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rehabilitation&#41; and social services are needed&#46; Chronic heart failure &#40;CHF&#41;&#44; stroke and chronic obstructive pulmonary disease &#40;COPD&#41; constitute diagnostic groups requiring both types of resources &#8211;social and health&#8211; as dictated by individual patient profiles&#46; Whereas the use of primary care services by such groups has frequently been described&#44; little is known about their disability patterns&#46; Recent research results emphasize the actions of interdisciplinary teams and information and communication technologies &#40;ICTs&#41;&#44; with special attention paid to fostering patient mobility at home and encouraging caregivers to undertake informal rehabilitation to achieve this goal<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Furthermore&#44; there is growing use of ICTs to support chronic home care by means of telemedicine<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> and ambient assisted living applications<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; 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The WHO-DAS II and the ICF Checklist were used to study the prevalence of disability in Spanish populations<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The 2006 Promotion of Personal Autonomy and Care of Dependent Persons Act &#40;<span class="elsevierStyleItalic">Ley 39&#47;2006&#44; de 14 de diciembre&#44; de promoci&#243;n de la autonom&#237;a personal y atenci&#243;n a las personas en situaci&#243;n de dependencia</span>&#41; lent impetus to the use of an ICF-based approach in the 2008 Disabilities&#44; Autonomy and Health Status Survey<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This study sought to assess disability in three groups of Spanish primary care patients with stroke&#44; CHF or COPD by using ICF-based methods to describe differences in disability patterns for the purpose of ICT-based service provision&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study population&#44; healthcare services and entities targeted for study</span><p id="par0025" class="elsevierStylePara elsevierViewall">The population generating the patients under study was geographically defined as that residing in former Health District XI of the Autonomous Region of Madrid &#40;Spain&#41;&#46; This population was entirely urban&#44; with the majority consisting of persons who had migrated from other Spanish regions from 1960 to 1970<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; In practice&#44; 98&#37; of this population was entitled to receive primary and hospital care free of charge&#44; provided by the Spanish public health services via the Madrid Institute of Health &#40;<span class="elsevierStyleItalic">Servicio Madrile&#241;o de Salud</span>&#41;&#46; The study population were older and had lower financial and educational levels than the general population in Madrid&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In December 2007&#44; healthcare in Health District XI was provided to 887&#44;134 individual holders of health insurance cards by 42 primary care teams&#44; comprising 521 general practitioners&#44; 111 pediatricians and 490 registered nurses&#46; Acute hospital care was provided by only three general hospitals&#44; namely&#44; the major-sized 12 de Octubre Hospital and two smaller institutions&#46; Individuals are required to be registered with a general practitioner&#44; who then becomes their compulsory supplier of health services&#46; General practitioners act as the gateway to healthcare for the population aged over 14 years and referrals to specialists&#46; The unified primary care electronic medical record is the main source of information on all diagnoses and health resources used by the patient&#46; As with other urban populations in Spain&#44; patients with CHF&#44; stroke&#44; or COPD are generally referred to hospitals or specialists by their general practitioners&#46; This study was conducted in a population of 198&#44;670 individuals over 14 years of age&#44; receiving care in the former Health District XI from 129 family medicine specialists who&#44; by way of inclusion criteria&#44; fulfilled two quality requirements in the electronic medical record registry&#44; namely&#58; <span class="elsevierStyleItalic">&#40;i&#41;</span> notes were kept on &#62;64&#37; of the visits &#40;75th percentile&#41;&#59; and <span class="elsevierStyleItalic">&#40;ii&#41;</span> the mean number of care episodes per patient was &#62;4<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Stroke&#44; CHF and COPD were selected from among 26 chronic conditions&#44; due to the comparatively higher mean individual use of health resources among patients with these diseases&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 300 patients with COPD&#44; stroke or CHF were identified from computer files kept on 3&#44;183&#44; 2&#44;658 and 1&#44;377 primary care users&#44; who were diagnosed with COPD&#44; stroke or CHF&#44; respectively&#44; and were being managed by the above-mentioned 129 physicians in 2007&#46; These numbers corresponded to prevalence figures of 21&#44; 18 and 9 per 1&#44;000 inhabitants&#44; respectively&#46; The numerators of these prevalence figures generated convenience samples&#44; yielding approximately 100 participating patients after attrition by death or refusal&#46; All participants had been officially resident in the district during the year preceding the first scheduled visit or longer&#46;A letter was mailed to all patients by the research team&#44; inviting them to participate in this study&#46; The patients&#8217; general practitioners were informed through an internal institutional procedure&#46; A week after the invitation had been sent&#44; an attempt was made to contact individual patients or their relatives by telephone in order to provide further information on the study and&#44; if the patient agreed to participate&#44; to make an appointment&#46; Letters were sequentially mailed&#44; with participants being selected until approximately 100 positive respondents had been enrolled&#44; corresponding to the profile outlined in <a class="elsevierStyleCrossRef" href="#sec0080">Table 1</a>&#46; The study included 99 volunteer patients with CHF&#44; 99 with stroke and 102 with COPD&#44; who were finally interviewed at home after informed consent had been obtained&#46; These numbers corresponded to different sampled proportions&#58; 3&#46;20&#37; for COPD&#44; 3&#46;72&#37; for stroke and 7&#46;19&#37; for CHF&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Instrument for disability measurement</span><p id="par0040" class="elsevierStylePara elsevierViewall">We used the 2nd edition of the WHO-DAS II&#44; an instrument tested in over 14 countries and 16 languages&#44; and shown to be a reliable and suitable tool with good metric properties in Spanish clinical and rehabilitation samples of chronic patients<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; The 36-item WHO-DAS II is a self-reported or interviewer-administered scale covering the following six disability domains assessed over the 30-day period preceding administration&#58; understanding and communication &#40;UAC&#41;&#44; getting around &#40;GAR&#41;&#44; self care &#40;SCA&#41;&#44; getting along with people &#40;GAP&#41;&#44; life activities &#40;LAC&#41;&#44; and participation in society &#40;PSO&#41;&#46; Items are answered on a 5-point Likert-type scale &#40;1&#58; none&#59; 5&#58; extreme&#41;&#44; which grades the difficulty experienced by the participant in performing a given activity&#46; Summary-index and domain scores range from 0 to 100&#46; We used the correct standards released by the WHO through its partner school in Spain&#44; the Psychiatry Research Unit at the Marques de Valdecilla Hospital in Santander<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; WHO-DAS II item content is summarily described in this issue of <span class="elsevierStyleSmallCaps">Gaceta Sanitaria</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and in Appendix I &#40;on-line&#41; as a version of the instrument for proxy informants&#46;The WHO-DAS II was chosen in preference to traditional instruments for several reasons&#46; Firstly&#44; the WHO-DAS II is an ICF-based instrument that is not only intended for epidemiological studies but&#44; as stated above&#44; has also proved useful in distinct clinical settings&#46; Secondly&#44; this instrument can be self-administered and used by experts or informal caregivers alike&#46; Thirdly&#44; WHO-DAS II measurements can be completed by ICF assessments of contextual&#44; physical and social environmental factors that have an impact on disability in addition to the effect of health conditions&#46; Fourthly&#44; some authors have commented on more subtle details&#58; while the Extended Katz and Lawton scales take instrumental activities of daily living measures&#44; such as those linked to domestic life&#44; into account&#44; these scales pay no attention to the various facets of disability that are known to be highly predictive of self-rated health and need for services&#44; i&#46;e&#46;&#44; the ability to communicate with others and maintain an active social life<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Field work</span><p id="par0050" class="elsevierStylePara elsevierViewall">In this study&#44; written informed consent was given by all participants in accordance with the Helsinki Declaration&#46; Participants were visited at home from April to September 2009&#44; where their disability was evaluated by professional interviewers purpose-trained in all the assessment procedures used in this study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 1&#44;053 letters were sent to the homes of patients in the sample&#44; explaining the study in general&#44; and the objective of the visit in particular&#46; Likewise&#44; their physicians were simultaneously informed about the study by surface mail&#46; Trained researchers from the Carlos III Telemedicine and e-Health Institute&#44; working in collaboration with the Madrid Regional Primary Care Authority for District XI&#44; contacted patients or their relatives by telephone to inform them of details of the current study and obtain verbal acceptance prior to written informed consent&#46; Seventy-five of the letters mailed were returned to the sender&#44; stamped &#8220;address unknown&#8221;&#46; Of the total number of persons telephoned&#44; 260 failed to answer the call&#44; 41 had died&#44; 349 refused to collaborate&#44; and 328 agreed to participate&#46; Finally&#44; 26 patients were not located at the date of