Use of a 3-Item Short-Form Version of the Barthel Index for Use in Stroke

Abstract

T he Barthel Index (BI) is a 10-item measure of basic activities of daily living (ADL). 1 The BI is the second most commonly used functional assessment scale in stroke trials and the most commonly used ADL assessment in adult rehabilitation.2,3 BI quantifies ADL in an ordinal, hierarchical scale that ranges from 0 to 20 or 0 to 100 depending on the scoring used. 4 BI is recommended as an outcome measure by various professional societies and guidelines.3 BI has proven prognostic utility, 5 it is used in clinical practice to inform rehabilitation and care planning, and it is used in research both to describe outcomes and as case-mix adjuster. The BI has proven a useful scale, but there is scope for improvement, for example, floor and ceiling effects of BI scoring are well described. 6 For any assessment, there is a trade-off between the time and effort required for testing and the validity of the data acquired. 7 Although administration time for BI assessment is modest, there is still opportunity cost, particularly in busy clinical settings. 8 Issues with time taken to complete a scale are important to the assessor (longer time spent in assessment gives less time for other clinical activity) and are important to the patient (test burden is a particular issue in the context of acute stroke). These issues will be more apparent in patients with physical, cognitive, or communication difficulties, yet this is exactly the population that requires robust assessment of function. In the National Health Service (NHS) England and Wales National Stroke Audit, completion rate of BI measures was ≈60%, with lack of time cited as the reason forBackground and Purpose-There may be a potential to reduce the number of items assessed in the Barthel Index (BI), and shortened versions of the BI have been described. We sought to collate all existing short-form BI (SF-BI) and perform a comparative validation using clinical trial data. Methods-We performed a systematic review across multidisciplinary electronic databases to find all published SF-BI.Our validation used the VISTA (Virtual International Stroke Trials Archive) resource. We describe concurrent validity (agreement of each SF-BI with BI), convergent and divergent validity (agreement of each SF-BI with other outcome measures available in the data set), predictive validity (association of prognostic factors with SF-BI outcomes), and content validity (item correlation and exploratory factor analyses). Results-From 3546 titles, we found 8 articles describing 6 differing SF-BI. Using acute trial data (n=8852), internal reliability suggested redundancy in BI (Cronbach α, 0.96). Each SF-BI demonstrated a strong correlation with BI, modified Rankin Scale, National Institutes of Health Stroke Scale (all ρ≥0.83; P<0.001). Using rehabilitation trial data (n=332), SF-BI demonstrated modest correlation with quality of life measures Stroke Impact Scale and 5 domain EuroQOL (ρ≥0.50, P<0.001). Prespecified prognostic factors were associated with SF-BI outcomes (all P<0.001). Our factor a...

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