HANDICAP IN INFLAMMATORY ARTHRITIS

Transcription

1 British Journal of Rheumatology 19;35: HANDICAP IN INFLAMMATORY ARTHRITIS R. H. HARWOOD, A. J. CARR,* P. W. THOMPSON* and S. EBRAHEM Department of Public Health, Royal Free Hospital Medical School, London NW3 2PF and * Department of Rheumatology, Poole Hospital NHS Trust, Poole, Dorset BH152JB SUMMARY Two instruments measuring handicap were evaluated and compared with clinical, laboratory and disability measures. Participants were 133 patients attending a rheumatology follow-up clinic in a district general hospital, of whom 12 were followed up after 3 months. Measurements included acute-phase response, early morning stiffness, pain, wellbeing, joint involvement (impairments), the Stanford Health Assessment Questionnaire (disability), the Disease Repercussion Profile and the London Handicap Scale (handicap). A substantial burden of disability and handicap was recorded. There were moderate correlations between impairments (.4 < rho <.6), and moderate to strong correlations between disability and handicap measures (.4 < rho <.8). Correlations between impairment and disability/handicap were weak (rho <.4). Mean changes in all variables over 3 months were small, and none was statistically significant. A comprehensive description of the impact of disease and treatment requires measurements to be made of impairments, disabilities and handicaps. The use of clinical and laboratory variables alone may be misleading. KEY WORDS: Outcomes, Health status, Impairments, Disability evaluation. Handicaps, Rheumatoid arthritis. MEASURES of disease activity and severity are required to assess patients' needs, monitor progress and compare the effects of interventions. Traditional measures of severity have concentrated on clinical or laboratory variables. More recently, instruments have been developed to measure other consequences of disease, including disability, psychological sequelae and overall health status [1-3]. The International Classification of Impairments, Disabilities and Handicaps [4] attempted to give a logical and comprehensive framework for considering these consequences. Impairments refer to abnormalities of anatomical, physiological or psychological structure or function. Examples from the Qassification include pain, weakness and stiffness and, by extension, laboratory markers such as the erythrocyte sedimentation rate (ESR) and estimates of subjective 'wellbeing'. Disabilities are limitations in the performance of tasks or activities (such as dressing, walking or preparing food). Handicaps refer to the disadvantages suffered because of ill health (e.g. social isolation and reduced income), and take into account the physical environment, the availability of help and resources, and the importance accorded by each individual to different activities. The relationships between impairments, disabilities and handicaps are important because, conventionally, clinicians monitor disease severity and progression using measures of impairment (or other 'biological' indicators), which are assumed to be fairly objective. Measuring disability has also become well established. However, these things are ultimately of less concern to Submitted 25 November 1994; revised version accepted 18 March 19. Correspondence to: R. Harwood, Department of Health Care of the Elderly, B Floor Medical School, Queen's Medical Centre, Nottingham NG7 2UH. 891 patients than handicap. Handicap is also important because it may be reduced even when impairment and disability cannot (by means of environmental modifications, social benefits and so on). By avoiding irrelevant and immutable items, handicap measures are potentially more sensitive to change, important in the evaluation of interventions. In any one individual, there may be wide discrepancies between the severity of impairments, disabilities and handicaps. In groups of subjects, the relationship between them may, however, be more or less linear. If this is so, for epidemiological and health services research purposes it would make little difference what is measured, since handicap could be assumed from measures of impairments. This study aimed to evaluate two new handicap measurement scales in a group of patients attending a rheumatology clinic, and to describe the association between measures of impairment, disability and handicap. METHODS Patients, setting and measurements Consecutive patients attending a rheumatology follow-up clinic in a district general hospital were registered for the study. Patients diagnosed as having an inflammatory arthritis by a consultant rheumatologist were routinely followed up by specially trained nurses and physiotherapists. Data were collected during clinic visits and by interview with a research assistant (AJQ. Clinical and laboratory data were recorded, including rheumatoid factor status, haemoglobin, ESR, C-reactive protein (CRP), duration of early morning stiffness, and two indices of joint involvement, the Ritchie and Thompson-Kirwan indices [5,6]. The Ritchie Index measures joint tenderness, by rating each group of joints on a -3 scale, then summing the scores for different groups of 19 British Society for Rheumatology on 27 June 218