the visit and&#44; of the 302 patients who did receive visits from field workers&#44; two refused to sign the consent form and 300 were assessed&#46; Differences between positive and negative respondents were less than 5&#37; by sex and were statistically non-significant by age group and comorbidity&#44; i&#46;e&#46;&#44; the number of diagnoses&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Home visits were made approximately one week after dispatch of the letter and were conducted satisfactorily&#44; despite frequent extensions due to patients or relatives needing or requesting support&#46; A team of three interviewers&#44; consisting of two social workers and one university graduate in social sciences&#44; trained by disability assessment experts in using the WHO-DAS II&#44; assessed disability at the patients&#8217; homes using a structured questionnaire adapted to the Spanish version of the 36-item WHO-DAS II and a set of items designed to examine patients&#8217; ability to use interactive telecommunication devices at home&#46; Diagnostic profiles were drawn from general practitioners&#8217; records&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The study sample was an aged&#44; lower-middle or working-class population&#44; with significant inequalities in terms of socioeconomic profiles&#58; 54&#46;3&#37; male&#44; 45&#46;7&#37; female&#44; mean age 74&#46;4 years&#46; The majority belonged to working- or lower-middle class families&#59; those needing help and not living alone were assisted by their relatives&#44; usually daughters&#46; Professional help was scarce&#58; in general&#44; subjects had home help for 1 hour on 2 days a week&#46; Most of the individuals included in the study sample were residents of Health District XI&#46; Most of the households were 3- to 4-room apartments in 4- to 5-storey buildings without an elevator&#46; The patients spent long periods of time without leaving home&#44; engaged in very few outdoor activities&#44; most of which involved visits to the primary care health center&#44; and were almost always assisted by a relative&#46; Persons with severe disabilities used special transport &#40;ambulance&#41;&#46; Ten percent of answers were provided by relatives&#47;caregivers and 90&#37; by patients&#46; In several cases &#40;15&#37;&#41;&#44; the survey was conducted with support from family members&#44; due to the patients&#8217; difficulties in providing answers or giving consent&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Data-analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">A WHO-DAS II score database was compiled&#46; Items addressing work status were differentially treated&#44; as stipulated by the Promotion of Personal Autonomy and Care of Dependent Persons Act<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; since most individuals in our sample were not gainfully employed&#46; The sexuality item was also excluded from the analysis&#44; due to an unusually high proportion of missing values&#46; The life activities domain was assessed in terms of work only among participants who still performed such activities&#46; Missing data for items with less than 30&#37; of missing values were replaced by the mean of the remaining domain values&#44; in line with reported methods<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a>&#46; Any individual leaving more than one WHO-DAS II domain blank was excluded from the analysis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The prevalence of disability was calculated as a percentage&#46; For analytical purposes&#44; disability for specific domains or in different diagnostic groups was assessed and dichotomized as present &#40;if severe or complete&#41;&#44; or as absent &#40;if none&#44; mild or moderate&#41; in terms of the ICF categories&#46; Prevalence odds ratios &#40;OR&#41; were reported as crude or as obtained from unconditional logistic regression&#46; The study was approved by the 12 de Octubre Hospital <span class="elsevierStyleItalic">ad hoc</span> Research Ethics Committee&#44; as indicated in report number 09&#47;42&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Sociodemographic features of the study sample as well as ICF disability levels are shown in <a class="elsevierStyleCrossRef" href="#sec0080">Table 1</a>&#46; Diagnostic groups displayed varied personal and life characteristics&#44; with the proportions of women&#44; elderly individuls&#44; widows&#47;widowers and receivers of support from relatives or professional caregivers increasing from lowest in patients with COPD to highest in those with CHF&#46; Extreme disability was absent in all three diagnostic groups&#46; Seventy-seven patients&#44; one-fourth of the pooled group&#44; had ICF severe disability&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Group disability levels&#44; including mean point estimates and 95&#37;CI&#44; are shown in <a class="elsevierStyleCrossRef" href="#fig0010">figure 1</a>&#46; Disability levels were lowest in patients with COPD and highest in those with stroke&#44; with a somewhat larger proportion of ICF moderate disability sufferers than that seen for the CHF group&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Disability patterns in ICF specific domains are depicted in <a class="elsevierStyleCrossRef" href="#fig0015">figure 2</a>&#46; In contrast to total or general disability&#44; ICF extreme disability was present in non-negligible percentages for life activities in CHF &#40;24&#37;&#41;&#44; and stroke &#40;11&#37;&#41;&#44; as well as for mobility and self-care in stroke and CHF&#46; Participation in society and human relationships were the least affected domains in all three groups&#44; in which the differences were small&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Sex-specific patterns for domains are shown in <a class="elsevierStyleCrossRef" href="#fig0020">figure 3</a> for COPD&#44; CHF and stroke&#46; Higher prevalences of severe&#47;extreme disability were in general observed in women&#44; except in the human relationships and self-care domains&#44; where differences in disability prevalences between genders appeared to be smaller&#46; The highest prevalence of ICF severe&#47;extreme disability was seen for mobility and social participation among persons with CHF and stroke&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The results of comparing the prevalence of ICF severe&#47;extreme disability for specific domains among groups and between the sexes&#44; by using logistic models&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a>&#46; When compared with COPD&#44; significant 2- to 3-fold OR differences were observed in five domains for stroke and a 2-fold variation was found in three domains for CHF&#44; including activities and social participation&#46; When differences by sex within groups were examined&#44; the only significant difference for global scores was observed for stroke &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;8&#59; 95&#37;CI&#58; 1&#46;12-6&#46;97&#41; in women&#46; However&#44; in the six-model groups&#44; women had almost systematically higher disability than men&#44; with the variation for life activities in COPD and stroke&#44; and for communication in COPD&#44; being particularly high&#44; 5- to 6-fold&#44; and statistically significant&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The prevalence of ICF disability categories for each of the six WHO-DAS domains among the moderate-disability group&#44; when calculated for the global WHO-DAS II score in the diagnosis-pooled group&#44; is shown in <a class="elsevierStyleCrossRef" href="#fig0025">figure 4</a>&#46; There was a remarkably high prevalence of severe&#47;extreme disability categories&#44; namely&#44; 58&#37; in mobility&#44; 50&#37; in ife activities and 16&#37; in self-care&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">The results of this study suggest that the disability patterns of the three clinical populations with selected somatic disorders show different prevalences of severe&#47;extreme disability according to the total WHO-DAS II score&#46; Prevalence was highest for stroke and CHF&#44; yet there were also some similar traits&#44; the following two in particular&#58; <span class="elsevierStyleItalic">&#40;i&#41;</span> the higher prevalence among women versus men&#44; particularly for stroke&#59; and <span class="elsevierStyleItalic">&#40;ii&#41;</span> the specific pattern by ICF domain&#44; with the highest severe&#47;extreme limitations being experienced in life activities and mobility&#46; Severe restrictions were also seen in social participation for stroke and CHF and&#44; to a lesser extent&#44; for COPD&#46; In addition&#44; moderate disability according to total WHO-DAS II score concealed substantial proportions of persons with severe&#47;extreme disability in mobility&#44; life activities and self-care&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A potential weakness of this study lies in the selection having been made by non-institutional residence&#44; physician inclusion criteria&#44; participation&#44; and recruitment of the most frequent primary care users&#44; and perhaps the most disabled patients&#46; A surprising result &#8211;attributable in part to selection bias&#8211; was the high frequency of women with COPD &#40;38&#37;&#41;&#44; since COPD is linked to smoking history&#44; which tends to be a characteristic biographical feature of Spanish men&#46; The high level of age-adjusted disability among women with stroke is consistent with stroke being the leading cause of death among Spanish women&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Instrument properties might generate uncertainty due to the field of application&#46; Garin et al&#46; described WHO-DAS-based patterns of disability in seven European diagnostic groups affected by chronic diseases and revealed a latent structure originally designed by the WHO-DAS II developers<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Accordingly&#44; the profiles described in this study for global WHO-DAS II scores may be partly due to clinical severity&#46; Similarly&#44; warnings of ceiling effects described for the WHO-DAS in general populations&#44; and suggested in this study for mobility and life activities in participants classified as moderately disabled by global WHO-DAS scores&#44; might reflect a continuum phenomenon linked to the original underlying structure&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Attention should be drawn to the remarkable disability traits in each of the three diagnostic groups&#44; and in the moderately disabled as per global disability score&#46; The