Assessing Reliable and Clinically Significant Change on Health of the Nation Outcome Scales: Method for Displaying Longitudinal Data

Unit of Epidemiology and Social Psychiatry, 'Mario Negri' Institute for Pharmacological Research, Via Eritrea 62, 20157 Milan, Italy.
Australian and New Zealand Journal of Psychiatry (Impact Factor: 3.41). 09/2005; 39(8):719-25. DOI: 10.1111/j.1440-1614.2005.01656.x
Source: PubMed

ABSTRACT Many authors recommended that reliable and clinically significant change (RCSC) should be calculated when reporting results of interventions. To test the reliability of the Health of the Nation Outcome Scales (HoNOS) in identifying RCSC, we applied the Jacobson and Truax model to two HoNOS assessments in a large group of people evaluated in 10 community mental health services in Lombardy, Italy, in 2000.
The HoNOS was administered to 9817 patients; of these, 4759 (48%) were re-assessed. Reliable change (RC) was calculated using Cronbach's alpha (alpha), as a parameter of the reliability of the measure. Clinical significance cut-offs were calculated using a classification of severity based on HoNOS items.
In the whole sample, the clinical improvement cut-off was 11 and the remission cut-off was 5. Considering the severe patients, the clinical improvement cut-off was 12. The RC index calculated on the whole group and on the subgroup of severe patients indicated that eight-point and seven-point changes, respectively, were needed to be confident that a real change had occurred. Longitudinal changes were depicted on two-dimensional graphs as examples of reporting RCSC on HoNOS total scores in a routine data collection: 91.6% of the whole sample (4361) was stable, 5.6% (269) improved and 1.8% (129) worsened.
Our study proposes a methodological framework for computing RCSC normative data on a widely used outcome scale and for identifying different degrees of clinical change.

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    • "The clinical status of the patients was measured at monthly intervals with the Health of the Nation Outcome Scale (HoNOS), to assess behavioral problems and disability [18, 19], and the 24-item Brief Psychiatric Rating Scale (BPRS), to assess general psychopathology [20, 21]. "
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    • "These items are grouped in four subscales: behavioral problems, impairment problems, symptoms problems and social problems [40]. Clinicians rate HoNOS before and after interventions, so that changes attributable to the interventions (outcomes) can be measured [41]. A higher score on each HoNOS subscale corresponds to greater occurrence of problems in the corresponding areas. "
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    • "This definition is similar to, but more restrictive than that proposed by Harvey et al. (2006). As for psychosocial functioning, we adopted HoNOS cut-off thresholds proposed by the authors who validated the Italian version of the scale (Parabiaghi et al., 2005) to identify meaningful functional change, defining patients as improved if their HoNOS total score decreased at least by 8 points after treatment and functionally normalized if their HoNOS total score at the end point was ≤5, starting from a baseline score N5. "
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