2 892 BRITISH JOURNAL OF RHEUMATOLOGY VOL. 35 NO. 9 Age(yr) Disease duration (yr) London Handicap Scale Health Assessment Questionnaire (HAQ) Disease Repercussion Profile Functional activities Social activities Job and money Relationships Body image Pain visual analogue scale Wellbeing visual analogue scale Ritchie Index Thompson-Kirwan Index Duration of early morning stiffness (min) C-reactive protein (mg/1) Erythrocyte sedimentation rate (mm/h) Haemoglobin (g/dl) TABLE I Initial characteristics of patients Mean Median Interquartile range Range ^ joints. The Thompson-Kirwan Index is a combined measure of joint tenderness and soft tissue swelling. Each joint has a weight assigned and these scores are summed for the involved joints. Pain and general wellbeing were measured on 1 mm long visual analogue scales (VAS; = no pain and maximum wellbeing, 1 = maximum pain and worst wellbeing) [7, 8]. Disability was measured using the Stanford Health Assessment Questionnaire (HAQ), which includes items on dressing and grooming, rising, eating, walking, hygiene, functional reach and grip, and activities [9]. Handicap was measured using a newly developed arthritis-specific measure, the Disease Repercussion Profile (DRP) [1], and a generic measure, the London Handicap Scale [11-13]. The DRP comprises six VAS covering the importance to the patient of the effect of arthritis on day-to-day (functional) activity, social activity, employment/ money, relationships, emotions and body image. Each is given a score between and 1, with representing 'not at all important' and 1 being 'extremely important'. The resulting profile is a guide to the handicap experienced by the individual as a result of arthritis, combining both the extent to which disease affects life and the value to the individual of each area. The London Handicap Scale has six dimensions, covering mobility, physical independence, occupation, social interaction, orientation and economic selfsufficiency. Weighted scores from each of these dimensions are combined into a single index, ranging from 1 in subjects experiencing no disadvantage to for subjects with extreme disadvantage in every dimension. The weights were derived from a general population sample, making the measure valid for group comparisons rather than individual assessments. Patients were reviewed 3 months later using the same measurements. Statistical analyses Analyses aimed to characterize the distribution of handicap in this population, and to test the hypotheses that there were linear relationships between measures of disease activity, disability and handicap. The relationship between 'individual' handicaps measured on the different dimensions of the DRP and the 'societal' handicap quantified by the London Handicap Scale was examined. The internal consistency of the disability and handicap scales was calculated using Cronbach's TABLE II Distribution of handicaps on the six dimensions of the Disease Repercussion Profile Importance of problem ( - none, 1 - very) Functional activities Social activities Job/money Relationships Body image 3(11%) 41 (32%) 85 (66%) 83 (65%) 64 (5%) 67 (52%) 6 (5%) 3 (2%) 2 (2%) 5 (4%) 9(7%) 1 (8%) 6 (5%) 5 (4%) 26 (2%) 22 (17%) 1 (8%) 7 (5%) 1 (8%) 13 (1%) 24 (19%) 2 (16%) 11 (9%) 12 (9%) 15 (12%) 18 (14%) 32 (25%) 31 (24%) 13 (1%) 2 (16%) 3 (23%) 21 (16%) on 27 June 218

3 HARWOOD ET AL.: HANDICAP IN INFLAMMATORY ARTHRITIS 893 TABLE III Distribution of handicaps on the six dimensions of the London Handicap Scale Level of disadvantage (1 least, 6 = most) Mobility Physical independence Occupation Social integration Orientation Economic self-sufficiency 36 (31%) 26 (22%) 11 (9%) 51 (44%) 91 (78%) 21 (19%) 45 (38%) 22 (19%) 35 (3%) 43 (37%) 24 (21%) 51 (44%) a statistic and performing a principal components factor analysis. Correlations between measures of impairment, disability and handicap were measured using Spearman's rank correlation coefficient (rho). Sensitivity to change was measured by calculating mean and median changes over 3 months for each variable. 