Health classifications: Developments and applications

1. Health classifications: Developments and applications National Centre for Classification in Health Richard Madden

2. Outline • Family of International Classifications (WHO-FIC) • Australian modifications: future possibilities • Applications, including Activity Based Funding (ABF) • Sub-acute assessment instruments

3. WHO Family of Classifications: Reference Classifications International Classification of Diseases – ICD International Classification of Functioning, Disability and Health – ICF International Classification of Interventions – ICHI

4. International Classification of Diseases (ICD)

5. ICD Revision • ICD has existed since late 19th century • Earlier work by Farr, Bertillon (Moriyama 2011, NCHS website) • Designed for cause of death classification • Morbidity as a secondary use from 1948 • ICD-10 1990 • ICD revision • Revision process • Foundation layer • Versions (Linearisations) • Coding standards • Implications for user countries

6. ICD-11 Morbidity Coding Standards • ICD-10 version only for single condition coding • hence the Australian Coding Standards, for multiple condition coding • Standards have been debated by the Morbidity Reference Group (2007-2010) and the Morbidity TAG (2010-2012), but there is no finality • Aim is a set of standards for multiple condition coding • Issues include • Post coordination (X chapter) • Main condition

7. Implications for user countries • Field trials for Morbidity version • to test morbidity version (against ICD-10 and national modifications) • to analyse problematic topics • to influence final version of ICD-11 morbidity • Inclusion of ICD-11 material in ICD-10 and so national modifications • Future national morbidity applications/modifications of ICD-11: • aim should be early (2019?) adoption of ICD-11 for morbidity with minimum modification • WHO will require national modification material to be included in ICD-11

8. International Classification of Health Interventions

9. Development of ICHI • WHO International Classification of Procedures in Medicine: 1978 • Decision not to update in late 1980s • Multiple national classifications • Australia • Canada • China • France • Germany • UK • US

10. Why develop ICHI? • Proliferation of national classifications • Limited scope of national classifications • Many countries without a classification • Enable international comparisons

11. ICHI Development to date • Began 2007, by WHO-FIC Family Development Committee • Structure, Content Model and Coding Scheme finalised 2010 • Alpha version released October 2012 • Target, Action and Means axes • Medical and surgical interventions • Public health interventions • Editorial and coding rules • Alpha 2 version October 2013, further development for • Functioning interventions • Mental health interventions • Nursing interventions • Primary care interventions

12. Features of ICHI • Limited granularity • Useable as is in some countries • Facilitate international comparisons • Limited updating required • Broad coverage • Ensures counting of all types of interventions • Base for national classifications • Map existing classifications to ICHI (Canada, China, France use same structure) • New national classifications • Redevelopment of existing classifications (Australia, Germany, UK)

13. ICHI Organising Principle “What is done to whom, and how” Excludes: Who performs the intervention (Provider) Why (Diagnosis, functioning) Where (Setting)

14. Health Intervention 1. Target 2. Action 3. Means

15. International Classification of Functioning, Disability and Health (ICF)

16. Activities Participation Body functions & structures Environmental Factors Personal Factors ICF biopsychosocialmodel Health Condition (disorder/disease) 16

17. ICF dimensions Body functions Body structures Activities and participation (A & P) Environmental factors

18. Broad description of Health: ICD and ICF together ICD and ICF together: ‘provide exceptionally broad yet accurate tools to capture the full picture of health’ (ICD-10 Second Edition) ‘provide a broader and more meaningful picture of the health of people or populations’ (ICF) Focus on ICD alone ignores important aspects of health

19. Related WHO-FIC Classifications • ATC (medicines) • ICPC (primary care) • ICECI (external causes) • ICNP (nursing practice) • ISO 9999 (aids and appliances)

20. Future Australian Classifications: ICD • Need for Australian modification will change/diminish; will depend on • Content of ICD morbidity version • ICD updating: timeliness and quality • ICD coding standards (not likely to replace ACS) • Matter for many agencies to consider : AIHW, IHPA, NHISSC, jurisdictions

