Many outcome measures are currently used in department of rehabilitation medicine in hospitals of Korea. Routine outcome measures are recommended to evaluate the efficacy of rehabilitation and to compare the therapeutic effects of different programs and practices.1 The need for measuring rehabilitation outcomes is undisputed, but there have been few reports regarding which outcome measure instruments are most commonly employed in routine clinical rehabilitation practice in Korea.

Generally, patients who need rehabilitation are treated in general hospitals (training hospitals) in acute and subacute phase and transferred to rehabilitation hospitals or care hospitals in subacute and chronic phase in Korea. Rehabilitation is shown to be more effective when rehabilitation teams work together towards an achievement of person-centered goals. And the achievement of goals could be represented by the change of score of outcome measures.2 If outcome measures are different in each hospital, as in Korea, goal achievement could not be analyzed due to different outcome measures in different hospitals. It is helpful to develop a common 'basket' of recommended instruments which may help to guide treatment units which desire to employ formal measures but do not know how to go about it or which to choose. These common 'basket' of recommended instruments could be selected on the basis that (a) there is published evidence for their validity and reliability, and that (b) they are in regular and frequent use in the course of routine practice in Korea.3,4

Therefore, this study was performed to evaluate which current outcome measures are most commonly employed in Korea.

This survey was conducted by an e-mail questionnaire (Appendix). The questionnaire included the following items: areas of rehabilitation the centers provide, outcome measures used in each category (dependency, mobility & balance, upper extremity function, cognition, language, perception, mood, quality of life, and pain), what to do with outcome measure results, reasons for not employing outcome measures, degrees of satisfaction with the current outcome measures, and necessary conditions for the common 'basket' of outcome measures. Surveys had 9 questions and if response rate is below 60% out of 9 questions, we exclude the questionnaire. Approval for sending e-mail for survey on outcome measures was granted by the institutional review board of Pusan National University Hospital.

One hundred and sixty-four rehabilitation centers in Korea (75 training hospitals, 20 rehabilitation hospitals and 70 care hospitals) received the questionnaire. These numbers of hospitals represent almost all rehabilitation centers registered in the Korea academy of rehabilitation medicine. After sending the e-mail questionnaire, we made a phone call to notify and inform respondents regarding the e-mail questionnaire. A second copy of the questionnaire was sent to respondents if they did not answer within 1 week. There was no questionnaire which shows response rate of questions below 60%. All respondents were rehabilitation physiatrists working in the hospitals. The data from the returned questionnaire was entered into a spreadsheet and subjected to descriptive and simple quantitative analyses.

Of the total 165 questionnaires sent out (75 training hospitals, 20 rehabilitation hospitals and 70 care hospitals), 99 (60%) were returned, of which 35 were returned on the first approach and 64 returned after the reminder. The response rates of training, rehabilitation hospitals, and care hospital were 60%, 60% and 55%, respectively. Fig. 1 shows a flow diagram of the responses. Of these 99 respondents, 94 (95%) collected some outcome measures as part of routine clinical practice and 5 (5%) did not. Although there were sometimes multiple reasons, the reasons for not employing outcome measures were as follows: the lack of evaluators (40%), the lack of time and money (25%), and the lack of consensus among staff on which measures to employ (4%). Of the 94 centers which collected some outcome measures, 88 (94%) provided neurorehabilitation and 82 (88%) offered spinal injury rehabilitation. Eighty-six (92%) provided musculoskeletal and 42 (45%) provided amputee rehabilitation. Seventy-eight centers (83%) undertook rehabilitation of the elderly, 33 (35%) undertook rehabilitation for pediatric patients, 19 (21%) undertook cardiac rehabilitation, and 22 (23%) undertook pulmonary rehabilitation.

A wide range of different measures were in use, of which the most frequently used instruments were grouped by category and popularity (Table 1). K-MBI (80%) was the most popular global outcome measures. K-BBS (53%) was used most frequently for balance assessment. Upper extremity function was checked with hand grip strength test (70%) and Box and block test (67%) most commonly. K-MMSE was the most popular cognitive function test (75%). PARADISE K-WAB was the most popular language test (67%). Depression and pain were measured by Beck Depression Inventory most frequently (55%) and by Visual Analogue Scale (VAS) (86%) most frequently.

Sixty-three (67%) centers have routine discussions about their patients' achievement of goals or future planning based on the results of outcome measure. Sixty-three (67%) respondents reported that they routinely included the results of outcome measures in discharge summaries.

We also evaluated satisfaction degree with each outcome measure. Only a small number of respondents were completely satisfied with their outcome measures (8%); the majority were only neutrally satisfied (55%), leaving another 16% to 12% either moderately satisfied or dissatisfied with their outcome measures.

Finally, we asked "Would you be interested in using the common 'basket' of recommended outcome measures for documenting patients' statuses or progression?" 77 (78%) of the respondents answered that they were interested in using the common 'basket' of recommended outcome measures and that they would use the common 'basket' of recommended outcome measures if the measures were available. The recommended prerequisites for standardized outcome measures are listed in Table 2. Seventy-eight (78%) units responded that they would use a standardized outcome measures if there is an agreed standardized outcome measures lists (80%) and support of money and time (43%).