'Effect sizes' (mean change/s.d. of the initial distribution) were calculated to standardize the magnitude of changes for the different ranges of scores seen in the population [14, 15]. Conventionally, an effect size of 5=.8 is considered to reflect a large change,.5-.8 a moderate change and.2-.5 a small change. The statistical significance of differences between the initial and 3 month measurements was tested with a Wilcoxon signed-rank test. To demonstrate the range of changes, the upper and lower quartiles of change were calculated, and standardized for initial S.D. (to make them comparable to the effect size). Correlations between changes were calculated (Pearson's r) as a test of internal validity. Patients who had full data on all the variables were compared with those who did not, to investigate whether they differed systematically. Median age, duration of disease, initial HAQ score, pain score, Ritchie Index, haemoglobin concentration and sex distribution were compared for patients with and without initial London Handicap Scale scores, duration of early morning stiffness, ESR and CRP. Patients who were followed up after 3 months were also compared with those who were not. frequency 23 (2%) 42 (36%) 19 (16%) 14 (12%) 2 (2%) 22 (19%) 13(11%) 25 (22%) 37 (32%) 9(11%) 16 (14%) 1 (1%) 15 (13%) 5 (4%) RESULTS A total of 133 patients were registered; 126 (95%) had rheumatoid arthritis, two had Reiter's syndrome and five had psoriatic arthropathy. Seventy-five per cent were rheumatoid factor positive. Mean age was 61 yr (range 22-84) and mean disease duration was 11 yr (range.7-4 yr); 74% were female, 17% lived alone, 57% had retired, 2% were housewives and 2% were employed. Co-morbid disease was present in 5% of subjects; 35% reported one additional diagnosis, 13% two diagnoses, 2% three diagnoses and one subject six diagnoses. The commonest additional diagnosis was hypertension in 23%. Follow-up data at 3 months were available on 12 subjects, although with some missing data, numbers for some variables were fewer, notably 79 for the London Handicap Scale, 86 for early morning stiffness and 24 for the ESR. Missing data arose partly due to changes in the routine practice of the clinic (the choice between the ESR and CRP), through failure of clinic staff to record some variables and of some patients to attend for blood tests, and because the London Handicap Scale was added to the battery of measurement instruments after the start of the study. Scale characteristics of the disability and handicap measures Cronbach's a statistic was.95 for the HAQ,.84 for the six items in the DRP and.83 for the six items of the London Handicap Scale, indicating good internal consistency for the scales. This was confirmed with the principal components factor analysis. Each scale had one dominant factor (accounting for 65% of the variance in the HAQ, 55% of the variance in the DRP and 55% of the variance in the London Handicap Scale). Initial characteristics»! u-» no* n-4* 4i-M si-m «-7» handicap (tore n-m»-»»i-ioe -116 Fio. 1. Distribution of London Handicap Scale scores. on 27 June 218 Pain, wellbeing, HAQ and London Handicap Scale scores were approximately symmetrically distributed, whilst the distributions of other variables were all markedly skewed (Table I). The mean HAQ score was 1.6 (out of 3, range -3) and the mean London Handicap Scale score was 73 (out of 1, range 39-1), indicating considerable disability and handicap in the study population. Responses on the individual components of the DRP demonstrated that severe handicap was common in functional activities

4 894 BRITISH JOURNAL OF RHEUMATOLOGY VOL. 35 NO. 9 ESR EMS Pain Wellbeing Ritchie Index Thompson-KJrwan Index TABLE IV Relationships between measures of impairment (Spearman's rank correlation coefficient) CRP ESR EMS Pain Wellbeing Ritchie.36f.1.3t $.29*.18.23*.421.5$.52$.54$.33$.59$.52$.37J CRP, C-reactive protein; EMS, duration of early morning stiffness; ESR, erythrocyte sedimentation rate. P <.5; t^ <.1; \P <.1..44$.32$.51J and social activities, but significant minorities also experienced handicap in other dimensions (Table II). On the London Handicap Scale, occupation and physical independence were particular problems, whilst orientation handicap was relatively slight (as might be expected in an out-patient rheumatology population; Table III). The distribution of scores on the London Handicap Scale is shown in Fig. 1. The 17 patients with missing initial London Handicap Scale data were younger than those with data (median 52 yr compared with 64 yr) and were more likely to be female (88% compared with 72%). However, disease duration, HAQ, pain and Ritchie scores, and haemoglobin were similar. The 3 patients with missing CRP data had a longer duration of disease (median 11 yr compared with 6 yr), but were otherwise similar to those with data. There were no differences between patients with and without initial early morning stiffness data and ESR measurements, nor between patients with and without follow-up data. Associations between measures of disease Impairment-impairment. There were moderately strong correlations (.4 < rho <.6) between most laboratory and clinical measures (broadly measures of impairment: Ritchie Index, Thompson-Kirwan Index, duration of early morning stiffness, pain, wellbeing, CRP, ESR), although some associations were only weak, in particular those involving the CRP (Table IV). Impairment-disability I handicap. The associations between laboratory/clinical variables on the one hand and disability/handicap measures on the other were weaker than those amongst the impairment measures alone. All the