COOP Charts

Dartmouth COOP Functional Health Assessment Charts: Brief Measures for Clinical Practice

Eugene C. Nelson, John H. Wasson, Deborah J. Johnson and Ron D. Hays

INTRODUCTION
BACKGROUND
CLINICAL USE OF THE COOP CHARTS
CONCLUSIONS
REFERENCES

INTRODUCTION

The Dartmouth Primary Care Cooperative Information Project (COOP ) chart system has been developed and refined for over a decade for the purpose of making a brief, practical and valid method to assess the functional status of adults and adolescents. The system was developed by the Dartmouth COOP Project, a network of community medical practices that cooperate on primary care research activities.

The charts are similar to Snellen charts, which are used medically to measure visual acuity quickly in busy clinical practices. Each Chart consists of a title, a question referring to the status of the patient over the past 2-4 weeks, and 5 response choices. Each response is illustrated by a drawing that depicts a level of functioning or well-being along a 5 point ordinal scale.(1,2) The illustration makes the Charts appear "friendly" without seeming to bias their responses(3).

The Charts are a simple, easily administered, self-scoring system for screening, assessing, monitoring and maintaining patient function. This system has been tested in many different practices, in both North America and elsewhere, to evaluate and establish its reliability, validity and acceptability. One set of the Charts--the WONCA version for adults (Fig. 1)--has been developed as the international standard for classifying the functional status of adult medical patients in primary care settings (4). The COOP/WONCA version of the charts which differ somewhat from the original COOP Charts by asking about function in the previous 2 weeks (rather than 4 weeks). The dimensions of health status measured by the health charts are: Physical, Emotional, Daily Activities, Social Activities, Social Support, Pain, and Overall Health. The adult Charts have been used widely. (5-22)

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BACKGROUND

The methods used to evaluate the reliability and validity of the charts are comparable to those that other researchers have used to assess their health status measures. For example, the techniques we used to check reliability and validity are similar to those used to evaluate the RAND health status measures(23), the Sickness Impact Profile(24), and the Duke-UNC Health Profile(25). Therefore, it is possible to compare the reliability and validity of the charts with those other multidimensional measures. When this is done, the reliability and validity coefficients of the charts are similar to those observed for these other measures.

Studies to assess the Charts' reliability, validity, acceptability and clinical utility were conducted on over 2,000 patients in four diverse clinical settings. One-hour test-retest intraclass correlations for elderly patients ranged from .78 to .98 and from .73 to .98 for low income patients. The average Pearson product-moment correlation between Charts and previously validated measures of function was .62 (Table 1) and the Charts were as capable of detecting the association between disease and functioning as were longer, standard measures. Most clinicians and patients reported that the Charts are easy to use and provide a valuable tool to measure overall function in busy office practice.(2, 26) Table 2 and Table 3 illustrates how the Charts scores generally parallel RAND measures of function in the Medical Outcome Study (MOS).

The Adolescent Charts (Fig. 2) have been used in doctors' offices and school classrooms for both English- and Spanish-speaking youths(27,28). Six charts were determined to be the most effective in measuring mutually exclusive dimensions of health and social problems: Physical Fitness, Emotional Feelings, School Work, Social Support, Family Communication and Health Habits. (See Table 19-4.) The average correlation between charts and longer sets of questions measuring the same health dimension was .62; for non-corresponding correlations the average was .32. Average test-retest intra class correlations for six charts was .77. Compared with multi-item questionnaires, respondents found the Charts easier to understand and less likely to induce dishonest replies.

Adolescent girls will generally score worse than boys on the Physical Fitness and Emotional Feelings charts but better on the (at-risk) Health Habits charts. The scores of teenagers known to have behavioral problems will be worse on the Health Habits Chart. Simplified versions of the Adolescent Charts suitable for administration to children, aged 8-12, will have somewhat less reliability and validity.

TABLE 1. Correlation of adult COOP charts with adult Rand measures
MOS scales	COOP charts
MOS scales	Physicial function	Emotional status	Role function	Social function	Pain	Overall health	Social support
Physical function	0.59*	0.12	0.52	0.34	0.36	0.43	0.15
Emotional status	0.01	0.69*	0.41	0.53	0.25	0.48	0.44
Role function	0.40	0.29	0.60*	0.47	0.40	0.50	0.27
Social function	0.20	0.44	0.53	0.62*	0.33	0.52	0.36
Pain	0.28	0.30	0.50	0.43	0.60*	0.41	0.27
Overall health	0.37	0.33	0.51	0.44	0.38	0.61*	0.30
Social support	0.05	0.41	0.24	0.34	0.17	0.32	0.61*
	*Convergent correlations.