existence of a systematically higher proportion of clinical populations showing severe&#47;extreme disability in specific domains such as mobility and life activities &#8211;as observed in this study and in reported observations of a composite population&#44; composed of a very old general Spanish and a comparatively younger elderly Turkish population<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> studied using the WHO-DAS II&#8211; may suggest an instrument- or ICF-related feature&#46; A potential explanation for this pattern is that the WHO-DAS II may specifically capture the nature of disability&#44; i&#46;e&#46;&#44; aspects capable of being offset by personal help or performance&#46; The pattern may highlight the potential usefulness of individual domain-specific WHO-DAS II scores for detecting the need for personal help and for planning resource allocation using information systems&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">One implication of the concealment properties of the global WHO-DAS measure for planning is that&#44; perhaps due to the broad scope of the ICF measurements&#44; individuals needing personal help to counterbalance disability in mobility and life activities would remain undetected by the global score&#46; This disadvantage points to potential shortcomings of ICF global measurements to detect the need for personal help&#44; a key variable determining the planning and provision of services&#44; whether by the WHO-DAS II&#44; ICF checklist or disease-specific or generic core sets&#46; A validated ICF-based index of need for personal help&#44; such as that proposed on other grounds<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#44; might be useful for screening both undetected and unmet need for help&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Caution should be exercised when interpreting reported WHO-DAS II measurements&#46; For instance&#44; authors use average WHO-DAS global scores of disabled persons&#44; namely&#44; those scoring a minimum of 1 point in each disability field<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; The present authors and&#44; occasionally&#44; Donmetz et al<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> report the prevalence of severe&#47;extreme disability&#46; A reason for using proportions &#40;i&#46;e&#46;&#44; prevalence frequencies&#41; is that this measure is suitable for epidemiological analysis&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Health authorities have proposed the use of medical and social resources to optimize care programs in specific groups<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a>&#46; Our results suggest that there are differential areas for improvement determined by diagnosis and that instrumental life activities and mobility generally constitute broad spheres for intervention&#46; Information systems to be used for coordinating or monitoring care and support services should take into account disability patterns in the specific domains described in this study&#44; along with the nature of the services provided&#44; since these are frequently geared to reducing disability by means of distinct mechanisms&#44; e&#46;g&#46;&#44; compensating limitations in household or functional improvement through personal help or improving mobility through rehabilitation<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; A more in-depth approach encompassing both capacity and performance falls outside the WHO-DAS II framework and would require more sophisticated&#44; individualized ICF measurements&#44; including assessment of the physical and social environment&#44; e&#46;g&#46;&#44; by using the ICF Checklist or specific ICF core sets&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In all likelihood&#44; the three groups analyzed in the present study constitute a small proportion of the prevalence-etiological fraction of severe&#47;extreme disability&#44; which among the very old in Spain is reported to be predominantly due to mental &#40;psychiatric and dementia&#41; and neurological disorders&#44; with these accounting for 59&#46;76&#37; &#40;95&#37;CI&#58; 49&#46;26-65&#46;09&#41; and 20&#46;21&#37; &#40;95&#37;CI&#58; 7&#46;78-26&#46;07&#41; of prevalent severe&#47;extreme disability&#44; respectively<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; In this population&#44; major diagnoses for disability&#44; such as heart failure or stroke&#44; yielded ORs and 95&#37;CIs of 2&#46;41 &#40;0&#46;90-6&#46;46&#41; and 4&#46;42 &#40;1&#46;67-3&#46;45&#41;&#44; respectively&#44; for severe&#47;extreme disability according to the WHO-DAS II global score&#46; However&#44; the specific conditions making the highest contribution to disability status were Alzheimer&#39;s disease and depression&#44; with prevalence-etiological fractions of 31&#46;42&#37; &#40;95&#37;CI&#58; 28&#46;47-59&#46;76&#41; and 18&#46;62&#37; &#40;95&#37;CI&#58; 9&#46;85-20&#46;21&#41;&#44; respectively&#46; When compared with CHF&#44; the above-mentioned 2-fold prevalence of stroke may indicate that&#44; due to its being more or equally prevalent and more disabling than CHF&#44; stroke generates a higher disability burden in South Madrid than either CHF or COPD&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A non-negligible issue that is not addressed in this study is the difference between disease-generated disability &#40;as opposed to disability due to comorbidity&#41; and disability in persons with a specific diagnosis&#46; As stressed by Peat&#44; attributing disability to a specific health condition of interest potentially limits insights into important interventions&#44; such as managing comorbid interactions and targeting barriers in the physical&#44; social&#44; and attitudinal environment<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46; The approximately 2-fold prevalence of severe disability among stroke patients as compared to that in the younger COPD group &#40;<a class="elsevierStyleCrossRef" href="#sec0080">Table 1</a>&#41; resulted in an OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;62&#44; when age was controlled for in the model&#46; Disregarding statistical details&#44; this difference may illustrate conceptual and empirical aspects that can probably be advantageously approached when using the ICF model in general and clinical epidemiology&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">An important question when interpreting our results&#44; as well as those yielded by studies on health-related quality of life &#40;HRQoL&#41;&#44; refers to differences among findings obtained when disability is assessed using traditional&#44; disease-specific instruments&#46; In an ICF-oriented study on neurological disorders aimed at comparing disease-specific HRQoL instrument structures&#44; we identified limitations of these instruments&#44; which frequently neglect instrumental activities and social participation&#44; since they are mainly modelled on a biomedical rather than the ICF biopsychosocial paradigm<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46; An approximation to the well-justified use of disease-specific instruments in disability research<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> is the development by expert consensus of selected check-list items for ICF core sets for stroke and COPD&#59; core set validation and the development of a generic ICF core set for the elderly&#44; among whom there is substantial multimorbidity&#44; are also under way<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#8211;33</span></a>&#46; Caution may be required when proposing inferences from disability results obtained with distinct instruments or different core sets&#46; A short ICF dictionary&#44; with examples illustrating the content of specific items in the Extended Katz&#44; Modified Check-list and WHO-DAS II 36 when assessing stroke patients&#44; is summarized in Appendix II &#40;on-line&#41;&#46; In brief&#44; the ICF model may well provide an advantageous multipurpose background for developing information systems in primary care&#44; population surveys&#44; or clinical management for distinct diagnostic groups</p><p id="par0160" class="elsevierStylePara elsevierViewall">To sum up&#44; this descriptive study shows that disability is frequently present in COPD&#44; CHF&#44; and stroke&#44; with sex- and domain-related disability patterns somewhat similar to those reported for unselected elderly of advanced age by population studies&#46; When measured by WHO-DAS II global scores&#44; moderate disability conceals substantial proportions of severe&#47;extreme disability&#44; particularly in life activities and mobility&#44; among clinical and general populations alike&#46; Disability surveys as well as individual assessments and primary care data-monitoring systems could be widely assessed by information systems based on the ICF model&#46; In addition to ICF disability categories&#44; measurement of ICF-validated categories of need for personal aid might be called for&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Authors&#8217; contributions</span><p id="par0175" class="elsevierStylePara elsevierViewall">J&#46; de Pedro&#44; A&#46; Alberquilla and L&#46; Garc&#237;a-Olmos contributed to the study design&#46; C&#46;H&#46; Salvador&#44; J&#46;L&#46; Monteagudo and J&#46; de Pedro conceived the study&#46; P&#46; Garc&#237;a-Sagredo&#44; A&#46; Alberquilla and C&#46;H&#46; Salvador supervised the field study&#46; M&#46; Carmona&#44; G&#46; Bosca and F&#46; L&#243;pez-Rodr&#237;guez assessed disability and built a data base&#46; J&#46; Viru&#233;s and E&#46; Alcalde analyzed the data&#46; J&#46; de Pedro and G Bosca wrote the first and last drafts of the manuscript&#46; All authors contributed ideas&#44; revised different drafts of the manuscript and approved the final version&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Financial support</span><p id="par0180" class="elsevierStylePara elsevierViewall">This study was partially supported by a CENIT Program &#40;MICINN-CDTI&#41; &#91;CEN-2007-1010 &#8220;Digital personal environment for health and well-being &#8211; AmiVital&#8221; project&#93;&#44; by a grant from the Carlos III Health Institute &#91;AES FIS PI08-0435&#93;&#44; by CIBERNED &#40;J&#46; Viru&#233;s&#41; and by Projects PI06&#47;1098 and PI07&#47;90206 from the <span class="elsevierStyleItalic">Fondo de Investigaciones Sanitarias</span>&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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            3 => "Results"
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          "titulo" => "Keywords"