correlations with the CRP and Thompson-Kirwan Index were weak or absent. The Ritchie Index had weak to moderate correlations with all the disability/handicap measures, except the DRP jobs and money item. Pain, wellbeing and duration of early morning stiffness also showed weak correlations with all disability/handicap measures, except jobs/ money, but these correlations were stronger than would have been expected by chance alone. The ESR showed weak, but statistically significant, correlations with both the HAQ and London Handicap Scale, and DRP social activities and body image items (Table V). Disability-handicap. There were strong correlations between DRP items measuring functional and social activities (rho =.76). The other DRP items correlated less strongly with each other. The London Handicap Scale correlated strongly with the HAQ (Pearson's r =.76). There were moderately strong associations between the HAQ, London Handicap Scale and DRP subscales concerned with functional activities and social activities (.4 < rho <.6), but correlations with other DRP items were weaker. All the associations were statistically significant (Table VI). Changes over 3 months Mean changes were small for all variables (Table VH). The median change was zero for all variables except the Ritchie Index. The measure with the largest effect size was the ESR. However, the distribution of changes in the ESR was very skewed, making the mean a misleading summary. Typical experience is better reflected by the median, which was CRP ESR EMS Pain Wellbeing Ritchie Thompson-KJrwan TABLE V Relationships between measures of impairment and disability/handicap (Spearman's rank correlation coefficient) HAQ.17.41$.35$.26T.24f.4$ t -.29t -.25* -.21t -.35$ -.5 Functional t.26f.16.36$.12 Social.8.32f.4$.24f.22*.29$.8 Disease Repercussion Profile Job/money *.9.8 Relations $.2*.26t.25f *.18*.28f.28$.15 CRP, C-reactive protein; EMS, duration of early morning stiffness; ESR, erythrocyte sedimentation rate; HAQ, Health Assessment Questionnaire;, London Handicap Scale. *P <.5; \P <.1; $P <.1. Body.1.28*.2*.21*.2*.28t.12 on 27 June 218

5 HARWOOD ET AL.: HANDICAP IN INFLAMMATORY ARTHRITIS 895 HAQ DRP functional DRP social DRP money DRP relations DRP emotions TABLE VI Relationships between measures of impairment and disability/handicap (Spearman's rank correlation coefficient) -.71* Functional.59*.51J Social.54* -.52$.76* Disease Repercussion Profile Job/money o.u* -.34*.32*.21* Relations.36* -.47*.43*.51*.41* HAQ, Health Assessment Questionnaire;, London Handicap Scale; DRP, Disease Repercussion Profile. fp<.1; *i><.1. Variable CRP EMS ESR Pain WeUbeing Ritchie Index Thompson-Kirwan Index HAQ DRP functional activities DRP social activities DRP job/money DRP relationships DRP emotions DRP body image.2* -.31*.51*.4*.43f.52* TABLE VII Sensitivity to change of different measures (negative scores represent improvement unless stated otherwise) n Mean change (95% CI) -1 (-9,5) -3 (-46,41) + 5 (-7, 18) -.2 (-5, 4) (-2. 7) -.3 (-1.6, 1.) (-9, 16) -.6 (-.14,.2) +.9 (-1,3) (-.6,.6) -.6 (-1.4,.1) +.1 (-.5,.8) +.4 (-.3, 1.2) (-.8,.9) +.1 (-.7,.9) Median change -1. Effect size Standardized upper quartile change Body.43* -.35*.55*.39*.39*.5*.5* Standardized lower quartile change CRP, C-reactive protein (in mg/1); EMS, duration of early morning stiffness (in minutes); ESR, erythrocyte sedimentation rate (in mm/h); HAQ, Health Assessment Questionnaire;, London Handicap Scale (positive change in score represents improvement); DRP, Disease Repercussion Profile; 95% CI, 95% confidence limits. zero. None of the differences were statistically significant (P >.1). Patients' clinical courses showed considerable heterogeneity, illustrated by the upper and lower quartiles of changes. Using 'standard deviation' units (comparable with the effect size), the best improvements were.5 on the DRP social activities item and Ritchie Index, and the worst deteriorations were.6 in the ESR and wellbeing score. Associations between changes Change in ESR correlated strongly with change in CRP (r =.73). There were moderate correlations (.4 < r <.6) between changes in ESR and Thompson-Kirwan Index; Ritchie Index and Thompson-Kirwan Index; Ritchie Index and duration of early morning stiffness; HAQ and London Handicap Scale; wellbeing and pain; and DRP functional activities and social activities, emotions and body image. Other changes correlated weakly or not at all (r <.4). DISCUSSION Previous studies have compared measurements of arthritis severity using different instruments and shown considerable variation between them (e.g. [16]). The patients studied here were a heterogeneous group in terms of both diagnosis and duration of disease. They were chosen in the expectation of variability in cross-sectional indicators of disease activity and potential for change rather than to be representative of any particular patient group. Similarly, the indices of disease activity and severity were chosen