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TABLE 2. Comparison of MOS SF-36 multi-item scale score with COOP chart scores for patients with hypertension and diabetes
Domain	Hypertension		Diabetes		Depressive symptoms
Domain	COOP score	MOS score	COOP score	MOS score	COOP score	MOS score
Physical	49	49	48	48	49	50
Emotional	52	52	52	53	42	43
Daily activities	51	50	51	50	47	46
Social activities	52	52	51	50	44	45
Pain	50	50	51	50	47	47
Overall health	51	51	51	48	47	45

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TABLE 3. Formula for translation of COOP chart avearage scores to an estimated score for the SF-36 or its derivatives
MOS score to be predicted	Translation	COOP chart item
Physical	105.6 minus (Physical times 13.5)	Physical
Mental Health	98.2 minus (Emotional times 12.1)	Feelings
Social Activities	104.1 minus (Social times 14.4)	Social Activities
Pain	98.5 minus (Pain times 11.4)	Pain
Role Physical	88.7 minus (Daily Activities times 18.5)	Daily Activities
Role Emotional	94.6 minus (Daily Activities times 14.3)	Daily Activities
Overall Health	90.9 minus (Overall times 11.8)	Overall Health

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TABLE 4. Correlation of adolescent COOP charts with long-form measures of function
Multi-item questionnaire scales	COOP charts
Multi-item questionnaire scales	Physicial fitness	Emotional feelings	School work	Social support	Family communication	Health habits
Physical	0.52*	0.50	0.25	0.35	0.23	0.31
Emotional	0.34	0.74*	0.16	0.65	0.45	0.31
School work	0.35	0.06	0.66*	0.27	0.50	0.49
Social support	0.04	0.45	0.17	0.68*	0.43	0.25
Family communication	0.22	0.40	0.31	0.67	0.72*	0.16
Health habits	0.36	0.43	0.38	0.44	0.28	0.71*
	*Convergent correlations.

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CLINICAL USE OF THE COOP CHARTS

The clinical advantages of the Charts are ease of administration and scoring. However, compared to longer multi-item instruments, single-item Charts are likely to have less precision(29). Clinicians argue that this loss of precision is not critical.(23)

Practicing clinicians typically ask 3 questions about health status assessment:

Why do you measure functional status?
How do you fit functional measurement into a patient encounter of limited duration?
What do you do with the information from the assessment?

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Why?

The "why" question has been addressed by many authoritative sources in medicine. For example, the American College of Physicians has listed these potential benefits of health status assessment(31):

Detecting, quantifying, and identifying the source(s) of decreased functional capacity
Guiding management decisions
Guiding the efficient use of resources
Improving the prediction of the course of chronic disease
Improving patient outcomes: symptoms, mortality, satisfaction with care, function, and quality of life.

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How?

The COOP Charts were designed to fit into the standard data collection routine of busy ambulatory practices. The Charts can be administered via two modes: (a) clinician administered (physician, nurse, medical assistant) or (b) patient self-administered. The Charts' major positive feature for the clinician and office staff is their user-friendliness. This instrument is easy to administer and score, and requires few consumable supplies. The scores can be easily recorded in the medical record using a patient data flow sheet.

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What?

For practical purposes, a Chart score of 4 or 5 should always be considered abnormal. Once a clinician knows that a patient's score is "abnormal," the critical step is to verify the score and make a specific functional diagnosis. Once the specific cause for the dysfunction(s) is recognized, the clinician then has to determine the need for special resources to manage the problem.

The ease of administering the COOP Charts has also made them helpful for efficiently evaluating care that patients have received, delivering patient education, and rapidly measuring patient opinion of care received to manage a functional problem.(32) Patient-based information about their health and their experiences with the health care system can be used to improve care in two ways: (a) to immediately improve patient care during the office visit; and (b) to feed back into the re-design of care for future patients. (Fig 3).

The COOP Chart-based questionnaire titled "Improve Your Medical Care", illustrates these two approaches. The questionnaire asks about function, clinical symptoms and health risk. It also asks about the patient's perception of the doctor's awareness of problems, as well as perceptions of treatment benefit and doctor explanations about the problems. In short, the questionnaire allows the doctor to see through the patient's eyes.

Many practices use bar-code scanning of the "Improve Your Medical Care" questionnaire to generate automatically a patient health report letter. Using computer-based algorithms, the letter immediately informs patients of health problems that could be addressed and accordingly tailors the prescription to treat the patient's problems. A computer-generated flow sheet is included in the medical record.

Individual patient feedback stimulates physicians and prompts them to discuss unmet needs and prescribe applicable and educational self-care "homework". When aggregated responses are examined, physicians are encouraged to focus on areas where improvements in the process of care will generate the greatest impact for future patients. Ongoing monitoring of patient-based information produces a constant stream of ideas for changing the delivery process to get better results.

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CONCLUSIONS

Integration of functional assessment in clinical practice has hardly begun but it promises to be a useful means to improve care quality and provider/patient communication. The cost of implementing the approaches described above is small. Patient and provider appreciation is immediate.

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References:

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