using the Rasch model for ordered response options. RESULTS: A clinical measure with 74 country-specific and seven common ICF categories was created with the pooled data of all countries but Hungary. The overall fit statistic according to the chi(2) was chi(df=405)(2)=451.73, P=0.054, and the Z-fit statistic was Z(mean)=-0.041 (Z(standard deviation [SD])=1.01) for items and Z(mean)=-0.15 (Z(SD)=1.19) for persons. The Person Separation Index r(beta) was 0.92. CONCLUSION: For the first time, a cross-cultural clinical measure of functioning was constructed which integrates ICF categories. The results of this investigation are promising and can contribute to the acceptance and usefulness of the ICF in clinical practice.

Items from patient-oriented instruments can be integrated into interval scales to operationalize categories of the International Classification of Functioning, Disability and Health.

OBJECTIVE: To exemplify the construction of interval scales for specified categories of the International Classification of Functioning, Disability and Health (ICF) by integrating items from a variety of patient-oriented instruments. STUDY DESIGN AND SETTING: Psychometric study using data from a convenience sample of 122 patients with rheumatoid arthritis. Patients completed six different patient-oriented instruments. The contents of the instrument items were linked to the ICF. Rasch analyses for ordered-response options were used to examine whether the instrument items addressing the ICF category b130: Energy and drive functions constitute a psychometrically sound interval scale. RESULTS: Nineteen items were linked to b130: Energy and drive functions. Sixteen of the 19 items fit the Rasch model according to the chi-square (chi(2)) statistic (chi(2)(df=32)=38.25, P=0.21) and the Z-fit statistic (Z(Mean)=0.451, Z(SD)=1.085 and Z(Mean)=-0.223, Z(SD)=1.132 for items and persons, respectively). The Person Separation Index r(beta) was 0.93. CONCLUSION: The ICF category interval scales to operationalize single ICF categories can be constructed. The original format of the items included in the interval scales remains unchanged. This study represents a step forward in the operationalization and future implementation of the ICF.

A deployment and Research Roadmap for Semantic Interoperability: the EU semantic health project.

The purpose of this EU funded project is to describe a short and medium term Research and Deployment Roadmap for Semantic Interoperability in e-health. It started by defining 4 levels and 3 dimensions for Semantic Interoperability. The vision is to reconcile the needs for the direct patient care safety, biomedical and clinical research and for public health by the reuse of direct care data: from gene to individuals and populations. The methodology is presented and preliminary results and milestones for the short and the long term are set. We conclude by statements on the main characteristics and needs of the roadmap to sustain better health for individual and populations in the changing EU health care systems.

Content comparison of health-related quality of life instruments for obstructive sleep apnea.

BACKGROUND AND PURPOSE: Due to the increasing importance of quality of life assessments in obstructive sleep apnea (OSA) patients and due to an increased use of the International Classification of Functioning, Disability and Health (ICF), for comparative purposes it is essential to understand the relationship between health-related quality of life (HRQOL) instruments and the ICF. The purpose of this study was to compare the content covered by OSA-specific instruments using the ICF. PATIENTS AND METHODS: OSA-specific instruments were identified, including the Calgary Sleep Apnea Quality of Life Index, the Functional Outcomes of Sleep Questionnaire, the Obstructive Sleep Apnea Patient-Oriented Severity Index, and the Quebec Sleep Questionnaire, and linked to the ICF by six health professionals according to standardized guidelines. The degree of agreement between health professionals was calculated by means of the kappa statistic. RESULTS: A total of 308 concepts were identified and linked to 78 different ICF categories; 35 categories of the component body function, one category of the component body structure, 38 categories of the component activities and participation, and four categories of the component environmental factors. Only contents within the chapters mental functions, mobility and social life were addressed by all instruments. Forty-seven categories were covered by only one instrument. CONCLUSION: The ICF proved highly useful for the comparison of HRQOL instruments. This analysis may help researchers and clinicians to choose the most appropriate HRQOL instrument for a specific purpose as well as help to compare study outcomes of studies using different instruments for HRQOL assessment.

Depression, chronic diseases, and decrements in health: results from the World Health Surveys.

BACKGROUND: Depression is an important public-health problem, and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression, alone or as a comorbidity, on overall health status. METHODS: The WHO World Health Survey (WHS) studied adults aged 18 years and older to obtain data for health, health-related outcomes, and their determinants. Prevalence of depression in respondents based on ICD-10 criteria was estimated. Prevalence values for four chronic physical diseases--angina, arthritis, asthma, and diabetes--were also estimated using algorithms derived via a Diagnostic Item Probability Study. Mean health scores were constructed using factor analysis and compared across different disease states and demographic variables. The relation of these disease states to mean health scores was determined through regression modelling. FINDINGS: Observations were available for 245 404 participants from 60 countries in all regions of the world. Overall, 1-year prevalence for ICD-10 depressive episode alone was 3.2% (95% CI 3.0-3.5); for angina 4.5% (4.3-4.8); for arthritis 4.1% (3.8-4.3); for asthma 3.3% (2.9-3.6); and for diabetes 2.0% (1.8-2.2). An average of between 9.3% and 23.0% of participants with one or more chronic physical disease had comorbid depression. This result was significantly higher than the likelihood of having depression in the absence of a chronic physical disease (p<0.0001). After adjustment for socioeconomic factors and health conditions, depression had the largest effect on worsening mean health scores compared with the other chronic conditions. Consistently across countries and different demographic characteristics, respondents with depression comorbid with one or more chronic diseases had the worst health scores of all the disease states. INTERPRETATION: Depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes. The comorbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression. These results indicate the urgency of addressing depression as a public-health priority to reduce disease burden and disability, and to improve the overall health of populations.