as illustrative of the different levels under consideration, rather than a comprehensive cataloguing of all the potential impairments and disabilities suffered by patients. Data were unfortunately incomplete for some variables. The absence of data will have reduced the precision of the correlation coefficients involving these variables, but should not have biased them, since there is no reason to assume that the relationship between variables will have been different in groups with and without data. In any case, differences in demographic and initial disease severity indicators were small when patients with complete and incomplete data were compared, suggesting that missing data were essentially random. The measures of broadly defined 'impairment' correlated moderately strongly with each other, although the previously reported strong association on 27 June 218

6 8 BRITISH JOURNAL OF RHEUMATOLOGY VOL. 35 NO. 9 between the CRP and the Thompson-Kirwan Index (a weighted tender and swollen joint count) was not replicated here [6]. The three 'functional' measures (HAQ, DRP and London Handicap Scale) correlated more strongly with each other, confirming that they were measuring the same sorts of things, albeit with different emphases, indicating good construct validity. However, the other indices of disease activity cannot be taken as proxy measures of these, since the associations between them were only weak to moderate. The proportion of the variability in 'functional' outcomes explained by variation in laboratory and clinical variables was small (r 2 =.2-.16). In many ways, this is not surprising; indicators of rheumatic disease inflammatory activity will have little bearing on co-morbid conditions or accumulated joint damage. This does not imply that clinical and laboratory measures are not useful: disease-modifying drugs should clearly be targeted at those with biologically 'active' disease, which cannot be defined in terms of disability or handicap alone. However, the success of such treatment should be judged according to its impact on handicap. In those with established joint damage, co-morbid conditions or psychological sequelae of arthritis, disease modification may play a minor role compared with rehabilitation and environmental modification. In such cases, outcomes can only be measured using instruments specifically designed for the purpose. We have demonstrated that two new instruments for measuring handicap behave as valid scales, and give information additional to that obtained from clinical and biological variables. By definition, handicap is an individual entity. In clinical practice, this means determining for each individual the extent of disadvantage experienced compared with his or her peers, including both severity of limitation and the importance or value accorded to the limitation. The DRP is an aid to achieving this. Evidence has been presented previously that its dimensions give good coverage of the range of perceived disadvantages [1]. The London Handicap Scale adopts a different approach, defining a set of competencies that are generally expected of people, and putting explicit values on limitations (based on relative desirability or 'utility' measurements) according to the opinions of samples of the general population [13]. Whilst the descriptive framework may be found useful with individuals, the primary intention is that this scale be applied in epidemiological and health services research studies, such as trials, needs assessment exercises and descriptive studies of groups. In these settings, we need to be able to generalize and, ideally, summarize results in a single numerical index. The London Handicap Scale has limited validity when applied to individuals; in this respect, the DRP and London Handicap Scale are complementary. The HAQ, like many disability measures, suffers from arbitrary scaling and no account being taken of the importance of the activities to the individual concerned. In clinical practice, it is better to assess individual disabilities separately (e.g. walking, dexterity, dressing), as a prelude to suggesting remedial interventions. The overall impact of impairments and disabilities (i.e. handicaps) needs separate and explicit consideration in order to set priorities and judge overall effectiveness. Severity measurements should be capable of detecting clinically important changes. In this study, overall changes were small, although the distribution of changes was wide, suggesting that patients who improved were balanced by others who deteriorated. The fact that changes on different measures correlated beyond what would be expected by chance suggests that changes were real rather than the result of measurement error. It was perhaps optimistic to expect dramatic changes over 3 months of follow-up in patients with an average disease duration of 11 yr. The patients studied were routine follow-up patients, and would not be expected to show large changes