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          "titulo" => "Introduction"
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        5 => array:3 [
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              "titulo" => "Study population&#44; healthcare services and entities targeted for study"
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              "identificador" => "sec0020"
              "titulo" => "Patients"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Instrument for disability measurement"
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              "identificador" => "sec0030"
              "titulo" => "Field work"
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          "identificador" => "xack979"
          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-05-13"
    "fechaAceptado" => "2011-08-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec12929"
          "palabras" => array:5 [
            0 => "Chronic disease"
            1 => "Disability"
            2 => "Functioning"
            3 => "Primary care"
            4 => "WHODAS II"
          ]
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      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec12930"
          "palabras" => array:5 [
            0 => "Enfermedades cr&#243;nicas"
            1 => "Discapacidad"
            2 => "Funcionamiento"
            3 => "Atenci&#243;n primaria"
            4 => "WHODAS-2"
          ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The planning&#44; provision and monitoring of medical and support services for patient groups with chronic ailments may require disability assessment and registration&#46; The purpose of this study was to assess disability in three groups of patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; chronic heart failure &#40;CHF&#41; or stroke&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Convenience samples of consecutive patients diagnosed with COPD &#40;102&#41;&#44; CHF &#40;99&#41;&#44; and stroke &#40;99&#41; were taken from 1&#44;053 primary care users in the southern area of the autonomous region of Madrid&#46; The patients were informed of the study and were assessed in their homes by trained field workers using the World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">None of the groups had patients with extreme disability on their global WHO-DAS II scores&#46; The prevalence of severe disability differed among the groups and was highest for stroke and CHF &#40;33&#46;33&#37; and 29&#46;29&#37;&#44; respectively&#41; and lowest for COPD &#40;14&#46;71&#37;&#41;&#46; The three groups shared two similar traits&#44; namely&#44; a higher prevalence of disability among women than men&#44; and a specific pattern by domain&#44; with the highest prevalence of severe&#47;extreme limitations being found in household life activities and mobility&#46; Severe restrictions in Social Participation were more frequent in patients with stroke and CHF&#46; The group with moderate disability according to the global WHODAS II score &#40;n&#61;94&#41; showed a high prevalence of severe limitations in mobility&#44; life activities and self-care&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Disability among non-institutionalized persons with COPD&#44; CHF and stroke is frequent and shows gender- and domain-related patterns similar to those described in a population-based study performed using the WHO-DAS II in elderly persons in Spain&#46; ICF-validated disability categories could be useful in epidemiological surveys&#44; individual assessments and primary care data monitoring systems&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La planificaci&#243;n&#44; prestaci&#243;n y monitorizaci&#243;n de servicios sociales y sanitarios a pacientes con trastornos cr&#243;nicos puede requerir evaluaci&#243;n y registro de su discapacidad&#46; El objetivo de este estudio fue evaluar la discapacidad de tres grupos de pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#44; insuficiencia cardiaca congestiva &#40;ICC&#41; o ictus&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Pacientes con EPOC &#40;102&#41;&#44; ICC &#40;99&#41; e ictus &#40;99&#41;&#44; vistos consecutivamente&#44; identificados de una lista de 1053 usuarios de atenci&#243;n primaria en el sur de la Comunidad Aut&#243;noma de Madrid&#44; Espa&#241;a&#46; Tras ser informados&#44; fueron evaluados en sus casas por entrevistadores entrenados utilizando WHODAS-2&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">No hubo casos de discapacidad extrema&#44; pero las tres poblaciones mostraron prevalencias de discapacidad grave seg&#250;n WHODAS-2 total&#44; m&#225;s altas en ictus e ICC &#40;33&#44;33&#37; y 29&#44;29&#37;&#44; respectivamente&#41; y menores en EPOC &#40;14&#44;71&#37;&#41;&#46; Los grupos compart&#237;an un patr&#243;n de discapacidad m&#225;s alta en mujeres y otro espec&#237;fico por dominios&#44; con prevalencias m&#225;s altas de discapacidad grave&#47;extrema en actividades dom&#233;sticas y movilidad<span class="elsevierStyleBold">&#46;</span> La participaci&#243;n social estaba m&#225;s restringida en ictus e ICC&#46; El grupo con discapacidad moderada en WHODAS-2 global &#40;94 enfermos&#41; mostraba prevalencias altas de discapacidad grave en movilidad&#44; actividades diarias dom&#233;sticas y autocuidado&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La discapacidad en personas no institucionalizadas con EPOC&#44; ICC e ictus es frecuente&#44; con patrones por sexo y dominio similares a los descritos en Espa&#241;a con WHODAS-2 en un estudio poblacional de personas de edad avanzada&#46; Las categor&#237;as CIF de discapacidad podr&#237;an utilizarse en encuestas epidemiol&#243;gicas y evaluaciones individuales&#44; as&#237; como en sistemas de informaci&#243;n orientados a la monitorizaci&#243;n de la discapacidad en atenci&#243;n primaria&#46;</p>"
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            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean and 95&#37;CI values as well as prevalence of different International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; categories by World Health Organization Disability Assessment Schedule II &#40;WHO-DAS&#41; II global score in three diagnostic groups&#46; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; chronic heart failure&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mean and 95&#37;CI values as well as prevalence of different International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; categories by World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41; score in different domains for each diagnostic group&#46; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; chronic heart failure&#46;</p>"
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        "etiqueta" => "Figure 3"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Sex-specific prevalence of different International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; categories by World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41; score in different domains for each diagnostic group&#46; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; chronic heart failure&#46;</p>"
        ]
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        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Prevalence of different International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; disability categories by World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41; score in different domains among the moderately disabled following global WHO-DAS II scores in the three diagnostic groups&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">WHO-DAS II&#58; World Health Organization Disability Assessment Schedule II&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; chronic heart failure&#59; ICF&#58;International Classification of Functioning&#44; Disability and Health&#59; OR&#58; odds ratio&#59; 95&#37;CI&#58; 95&#37; confidence interval&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">WHO-DAS II domain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="5" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Disease entity&#44; reference COPD</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Risk for women&#44; reference men</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">CHF</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Stroke</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">COPD</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">CHF</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Stroke</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Understanding and communicating&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">Getting around&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Self-care&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#46;87-4&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Getting along with people&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;0&#46;37-2&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;0&#46;31-3&#46;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Life activities&#58; household&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;1&#46;14-4&#46;48&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;1&#46;63-15&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;1&#46;93-18&#46;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Life activities&#58; work&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparative disability patterns by WHO-DAS II domain&#44; sex and disease&#46; Age- and&#44; when appropriate&#44; age- and sex-adjusted OR and 95&#37;CI for ICF severe or complete disability&#46;</p>"
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        "texto" => "<p id="par0190" class="elsevierStylePara elsevierViewall">The authors acknowledge support for implementing patient identification and selection to Dr&#46; Juan Jos&#233; Mu&#241;oz &#40;Managing Director&#41; and Dra&#46; M&#170; Teresa Alonso &#40;Medical Director&#41; from Primary Care Management I&#44; Area 11 Madrid&#44; as well as to Esther Franco&#44; Cristina Mart&#237;nez&#44; Cristina Ruiz and Olga Burzaco from the Institute for Health Sciences of Aragon for support with training on the application of the WHO-DAS II&#46;</p>"
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Original Article
ICF disability measured by WHO-DAS II in three community diagnostic groups in Madrid, Spain
Discapacidad CIF, según WHODAS-2, en tres grupos diagnósticos de atención primaria en un Área de Salud del sur de Madrid, España
Jesús de Pedro-Cuestaa,
Corresponding author
jpedro@isciii.es

Corresponding author.
