[Fwd: MDS]

[Guest guest]

The attached note from Guccione (APTA Division of Practice and Research)

is forwarded, with permission, because I think it might be of general interest.

I, for one, would be very interested in more information regarding the MDS-PAC

development. Anyone have any further insights?

Mark

--

Mark R Eliason, PT

meliason@...

Apple Valley, Minnesota, USA

I have been reading the posts on the MDS and the FIM. I would like to

share with you some of the work we have been doing at APTA

regarding the MDS, which I hope you will also share with the members of

the listserve.

HCFA is currently revising the 9th draft of the Post-Acute Care MDS

(MDS-PAC), which promises to be " THE " MDS for all settings in the near

future and replace the MDS 2.0 in all settings. It has even been

mentioned that the MDS-PAC will replace the OASIS in home health

somewhere down the road. APTA, along with the other members of the

Trialliance (AOTA and ASHA), has been working directly with the

developers of the MDS-PAC to ensure that there is some relevance to

rehabilitation, a severe shortcoming in the first 8 drafts.

APTA as well as AOTA and ASHA have strenuously objected to HCFA's

intention to use the MDS-PAC as an outcome instrument based on the

fact that the information collected is far too crude to ensure that patient

groupings were homogeneous and received comparable therapy as

interventions. After the addition/modification of 23 specific items, we

feel more comfortable in supporting the MDS-PAC as a descriptive tool

which may be appropriate for certain kinds of comparative studies, but

do not support use of the MDS-PAC as a therapy-specific measure of

outcomes. We have also been able to bring some of the terminology

closer to Guide. However, there is no way that the MDS is suitable for

measuring function at the level necessary to plan interventiion or show

the effectiveness of therapy, except in the broadest sense.

The FIM has been shown to be reliable and valid, but primarily in stroke

patients. There is some indication that it is not sensitive to change in

patients without multisystem impairments, eg, the patient with severe

degenerative arthritis of both knees in contrast to the patient with stroke,

particularly with its summative scoring method. Due to the intense

lobbying of the FIM supporters against the 6th draft version of the

MDS-PAC, certain components of the FIM were incorporated into the

latest versions of the MDS-PAC. Originally, the MDS-PAC was to have

been completed by July 1, 1998. It has obviously missed that deadline.

I am somewhat concerned that MDS is being treated as a functional

assessment tool. At best, it is a summary of complex functional status

data which is collected by therapists. Similarly, I am concerned that FIM

proponents automatically assume that it is the single best instrument for

all settings involving older adults, especially inpatient rehabilitation.

Consistent with the Guide, functional assessment instruments should be

selected for their relevance to the characteristics of the patient

population. One size does NOT fit all. For some populations, the FIM will

be an excellent tool. However, in my experience it does not work well in

outpatient settings such as geriatric primary care clinics, where the

population's lowest level of function is higher than an inpatient

population's average level of function. Neither does the SF-36 which is

the most psychometrically documented instrument of all time, because it

was developed to be used on general medical adult populations. The

real key is the match between clinical needs and a reliable and valid

instrument. Thus, all of us need to distinguish between the necessary

paperwork such as the MDS (which does yield some broad-brush

insight) with functional assessment for a specific population or patient

with sufficient detail to plan and monitor treatment. Toward this end,

APTA is busily engaged in developing Part 4 of the Guide, which will

cover the standardization of functional assessment in physical therapy.

We anticipate that this project will be completed near the end of 2000 and

available by 2001.

A. Guccione, PhD, PT, FAPTA

Senior Vice President

Division of Practice and Research

American Physical Therapy Association