associated with initial presentation and starting effective therapy. Improvements might result from a combination of disease natural history, pharmacological intervention, rehabilitation and adaptation. Alternatively, intervention may only slow inevitable deterioration. In the absence of an untreated control group, we cannot tell. In view of the lack of overall change in patients, this study was unable to evaluate sensitivity to change fully. An important conclusion is that in studies of chronic diseases, impairment, disability and handicap outcomes should be defined separately, since any single outcome measurement will not be valid at other levels. In the assessment of interventions, it should be easiest to detect effects by measuring at the level closest to the target of the intervention. Drug treatment, for example, might be expected to show most effect at the level of impairment, whilst physiotherapy might be expected to show a disproportionate effect on disability compared with its effect on impairment. The ultimate goal, however, of any intervention must be to have an impact on functional ability in everyday life, i.e. to reduce handicap. Moreover, to be of use in cost-effectiveness comparisons, a generic health status measurement tool is required. Such measures must be equally valid across many different diseases or combinations of disease, and responsive to many different types of intervention, including medical, rehabilitative, psychological and social aspects of care. More speculatively, one might suggest that rehabilitation aimed at reducing disability and handicap may not receive the attention it deserves until we have suitable measurement tools for use at both the clinical and population levels. Defining the problems experienced by a group of patients is the first step in a 'needs assessment', an important public health function which is of acknowledged difficulty. Having defined problems, interventions can be formulated and evaluated, enabling strictly defined 'need' (the potential to benefit from an intervention) to be established [17]. Clearly, averting or limiting damage caused by active disease to safeguard future function is an important on 27 June 218

7 HARWOOD ET AL:. HANDICAP IN INFLAMMATORY ARTHRITIS 897 objective, but curing diseases or reversing impairments is often not possible, in which case the attention should turn to reducing disability and handicap directly. The danger exists that unless need can be defined and interventions evaluated using suitably valid instruments, services will not develop by virtue of a lack of information rather than a lack of benefit to patients. Copies of the handicap scales are available from the authors who will be pleased to advise on their application. ACKNOWLEDGEMENTS RHH was a Medical Research Council Training Fellow. AJC was funded by Wessex Regional Health Authority and the Rehabilitation and Medical Research Trust (Remedi). REFERENCES 1. Bowling A. Measuring disease: a review of disease-specific quality of life scales. Buckingham: Open University Press, Symmons DPM. Measuring outcome in rheumatoid arthritis which measures are suitable for routine clinical use? Br J Rheumatol 1995;34: Scott DL, Long AF, Silman A. Disease outcomes in rheumatology. Br J Rheumatol 1995;34: World Health Organisation. International classification of impairments, disabilities and handicaps. Geneva: WHO, Ritchie DM, Boyle JA, Mclnnes JM. Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Q J Med 18;37: Thompson PW, Silman AJ, Kirwan JR, Currey HLF. Articular indices of joint inflammation in rheumatoid arthritis: correlation with the acute phase response. Arthritis Rheum 1987^: Huskisson EC. Measurement of pain. J Rheumatol 1982; 9: Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2: Fries J, Spitz P, Young D. The dimensions of health outcomes: the Health Assessment Questionnaire disability and pain scales. J Rheumatol 1982;9: Carr AJ, Thompson PW. Towards a measure of patient-perceived handicap in rheumatoid arthritis. Br J Rheumatol 1994;33: Harwood RH, Gompertz P, Ebrahim S. Handicap one year after a stroke: validity of a new scale. / Neurol Neuroswg Psychiatry 1994;57: Harwood RH, Rogers A, Dickinson E, Ebrahim S. Measuring handicap: the London Handicap Scale, a new outcome measure for chronic disease. Qual Health Care 1994;3:ll Harwood RH, Ebrahim S. Manual of the London Handicap Scale. Nottingham: Department of Health Care of the Elderly, University of Nottingham, Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Med Care 1989; 27(suppl.):S Fitzpatrick R, Zicbland S, Jenkinson C, Mowat A. Importance of sensitivity to change as a criterion for selecting health status measures. Qual Health Care 1992;l: Bombardier C, Ware J, Russell IJ, Larson M, Chalmer A, Read JL. Auranofin therapy and quality of life in patients with rheumatoid arthritis. Am J Med 1986; 81: Stevens A, Gabbay J. Needs assessment needs assessment. Health Trends 1991;23:2-3. on 27 June 218