, Ángel Alberquillab, Javier Virués-Ortegaa, Montserrat Carmonac, Enrique Alcalde-Caberoa, Graciela Boscad, Fernando López-Rodríguezd, Pilar García-Sagredod, Luis García-Olmose, Carlos H. Salvadord, José Luis Monteagudod
a National Center for Epidemiology, and CIBERNED, Carlos III Institute of Health, Madrid, Spain
b Multiprofessional Education Unit for Family and Community Care (Center), Madrid, Spain
c Bioengineering and Telemedicine Unit, Puerta de Hierro University Hospital, Madrid, Spain
d Telemedicine and e-Health Unit, Carlos III Institute of Health, Madrid, Spain
e Multiprofessional Education Unit for Family and Community Care (Southwest), Madrid, Spain
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Prevalence of different International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; disability categories by World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41; score in different domains among the moderately disabled following global WHO-DAS II scores in the three diagnostic groups&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic diseases are regarded as long-term illnesses that will never be altogether healed&#46; Predominant among the most important chronic conditions are mental illness&#44; musculoskeletal or degenerative neurological disease and cardiovascular disease&#46; In general&#44; affected patients request a wide array of healthcare and social resources&#44; requiring special coordination at the primary care level&#46; Some conditions&#44; such as dementia&#44; may essentially demand social rather than medical or nursing services&#46; Others&#44; such as hypertension or diabetes&#44; mainly call for medical services&#46; Healthcare planning and coordination of the provision of both health and social services is particularly essential when disability-related medical &#40;e&#46;g&#46;&#44; rehabilitation&#41; and social services are needed&#46; Chronic heart failure &#40;CHF&#41;&#44; stroke and chronic obstructive pulmonary disease &#40;COPD&#41; constitute diagnostic groups requiring both types of resources &#8211;social and health&#8211; as dictated by individual patient profiles&#46; Whereas the use of primary care services by such groups has frequently been described&#44; little is known about their disability patterns&#46; Recent research results emphasize the actions of interdisciplinary teams and information and communication technologies &#40;ICTs&#41;&#44; with special attention paid to fostering patient mobility at home and encouraging caregivers to undertake informal rehabilitation to achieve this goal<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Furthermore&#44; there is growing use of ICTs to support chronic home care by means of telemedicine<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> and ambient assisted living applications<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Coding is basic for exploiting the capabilities of ICT<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The biopsychosocial model and classification system developed by the World Health Organization &#40;WHO&#41;&#44; i&#46;e&#46;&#44; the International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; model&#44; suggest that disability is a general construct not confined to disease-specific factors&#46; The ICF incorporates a comprehensive account of personal&#44; social and environmental factors and thus opens new avenues of research for the study of disability and its determinants&#46; Few population-based studies on disability assessment in specific chronic conditions have been conducted using methods linked to the WHO-ICF model&#46; A search of the literature in Medline&#44; using search terms such as &#8220;disability&#8221;&#44; &#8220;survey&#8221; and &#8220;primary care&#8221;&#44; diagnoses such as &#8220;stroke&#8221;&#44; &#8220;COPD&#8221; and &#8220;CHF&#8221; and selection criteria applied to abstracts&#44; yielded six reports<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;12</span></a>&#46; The instruments used for disability assessment varied&#46; The WHO Disability Assessment Schedule II &#40;WHO-DAS II&#41; was used in the Measuring Health and Disability in Europe &#40;MHADIE&#41; project&#44; two stroke studies &#8211;one Slovenian and the other German&#8211; and an Iranian study in the elderly population<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46; The well-known Katz and Lawton scales were used in a Finnish study on stroke among the population aged 65 to 74 years old<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Distinct questionnaires were used to measure severe COPD-related disability in Spain<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; The WHO-DAS II and the ICF Checklist were used to study the prevalence of disability in Spanish populations<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The 2006 Promotion of Personal Autonomy and Care of Dependent Persons Act &#40;<span class="elsevierStyleItalic">Ley 39&#47;2006&#44; de 14 de diciembre&#44; de promoci&#243;n de la autonom&#237;a personal y atenci&#243;n a las personas en situaci&#243;n de dependencia</span>&#41; lent impetus to the use of an ICF-based approach in the 2008 Disabilities&#44; Autonomy and Health Status Survey<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This study sought to assess disability in three groups of Spanish primary care patients with stroke&#44; CHF or COPD by using ICF-based methods to describe differences in disability patterns for the purpose of ICT-based service provision&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study population&#44; healthcare services and entities targeted for study</span><p id="par0025" class="elsevierStylePara elsevierViewall">The population generating the patients under study was geographically defined as that residing in former Health District XI of the Autonomous Region of Madrid &#40;Spain&#41;&#46; This population was entirely urban&#44; with the majority consisting of persons who had migrated from other Spanish regions from 1960 to 1970<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; In practice&#44; 98&#37; of this population was entitled to receive primary and hospital care free of charge&#44; provided by the Spanish public health services via the Madrid Institute of Health &#40;<span class="elsevierStyleItalic">Servicio Madrile&#241;o de Salud</span>&#41;&#46; The study population were older and had lower financial and educational levels than the general population in Madrid&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In December 2007&#44; healthcare in Health District XI was provided to 887&#44;134 individual holders of health insurance cards by 42 primary care teams&#44; comprising 521 general practitioners&#44; 111 pediatricians and 490 registered nurses&#46; Acute hospital care was provided by only three general hospitals&#44; namely&#44; the major-sized 12 de Octubre Hospital and two smaller institutions&#46; Individuals are required to be registered with a general practitioner&#44; who then becomes their compulsory supplier of health services&#46; General practitioners act as the gateway to healthcare for the population aged over 14 years and referrals to specialists&#46; The unified primary care electronic medical record is the main source of information on all diagnoses and health resources used by the patient&#46; As with other urban populations in Spain&#44; patients with CHF&#44; stroke&#44; or COPD are generally referred to hospitals or specialists by their general practitioners&#46; This study was conducted in a population of 198&#44;670 individuals over 14 years of age&#44; receiving care in the former Health District XI from 129 family medicine specialists who&#44; by way of inclusion criteria&#44; fulfilled two quality requirements in the electronic medical record registry&#44; namely&#58; <span class="elsevierStyleItalic">&#40;i&#41;</span> notes were kept on &#62;64&#37; of the visits &#40;75th percentile&#41;&#59; and <span class="elsevierStyleItalic">&#40;ii&#41;</span> the mean number of care episodes per patient was &#62;4<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Stroke&#44; CHF and COPD were selected from among 26 chronic conditions&#44; due to the comparatively higher mean individual use of health resources among patients with these diseases&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 300 patients with COPD&#44; stroke or CHF were identified from computer files kept on 3&#44;183&#44; 2&#44;658 and 1&#44;377 primary care users&#44; who were diagnosed with COPD&#44; stroke or CHF&#44; respectively&#44; and were being managed by the above-mentioned 129 physicians in 2007&#46; These numbers corresponded to prevalence figures of 21&#44; 18 and 9 per 1&#44;000 inhabitants&#44; respectively&#46; The numerators of these prevalence figures generated convenience samples&#44; yielding approximately 100 participating patients after attrition by death or refusal&#46; All participants had been officially resident in the district during the year preceding the first scheduled visit or longer&#46;A letter was mailed to all patients by the research team&#44; inviting them to participate in this study&#46; The patients&#8217; general practitioners were informed through an internal institutional procedure&#46; A week after the invitation had been sent&#44; an attempt was made to contact individual patients or their relatives by telephone in order to provide further information on the study and&#44; if the patient agreed to participate&#44; to make an appointment&#46; Letters were sequentially mailed&#44; with participants being selected until approximately 100 positive respondents had been enrolled&#44; corresponding to the profile outlined in <a class="elsevierStyleCrossRef" href="#sec0080">Table 1</a>&#46; The study included 99 volunteer patients with CHF&#44; 99 with stroke and 102 with COPD&#44; who were finally interviewed at home after informed consent had been obtained&#46; These numbers corresponded to different sampled proportions&#58; 3&#46;20&#37; for COPD&#44; 3&#46;72&#37; for stroke and 7&#46;19&#37; for CHF&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Instrument for disability measurement</span><p id="par0040" class="elsevierStylePara elsevierViewall">We used the 2nd edition of the WHO-DAS II&#44; an instrument tested in over 14 countries and 16 languages&#44; and shown to be a reliable and suitable tool with good metric properties in Spanish clinical and rehabilitation samples of chronic patients<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; The 36-item WHO-DAS II is a self-reported or interviewer-administered scale covering the following six disability domains assessed over the 30-day period preceding administration&#58; understanding and communication &#40;UAC&#41;&#44; getting