The questionnaire was widely distributed to obtain information from as many centers as possible. It is noteworthy that as many as 96% of the centers use some sort of outcome measures as part of routine clinical practice and 67% had routine discussions about their patient's achievement of goals. These results suggest that the common 'basket' of recommended outcome measures could be used effectively, if there is an agreement for usage of the common 'basket' of recommended outcome measures.

In our survey, it was clear that K-MBI is the most frequently employed for global outcome measures in Korea. K-MBI is simple, easy to score, but its disadvantage is the pronounced floor and ceiling effect.5 The reliability and validity of K-MBI was also verified in Korea.6 Most frequently employed measures for balance is K-BBS.7 The K-BBS is a 14-item scale that quantitatively assesses balance and risk for falls in older community-dwelling adults through direct observation of performance.8 The reasons why K-BBB is most frequently used to assess balance may be that the K-BBS can be easily administered with minimal equipment (chair, stopwatch, ruler and step) and space and that it takes only 10 to 20 minutes to complete the BBS. K-BBS has also a good reliability (0.98).9

K-MMSE was the most popular examination tool for cognition assessment. MMSE (Mini Mental State Examination) is a 30-point assessment tool that takes about 8 min to perform with older patients (range from 4 min to 21 min).10 MMSE correlates well with a number of cognitive screening tests and neuropsychological tests.11 The K-MMSE has reasonable sensitivity and specificity.12 The PARADISE K-WAB was the most commonly employed for language function tests. The PARADISE K-WAB has a high reliability (0.99) and validity.13 Because language quotient (LQ) takes longer time to perform,13 it is unlikely that every rehabilitation center use LQ in routine clinical practice. We could not investigate whether rehabilitation centers use aphasia quotient (AQ) rather than LQ in routine clinical practice. Additionally, an updated version of PARADISE K-WAB is published now, but in many rehabilitation centers, it is not widely used. It is reasonable to consider alternative such as Korean Test for Differential Diagnosis of Aphasia (KTDDA) or Daegu diagnostic aphasia examination for language function test in common 'basket' of recommended instruments. The validity of KTDDA is verified in Korea.14

For perception, depression, and pain evaluation, the most frequently used measures are line bisection test for perception, Korean version of Beck depression inventory (K-BDI) for depression and visual analogue scale (VAS) for pain, all of which take a short time and are easy to perform compared to other methods. Line bisection test, K-BDI, and VAS also have high reliabilities and validities.15-17 K-BDI was standardized on its reliability in Korea.18 VAS was also evaluated for its validity and reliability in Korea.19 Line-bisection test is used frequently for assessing perception but it is not evaluated for its reliability or validity in Korea. Hand grip strength test and Jebson Taylor hand function test are used for assessing hand functions most commonly but they are not evaluated for their reliability of validity in Korea.

The common 'basket' of recommended outcome measures is needed to make evaluation more effective. Selection of a suitable measure will inevitably depend on the setting, the nature of the service, conditions treated as well as other factors such as availability of staff's time. Recommended instruments should be not only valid, reliable and sensitive to change, but also simple and practical to use in a busy clinical service. One possible indicator of a scale's usefulness is whether it is widely used, since it is unlikely that evaluators will continue to collect data which they do not think clinically useful. As a first step, our survey was undertaken to determine which measures are currently in the most common use in the centers which performed outcome measurement as part of their routine clinical practice in Korea. Our survey presents the most commonly used outcome measures in each category (dependency, mobility & balance, upper extremity function, cognition, language, perception, mood, quality of life, and pain). These baskets of outcome measures could be used as recommended outcome measures in Korea because these instruments are valid, reliable, simple and practical to use as mentioned above. However, some of outcome measures are not currently evaluated for its validity and reliability. These tests need to be evaluated for its validity and reliability to be included in the common 'basket' of recommended outcome measures.

The degree of satisfaction with the current outcome measure system was not so high. The majority of the respondents (55%) were neutrally satisfied, leaving another 16% to 12% either moderately satisfied or dissatisfied with the current system. Seventy-eight percent of all respondents answered that they were interested in employing common 'basket' of recommended outcome measures and that they would use common 'basket' of recommended outcome measures if available. Prerequisites for common 'basket' of recommended outcome measures were standardized outcome measures lists (80%) and support of money and time (43%).

Our survey confirms that many centers employ outcome measures in their routine clinical practice. Although a wide variety of instruments are employed, common themes have emerged which may reasonably form the basis for the proposed common 'basket' of recommended outcome measures in Korea. In our survey, several limitations need to be mentioned. First, the most popular outcome measures and satisfaction degrees with current outcome measures were not analyzed between training hospitals, rehabilitation hospitals, and care hospitals. The main objective of our survey was to come up with the lists of most frequently used outcome measures which could be employed as a common 'basket' of recommended outcome measures. However, future study is needed to analyze the current system and outcome measure usage between different hospitals in rehabilitation in Korea. Also, some of the outcome measures need to be standardized to be included in the common 'basket' of recommended outcome measures. Lastly, this survey only shows most frequently used outcome measures but does not show outcome measures used in different diseases. Future survey with larger recruitment numbers and more specified outcome measure lists is needed.

In conclusion, the results of our survey demonstrate that routine outcome assessments have been widely performed in rehabilitation centers throughout Korea and there is also an agreement for need for common 'basket' of recommended outcome measures in rehabilitation.