21. Future Australian Classifications: ACHI Not reviewed since development in mid 1990s: • ACHI is based on the Medical Benefits Schedule, itself derived from the AMA’s Most Common Fee list (pre-Medibank) • ACHI has limited scope for expansion • Varying granularity • Does not cover ambulatory well • ICHI can provide a base for a new classification

22. Applications of ICD, ACHI and ICF • Activity Based Funding • Acute (possible inclusion of functioning) • Sub-acute (ICF based approach discussed later) • Ambulatory • Patient safety • Health system • Quality • Planning • Public health • Aggregation (vaccination coverage, infectious, chronic disease management) • Visibility

23. Sub-acute assessment instruments review • University of Sydney, August 2012-March 2013 • Followed 2011 PwC initial review and analysis • Wide consultation across Australia • Adopted ICF as the benchmark for assessment review • Reviewed a wide range of assessment instruments • Issues for specific groups: children, rural/remote, Indigenous • ‘Need for assistance’ is the assessment construct, not ‘difficulty’

24. Sub-acute classification: rehabilitation • AN-SNAP, reliant on FIM assessment • Opinions on the FIM varied: • Assesses need for assistance • Inpatients: FIM domains adequate (including Faculty view); others considered that the domains were not sufficient for complex rehabilitation care • Non-admitted: Broad agreement on the need for expansion of domain range • Critical comments were made on ceiling effects and the adequacy of the cognition domains • The training program was seen as a strength and also a burden (formality) • Strong view that the large investment in the FIM and related systems should not be discarded lightly

25. Rehabilitation Option 1: medium term Option 1(medium term): a combination of instruments FIM would be retained A second instrument would be added, to assess need for assistance in relation to the range of ICF A&P domains not covered by the FIM The Assessment of Living Skills and Resources (ALSAR) is proposed as the additional instrument Clinician could have the option of not using the ALSAR, with the minimum ALSAR score being assigned An additional instrument, the Rowland Universal Dementia Assessment Scale (RUDAS), could be included to improve assessment of cognition Alternative version for children: weeFIM + CASP

26. Rehabilitation Option 2: longer term Option 2 (longer term): development of a new instrument, AusRehab Designed to measure need for assistance AusRehab consists of 18 items covering the full range of ICF A&P domains Six of the 18 domains can be mapped directly from the FIM items, meaning that FIM users would need to assess 12 additional domains Broad groups of Activities and Participation domains: Learning, management and communication Mobility Self-careGetting along with people Performance in major areas of life Community participation

27. Rehabilitation Option 2 (continued) • AusRehab would apply to inpatients and non-admitted patients • Impact of behaviours of concern on costs: possible extra item • Suggested 5 point scale • Close alignment of AusRehab domains with Occup. Therapy AusTOMs • 15 domain version for children, AusRehabChild (includes Play)

28. Geriatric Evaluation and Management (GEM) Substantial inconsistency in use of the GEM care type across Australia: 68% of Australian GEM public hospital separations were in Victoria in 2010-11 The importance of co-morbidities in GEM patients Option 1: FIM + ALSAR, possibly also RUDAS Option 2: New instrument AusGEM 17 items across full range of ICF A&P domains In-patients and non-admitted patients Co-morbidities: test a small range for cost explanatory impact

29. Palliative care • General satisfaction with uses of phases of care • Four instruments in use (PCOC instruments) • Limited use of psycho-social factors • Longer term proposal to develop a new instrument: • AusPallCare 6 domains (incorporating the 4 RUG-ADL domains) Changing and maintaining body position Transferring ones' self Toileting Eating Interpersonal interactions and relationships Community, social and civic life

30. Palliative care (continued) • AIHW found that 45% of patients coded as receiving palliative care are not palliative care type. • AusPallCare should be applied to all patients receiving palliative care • Instrument for children needs more consideration, noting many patients are acute care type (strong interest from Australian and New Zealand Paediatric Palliative Care Reference Group)

31. Other care types • Psychogeriatric • Included in the considerations of the IHPA Mental Health Working Group, and decisions on assessment should be made in light of the recommendations of that Group • Possible 7 domain instrument described (ICF based, include RUG-ADL domains) • Maintenance • Continue with RUG-ADL • Issue of recording barriers to discharge (ICD codes)

32. Thank you