around &#40;GAR&#41;&#44; self care &#40;SCA&#41;&#44; getting along with people &#40;GAP&#41;&#44; life activities &#40;LAC&#41;&#44; and participation in society &#40;PSO&#41;&#46; Items are answered on a 5-point Likert-type scale &#40;1&#58; none&#59; 5&#58; extreme&#41;&#44; which grades the difficulty experienced by the participant in performing a given activity&#46; Summary-index and domain scores range from 0 to 100&#46; We used the correct standards released by the WHO through its partner school in Spain&#44; the Psychiatry Research Unit at the Marques de Valdecilla Hospital in Santander<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; WHO-DAS II item content is summarily described in this issue of <span class="elsevierStyleSmallCaps">Gaceta Sanitaria</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and in Appendix I &#40;on-line&#41; as a version of the instrument for proxy informants&#46;The WHO-DAS II was chosen in preference to traditional instruments for several reasons&#46; Firstly&#44; the WHO-DAS II is an ICF-based instrument that is not only intended for epidemiological studies but&#44; as stated above&#44; has also proved useful in distinct clinical settings&#46; Secondly&#44; this instrument can be self-administered and used by experts or informal caregivers alike&#46; Thirdly&#44; WHO-DAS II measurements can be completed by ICF assessments of contextual&#44; physical and social environmental factors that have an impact on disability in addition to the effect of health conditions&#46; Fourthly&#44; some authors have commented on more subtle details&#58; while the Extended Katz and Lawton scales take instrumental activities of daily living measures&#44; such as those linked to domestic life&#44; into account&#44; these scales pay no attention to the various facets of disability that are known to be highly predictive of self-rated health and need for services&#44; i&#46;e&#46;&#44; the ability to communicate with others and maintain an active social life<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Field work</span><p id="par0050" class="elsevierStylePara elsevierViewall">In this study&#44; written informed consent was given by all participants in accordance with the Helsinki Declaration&#46; Participants were visited at home from April to September 2009&#44; where their disability was evaluated by professional interviewers purpose-trained in all the assessment procedures used in this study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 1&#44;053 letters were sent to the homes of patients in the sample&#44; explaining the study in general&#44; and the objective of the visit in particular&#46; Likewise&#44; their physicians were simultaneously informed about the study by surface mail&#46; Trained researchers from the Carlos III Telemedicine and e-Health Institute&#44; working in collaboration with the Madrid Regional Primary Care Authority for District XI&#44; contacted patients or their relatives by telephone to inform them of details of the current study and obtain verbal acceptance prior to written informed consent&#46; Seventy-five of the letters mailed were returned to the sender&#44; stamped &#8220;address unknown&#8221;&#46; Of the total number of persons telephoned&#44; 260 failed to answer the call&#44; 41 had died&#44; 349 refused to collaborate&#44; and 328 agreed to participate&#46; Finally&#44; 26 patients were not located at the date of the visit and&#44; of the 302 patients who did receive visits from field workers&#44; two refused to sign the consent form and 300 were assessed&#46; Differences between positive and negative respondents were less than 5&#37; by sex and were statistically non-significant by age group and comorbidity&#44; i&#46;e&#46;&#44; the number of diagnoses&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Home visits were made approximately one week after dispatch of the letter and were conducted satisfactorily&#44; despite frequent extensions due to patients or relatives needing or requesting support&#46; A team of three interviewers&#44; consisting of two social workers and one university graduate in social sciences&#44; trained by disability assessment experts in using the WHO-DAS II&#44; assessed disability at the patients&#8217; homes using a structured questionnaire adapted to the Spanish version of the 36-item WHO-DAS II and a set of items designed to examine patients&#8217; ability to use interactive telecommunication devices at home&#46; Diagnostic profiles were drawn from general practitioners&#8217; records&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The study sample was an aged&#44; lower-middle or working-class population&#44; with significant inequalities in terms of socioeconomic profiles&#58; 54&#46;3&#37; male&#44; 45&#46;7&#37; female&#44; mean age 74&#46;4 years&#46; The majority belonged to working- or lower-middle class families&#59; those needing help and not living alone were assisted by their relatives&#44; usually daughters&#46; Professional help was scarce&#58; in general&#44; subjects had home help for 1 hour on 2 days a week&#46; Most of the individuals included in the study sample were residents of Health District XI&#46; Most of the households were 3- to 4-room apartments in 4- to 5-storey buildings without an elevator&#46; The patients spent long periods of time without leaving home&#44; engaged in very few outdoor activities&#44; most of which involved visits to the primary care health center&#44; and were almost always assisted by a relative&#46; Persons with severe disabilities used special transport &#40;ambulance&#41;&#46; Ten percent of answers were provided by relatives&#47;caregivers and 90&#37; by patients&#46; In several cases &#40;15&#37;&#41;&#44; the survey was conducted with support from family members&#44; due to the patients&#8217; difficulties in providing answers or giving consent&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Data-analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">A WHO-DAS II score database was compiled&#46; Items addressing work status were differentially treated&#44; as stipulated by the Promotion of Personal Autonomy and Care of Dependent Persons Act<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; since most individuals in our sample were not gainfully employed&#46; The sexuality item was also excluded from the analysis&#44; due to an unusually high proportion of missing values&#46; The life activities domain was assessed in terms of work only among participants who still performed such activities&#46; Missing data for items with less than 30&#37; of missing values were replaced by the mean of the remaining domain values&#44; in line with reported methods<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a>&#46; Any individual leaving more than one WHO-DAS II domain blank was excluded from the analysis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The prevalence of disability was calculated as a percentage&#46; For analytical purposes&#44; disability for specific domains or in different diagnostic groups was assessed and dichotomized as present &#40;if severe or complete&#41;&#44; or as absent &#40;if none&#44; mild or moderate&#41; in terms of the ICF categories&#46; Prevalence odds ratios &#40;OR&#41; were reported as crude or as obtained from unconditional logistic regression&#46; The study was approved by the 12 de Octubre Hospital <span class="elsevierStyleItalic">ad hoc</span> Research Ethics Committee&#44; as indicated in report number 09&#47;42&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Sociodemographic features of the study sample as well as ICF disability levels are shown in <a class="elsevierStyleCrossRef" href="#sec0080">Table 1</a>&#46; Diagnostic groups displayed varied personal and life characteristics&#44; with the proportions of women&#44; elderly individuls&#44; widows&#47;widowers and receivers of support from relatives or professional caregivers increasing from lowest in patients with COPD to highest in those with CHF&#46; Extreme disability was absent in all three diagnostic groups&#46; Seventy-seven patients&#44; one-fourth of the pooled group&#44; had ICF severe disability&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Group disability levels&#44; including mean point estimates and 95&#37;CI&#44; are shown in <a class="elsevierStyleCrossRef" href="#fig0010">figure 1</a>&#46; Disability levels were lowest in patients with COPD and highest in those with stroke&#44; with a somewhat larger proportion of ICF moderate disability sufferers than that seen for the CHF group&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Disability patterns in ICF specific domains are depicted in <a class="elsevierStyleCrossRef" href="#fig0015">figure 2</a>&#46; In contrast to total or general disability&#44; ICF extreme disability was present in non-negligible percentages for life activities in CHF &#40;24&#37;&#41;&#44; and stroke &#40;11&#37;&#41;&#44; as well as for mobility and self-care in stroke and CHF&#46; Participation in society and human relationships were the least affected domains in all three groups&#44; in which the differences were small&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Sex-specific patterns for domains are shown in <a class="elsevierStyleCrossRef" href="#fig0020">figure 3</a> for COPD&#44; CHF and stroke&#46; Higher prevalences of severe&#47;extreme disability were in general observed in women&#44; except in the human relationships and self-care domains&#44; where differences in disability prevalences between genders appeared to be smaller&#46; The highest prevalence of ICF severe&#47;extreme disability was seen for mobility and social participation among persons with CHF and stroke&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The results of comparing the prevalence of ICF severe&#47;extreme disability for specific domains among groups and between the sexes&#44; by using logistic models&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a>&#46; When compared with COPD&#44; significant 2- to 3-fold OR differences were observed in five domains for stroke and a 2-fold variation was found in three domains for CHF&#44; including activities and social participation&#46; When differences by sex within groups were examined&#44; the only significant difference for global scores was observed for stroke &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;8&#59; 95&#37;CI&#58; 1&#46;12-6&#46;97&#41; in women&#46; However&#44; in the six-model groups&#44; women had almost systematically higher disability than men&#44; with the variation for life activities in COPD and stroke&#44; and for communication in COPD&#44; being particularly high&#44; 5- to 6-fold&#44; and statistically significant&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The prevalence of ICF disability categories for each of the six WHO-DAS domains among the moderate-disability group&#44; when calculated for the global WHO-DAS II score in the diagnosis-pooled group&#44; is shown in <a class="elsevierStyleCrossRef" href="#fig0025">figure 4</a>&#46; There was a remarkably high prevalence of severe&#47;extreme disability categories&#44; namely&#44; 58&#37; in mobility&#44; 50&#37; in ife activities and 16&#37; in self-care&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">The results of this study suggest that the disability patterns of the three clinical populations with selected somatic disorders show different prevalences of severe&#47;extreme disability according to the total WHO-DAS II score&#46; Prevalence was highest for stroke and CHF&#44; yet there were also some similar traits&#44; the following two in particular&#58; <span class="elsevierStyleItalic">&#40;i&#41;</span> the higher prevalence among women versus men&#44; particularly for stroke&#59; and <span class="elsevierStyleItalic">&#40;ii&#41;</span> the specific pattern by ICF domain&#44; with the highest severe&#47;extreme limitations being experienced in life activities and mobility&#46; Severe restrictions were also seen in social participation for stroke and CHF and&#44; to a lesser extent&#44; for COPD&#46; In addition&#44; moderate disability according to total WHO-DAS II score concealed substantial proportions of persons with severe&#47;extreme disability in mobility&#44; life activities and self-care&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A potential weakness of this study lies in the selection having been made by non-institutional residence&#44; physician inclusion criteria&#44; participation&#44; and recruitment of the most frequent primary care users&#44; and perhaps the most disabled patients&#46; A surprising result &#8211;attributable in part to selection bias&#8211; was the high frequency of women with COPD &#40;38&#37;&#41;&#44; since COPD is linked to smoking history&#44; which tends to be a characteristic biographical feature of Spanish men&#46; The high level of age-adjusted disability among women with stroke is consistent with stroke being the leading cause of death among Spanish women&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Instrument properties might generate uncertainty due to the field of application&#46; Garin et al&#46; described WHO-DAS-based patterns of disability in seven European diagnostic groups affected by chronic diseases and revealed a latent structure originally designed by the WHO-DAS II developers<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Accordingly&#44; the profiles described in this study for global WHO-DAS II scores may be partly due to clinical severity&#46; Similarly&#44; warnings of ceiling effects described for the WHO-DAS in general populations&#44; and suggested in this study for mobility and life activities in participants classified as moderately disabled by global WHO-DAS scores&#44; might reflect a continuum phenomenon linked to the original underlying structure&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Attention should be drawn to the remarkable disability traits in each of the three diagnostic groups&#44; and in the moderately disabled as per global disability score&#46; The existence of a systematically higher proportion of clinical populations showing severe&#47;extreme disability in specific domains such as mobility and life activities &#8211;as observed in this study and in reported observations of a composite population&#44; composed of a very old general Spanish and a comparatively younger elderly Turkish population<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> studied using the WHO-DAS II&#8211; may suggest an instrument- or ICF-related feature&#46; A potential explanation for this pattern is that the WHO-DAS II may specifically capture the nature of disability&#44; i&#46;e&#46;&#44; aspects capable of being offset by personal help or performance&#46; The pattern may highlight the potential usefulness of individual domain-specific WHO-DAS II scores for detecting the need for personal help and for planning resource allocation using information systems&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">One implication of the concealment properties of the global WHO-DAS measure for planning is that&#44; perhaps due to the broad scope of the ICF measurements&#44; individuals needing personal help to counterbalance disability in mobility and life activities would remain undetected by the global score&#46; This disadvantage points to potential shortcomings of ICF global measurements to detect the need for personal help&#44; a key variable determining the planning and provision of services&#44; whether by the WHO-DAS II&#44; ICF checklist or disease-specific or generic core sets&#46; A validated ICF-based index of need for personal help&#44; such as that proposed on other grounds<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#44; might be useful for screening both undetected and unmet need for help&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Caution should be exercised when interpreting reported WHO-DAS II measurements&#46; For instance&#44; authors use average WHO-DAS global scores of disabled persons&#44; namely&#44; those scoring a minimum of 1 point in each disability field<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; The present authors and&#44; occasionally&#44; Donmetz et al<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> report the prevalence of severe&#47;extreme disability&#46; A reason for using proportions &#40;i&#46;e&#46;&#44; prevalence frequencies&#41; is that this measure is suitable for epidemiological analysis&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Health authorities have proposed the use of medical and social resources to optimize care programs in specific groups<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a>&#46; Our results suggest that there are differential areas for improvement determined by diagnosis and that instrumental life activities and mobility generally constitute broad spheres for intervention&#46; Information systems to be used for coordinating or monitoring care and support services should take into account disability patterns in the specific domains described in this study&#44; along with the nature of the services provided&#44; since these are frequently geared to reducing disability by means of distinct mechanisms&#44; e&#46;g&#46;&#44; compensating limitations in household or functional improvement through personal help or improving mobility through rehabilitation<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; A more in-depth approach encompassing both capacity and performance falls outside the WHO-DAS II framework and would require more sophisticated&#44; individualized ICF measurements&#44; including assessment of the physical and social environment&#44; e&#46;g&#46;&#44; by using the ICF Checklist or specific ICF core sets&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In all likelihood&#44; the three groups analyzed in the present study constitute a small proportion of the prevalence-etiological fraction of severe&#47;extreme disability&#44; which among the very old in Spain is reported to be predominantly due to mental &#40;psychiatric and dementia&#41; and neurological disorders&#44; with these accounting for 59&#46;76&#37; &#40;95&#37;CI&#58; 49&#46;26-65&#46;09&#41; and 20&#46;21&#37; &#40;95&#37;CI&#58; 7&#46;78-26&#46;07&#41; of prevalent severe&#47;extreme disability&#44; respectively<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; In this population&#44; major diagnoses for disability&#44; such as heart failure or stroke&#44; yielded ORs and 95&#37;CIs of 2&#46;41 &#40;0&#46;90-6&#46;46&#41; and 4&#46;42 &#40;1&#46;67-3&#46;45&#41;&#44; respectively&#44; for severe&#47;extreme disability according to the WHO-DAS II global score&#46; However&#44; the specific conditions making the highest contribution to disability status were Alzheimer&#39;s disease and depression&#44; with prevalence-etiological fractions of 31&#46;42&#37; &#40;95&#37;CI&#58; 28&#46;47-59&#46;76&#41; and 18&#46;62&#37; &#40;95&#37;CI&#58; 9&#46;85-20&#46;21&#41;&#44; respectively&#46; When compared with CHF&#44; the above-mentioned 2-fold prevalence of stroke may indicate that&#44; due to its being more or equally prevalent and more disabling than CHF&#44; stroke generates a higher disability burden in South Madrid than either CHF or COPD&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A non-negligible issue that is not addressed in this study is the difference between disease-generated disability &#40;as opposed to disability due to comorbidity&#41; and disability in persons with a specific diagnosis&#46; As stressed by Peat&#44; attributing disability to a specific health condition of interest potentially limits insights into important interventions&#44; such as managing comorbid interactions and targeting barriers in the physical&#44; social&#44; and attitudinal environment<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46; The approximately 2-fold prevalence of severe disability among stroke patients as compared to that in the younger COPD group &#40;<a class="elsevierStyleCrossRef" href="#sec0080">Table 1</a>&#41; resulted in an OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;62&#44; when age was controlled for in the model&#46; Disregarding statistical details&#44; this difference may illustrate conceptual and empirical aspects that can probably be advantageously approached when using the ICF model in general and clinical epidemiology&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">An important question when interpreting our results&#44; as well as those yielded by studies on health-related quality of life &#40;HRQoL&#41;&#44; refers to differences among findings obtained when disability is assessed using traditional&#44; disease-specific instruments&#46; In an ICF-oriented study on neurological disorders aimed at comparing disease-specific HRQoL instrument structures&#44; we identified limitations of these instruments&#44; which frequently neglect instrumental activities and social participation&#44; since they are mainly modelled on a biomedical rather than the ICF biopsychosocial paradigm<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46; An approximation to the well-justified use of disease-specific instruments in disability research<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> is the development by expert consensus of selected check-list items for ICF core sets for stroke and COPD&#59; core set validation and the development of a generic ICF core set for the elderly&#44; among whom there is substantial multimorbidity&#44; are also under way<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#8211;33</span></a>&#46; Caution may be required when proposing inferences from disability results obtained with distinct instruments or different core sets&#46; A short ICF dictionary&#44; with examples illustrating the content of specific items in the Extended Katz&#44; Modified Check-list and WHO-DAS II 36 when assessing stroke patients&#44; is summarized in Appendix II &#40;on-line&#41;&#46; In brief&#44; the ICF model may well provide an advantageous multipurpose background for developing information systems in primary care&#44; population surveys&#44; or clinical management for distinct diagnostic groups</p><p id="par0160" class="elsevierStylePara elsevierViewall">To sum up&#44; this descriptive study shows that disability is frequently present in COPD&#44; CHF&#44; and stroke&#44; with sex- and domain-related disability patterns somewhat similar to those reported for unselected elderly of advanced age by population studies&#46; When measured by WHO-DAS II global scores&#44; moderate disability conceals substantial proportions of severe&#47;extreme disability&#44; particularly in life activities and mobility&#44; among clinical and general populations alike&#46; Disability surveys as well as individual assessments and primary care data-monitoring systems could be widely assessed by information systems based on the ICF model&#46; In addition to ICF disability categories&#44; measurement of ICF-validated categories of need for personal aid might be called for&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Authors&#8217; contributions</span><p id="par0175" class="elsevierStylePara elsevierViewall">J&#46; de Pedro&#44; A&#46; Alberquilla and L&#46; Garc&#237;a-Olmos contributed to the study design&#46; C&#46;H&#46; Salvador&#44; J&#46;L&#46; Monteagudo and J&#46; de Pedro conceived the study&#46; P&#46; Garc&#237;a-Sagredo&#44; A&#46; Alberquilla and C&#46;H&#46; Salvador supervised the field study&#46; M&#46; Carmona&#44; G&#46; Bosca and F&#46; L&#243;pez-Rodr&#237;guez assessed disability and built a data base&#46; J&#46; Viru&#233;s and E&#46; Alcalde analyzed the data&#46; J&#46; de Pedro and G Bosca wrote the first and last drafts of the manuscript&#46; All authors contributed ideas&#44; revised different drafts of the manuscript and approved the final version&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Financial support</span><p id="par0180" class="elsevierStylePara elsevierViewall">This study was partially supported by a CENIT Program &#40;MICINN-CDTI&#41; &#91;CEN-2007-1010 &#8220;Digital personal environment for health and well-being &#8211; AmiVital&#8221; project&#93;&#44; by a grant from the Carlos III Health Institute &#91;AES FIS PI08-0435&#93;&#44; by CIBERNED &#40;J&#46; Viru&#233;s&#41; and by Projects PI06&#47;1098 and PI07&#47;90206 from the <span class="elsevierStyleItalic">Fondo de Investigaciones Sanitarias</span>&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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              "titulo" => "Study population&#44; healthcare services and entities targeted for study"
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              "titulo" => "Patients"
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              "titulo" => "Instrument for disability measurement"
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          "titulo" => "References"
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    "fechaRecibido" => "2011-05-13"
    "fechaAceptado" => "2011-08-08"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec12929"
          "palabras" => array:5 [
            0 => "Chronic disease"
            1 => "Disability"
            2 => "Functioning"
            3 => "Primary care"
            4 => "WHODAS II"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Enfermedades cr&#243;nicas"
            1 => "Discapacidad"
            2 => "Funcionamiento"
            3 => "Atenci&#243;n primaria"
            4 => "WHODAS-2"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The planning&#44; provision and monitoring of medical and support services for patient groups with chronic ailments may require disability assessment and registration&#46; The purpose of this study was to assess disability in three groups of patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; chronic heart failure &#40;CHF&#41; or stroke&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Convenience samples of consecutive patients diagnosed with COPD &#40;102&#41;&#44; CHF &#40;99&#41;&#44; and stroke &#40;99&#41; were taken from 1&#44;053 primary care users in the southern area of the autonomous region of Madrid&#46; The patients were informed of the study and were assessed in their homes by trained field workers using the World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">None of the groups had patients with extreme disability on their global WHO-DAS II scores&#46; The prevalence of severe disability differed among the groups and was highest for stroke and CHF &#40;33&#46;33&#37; and 29&#46;29&#37;&#44; respectively&#41; and lowest for COPD &#40;14&#46;71&#37;&#41;&#46; The three groups shared two similar traits&#44; namely&#44; a higher prevalence of disability among women than men&#44; and a specific pattern by domain&#44; with the highest prevalence of severe&#47;extreme limitations being found in household life activities and mobility&#46; Severe restrictions in Social Participation were more frequent in patients with stroke and CHF&#46; The group with moderate disability according to the global WHODAS II score &#40;n&#61;94&#41; showed a high prevalence of severe limitations in mobility&#44; life activities and self-care&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Disability among non-institutionalized persons with COPD&#44; CHF and stroke is frequent and shows gender- and domain-related patterns similar to those described in a population-based study performed using the WHO-DAS II in elderly persons in Spain&#46; ICF-validated disability categories could be useful in epidemiological surveys&#44; individual assessments and primary care data monitoring systems&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La planificaci&#243;n&#44; prestaci&#243;n y monitorizaci&#243;n de servicios sociales y sanitarios a pacientes con trastornos cr&#243;nicos puede requerir evaluaci&#243;n y registro de su discapacidad&#46; El objetivo de este estudio fue evaluar la discapacidad de tres grupos de pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#44; insuficiencia cardiaca congestiva &#40;ICC&#41; o ictus&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Pacientes con EPOC &#40;102&#41;&#44; ICC &#40;99&#41; e ictus &#40;99&#41;&#44; vistos consecutivamente&#44; identificados de una lista de 1053 usuarios de atenci&#243;n primaria en el sur de la Comunidad Aut&#243;noma de Madrid&#44; Espa&#241;a&#46; Tras ser informados&#44; fueron evaluados en sus casas por entrevistadores entrenados utilizando WHODAS-2&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">No hubo casos de discapacidad extrema&#44; pero las tres poblaciones mostraron prevalencias de discapacidad grave seg&#250;n WHODAS-2 total&#44; m&#225;s altas en ictus e ICC &#40;33&#44;33&#37; y 29&#44;29&#37;&#44; respectivamente&#41; y menores en EPOC &#40;14&#44;71&#37;&#41;&#46; Los grupos compart&#237;an un patr&#243;n de discapacidad m&#225;s alta en mujeres y otro espec&#237;fico por dominios&#44; con prevalencias m&#225;s altas de discapacidad grave&#47;extrema en actividades dom&#233;sticas y movilidad<span class="elsevierStyleBold">&#46;</span> La participaci&#243;n social estaba m&#225;s restringida en ictus e ICC&#46; El grupo con discapacidad moderada en WHODAS-2 global &#40;94 enfermos&#41; mostraba prevalencias altas de discapacidad grave en movilidad&#44; actividades diarias dom&#233;sticas y autocuidado&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La discapacidad en personas no institucionalizadas con EPOC&#44; ICC e ictus es frecuente&#44; con patrones por sexo y dominio similares a los descritos en Espa&#241;a con WHODAS-2 en un estudio poblacional de personas de edad avanzada&#46; Las categor&#237;as CIF de discapacidad podr&#237;an utilizarse en encuestas epidemiol&#243;gicas y evaluaciones individuales&#44; as&#237; como en sistemas de informaci&#243;n orientados a la monitorizaci&#243;n de la discapacidad en atenci&#243;n primaria&#46;</p>"
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            "etiqueta" => "Appendix A"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Sex-specific prevalence of different International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; categories by World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41; score in different domains for each diagnostic group&#46; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; chronic heart failure&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Prevalence of different International Classification of Functioning&#44; Disability and Health &#40;ICF&#41; disability categories by World Health Organization Disability Assessment Schedule II &#40;WHO-DAS II&#41; score in different domains among the moderately disabled following global WHO-DAS II scores in the three diagnostic groups&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">WHO-DAS II&#58; World Health Organization Disability Assessment Schedule II&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; chronic heart failure&#59; ICF&#58;International Classification of Functioning&#44; Disability and Health&#59; OR&#58; odds ratio&#59; 95&#37;CI&#58; 95&#37; confidence interval&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">WHO-DAS II domain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="5" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Disease entity&#44; reference COPD</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Risk for women&#44; reference men</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">CHF</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Stroke</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">COPD</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">CHF</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Stroke</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Understanding and communicating&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#46;62-2&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#46;14-5&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#46;10-13&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#46;68-4&#46;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#46;71-4&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Getting around&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">300&nbsp;