422 Bulletin of ¡heRoyal College of Psychiatrists
The Bethlem and Maudsley Hospital item sheets (B-MIS)
The development and reliability of an instrument for routine collection of summary clinical data
JEREMYTURK,Senior Registrar, Department of Psychological Medicine, Hospital for Sick Children, Great Ormond Street, London, WC1N 3JH (address for correspon dence); NASSERF. LOZA,Consultant Psychiatrist, Behman Hospital, Cairo, Egypt; JAN KASINSKI,Locum Senior Registrar, Department of Psychological Medicine, Hospital for Sick Children; RANDYKATZ, Honorary Lecturer, Institute of Psychiatry, De Crespigny Park, London, SE5; PETERMC&JFFIN, Professor, Department of Psycho logical Medicine, University of Wales College of Medicine, Heath Park, Cardiff; and ROBINMURRAY,Dean, Institute of Psychiatry, De Crespigny Park, London, SE5
The Bethlem and Maudsley Hospital item sheets (B- established. Also, it was not explicitly designed for MIS) are summaries in coded form which are com computer assimilation. Hence, a full revision was pleted for every patient admitted or readmitted to the undertaken, the goal being to produce them in a for joint hospitals. The Part 1 item sheet contains infor mat that allowed coded data to be presented in mation which is included in the Part 1case summary, readily storable and accessible form. as described in Notes on Eliciting and Recording Clinical Information? and is completed at the same time as the summary is prepared; that is, usually Background to the present study within a fortnight of the patient entering hospital. A working party drafted lists of items with the aim Similarly, the Part 2 item sheet contains information of covering in easily codable format most of the normally found in the discharge summary, and is 'hard' data contained in the admission and discharge completed at the same time that this summary is pre clinical summaries. For ease of completion and pared; shortly after the patient has left hospital. The coding it was aimed, where possible, to use a simple item sheets are restricted to pieces of information binary form i.e. present or absent. Thus, much 'soft' which can be readily coded by the registrar. Thus, of necessity, they concentrate on relatively 'hard' historical data had to be excluded. A small-scale preliminary inter-rater reliability data. study on a series of 20 consecutive admissions to a The primary aim of the item sheets is to provide a ward of the Bethlem Royal hospital was undertaken comprehensive data base for research and for moni by two of the authors (JK, PMcG). As a result, cer toring the work of the hospitals, which can be stored tain low reliability items were excluded. A glossary easily on computer, and rapidly accessed when needed. Coded data on in-patients of the joint hospi was prepared giving definitions, and directions, for each of the remaining items. Where possible, this tals have been collected in itemised form since the early 1950's, and have been used in a number of drew heavily on authoritative sources, for example definitions found within the glossary of the Present published studies.2'3 State Examination.6 Following this it was decided Earlier versions of the item sheets suffered from that a more detailed reliability study should be psychometric weaknesses. Some terms were felt to undertaken. be ambiguous and the format was felt to be over complicated. Ratings recorded on a selected number of the items in an early version were found to be unreliable.4 A further study5 showed marked varia The study bility in rater agreement. The author attributed this The medical records with accompanying admission finding to registrars tending to view the task of com and discharge summaries were obtained for two pleting item sheets as an unnecessary burden, and groups of consecutive admissions to acute adult psy hence often completing them in batches long after the chiatric units. Table I shows the mean, standard devi patients had departed. Test-retest and inter-rater ation, and range for the patients' ages, and the sex reliabilities for the individual items were never distribution of the patients studied. Table II lists the The Bethlem and Maudsley Hospital item sheets (B-MIS) 423 TABLEI agreement; 'agitation' and 'anxiety-with autonomie Age mean, standard deviation, and range, and sex ratio,for symptoms'. These items are considered further in the patients studied discussion section of this paper.
Age Standard Sex Comment Mean Deviation Range Male Female The results of this study confirm the usefulness of the Bethlem Royal and Maudsley Hospital item sheets 43.3 16.2 19-74 11 19 (B-MIS) in providing a reliable data collection sys tem which can be completed in approximately five minutes per patient, by the junior psychiatrist TABLEII responsible for that person. ICD-9 diagnosesof patients involvedin study The project emphasises the need for objective con trolled evaluation of such tools designed for data storage. Despite extensive committee work and Number of pilotting, there remained items (some of which patientsSchizophreniaDiagnosis represent extremely common psychiatric terms) for which reliability proved difficult to achieve. A project such as this allows for the refinement of such defi Manic depressive psychosis, depressed type 7 nitions, thereby improving their future usefulness, Manic depressive psychosis, manic type 5 enhancing diagnostic precision, and allowing reliable Neurotic depression 5 operationalisation for research purposes. Organic psychotic condition 1 The unreliability of the item 'agitated' was felt to Explosive personality11 1 have related to its particularly relaxed usage in the English language. The psychiatric term refers to Total 30 observed overt behaviour, not merely a subjective feeling of tension or anxiety. The glossary has been amended to reflect this. It now emphasises that the term refers to a specific set of behaviours which reflect underlying anxiety. ICD-9 diagnoses for these individuals at discharge The presence or absence of 'anxiety' was rarely from hospital. disputed. Controversy centred around whether there As the groups did not differ significantly on any of these variables the data were combined in the were indeed accompanying autonomie symptoms, or analysis of reliability. whether they were subjective perceptions without Two of the authors (JT, NL) rated item sheets physiological basis. In view of the good agreement as to which patients were anxious, and which were not, blind to each other. The resulting data were it was decided to create a unitary 'anxiety' term, computer coded in binary form. Individuals were identified by code number only, thereby ensuring thereby resolving the above dilemma. anonymity and maintaining confidentiality. A shortcoming of this study was the limited range of subjects, concentrating on patients with acute psy The accumulated data were analysed on the chiatric disorders requiring in-patient management. University of London Computer Centre AMDAHL computer, using a pre-existing programme.7 In most There is a need to confirm the findings on larger cases straightforward levels of agreement were samples of patients suffering from a variety of dis orders, and covering the extremes of age. Indeed, the assessed. For certain items, where one or other children's department of the Bethlem Royal and rater had given identical responses for all subjects, Maudsley hospitals has its own age-appropriate item inter-rater agreement was calculated as a simple sheets.8 It would seem logical and likely that item percentage, for statistical reasons. The initial computer analysis yielded six items sheet rating systems would require tailoring in order whose levels of inter-rater agreement were not sig to make them applicable to the population that is to nificantly better than chance. The definitions of these be rated. items, as contained in the guide and glossary to the item sheets were scrutinised, and reasons for dis agreements considered. Following mutually agreed Concluding remarks revision of the definitions, these items were rerated The Bethlem Royal and Maudsley hospital item for the 30 patients by JT and NL, again blind to each sheets (B-MIS) appear to be a reliable means of others ratings. This second analysis (Table III) left rapidly and readily coding information pertaining to two items with persisting significant levels of dis- adult psychiatric in-patients, which can be easily 424 Bulletin of the Royal College of Psychiatrists
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i!! o o * V V £ I ft- ft« ^ li I!i *:s 42(> Bulletin of the Royal College of Psychiatrists computerised, stored, and retrieved as required for usefulness of any data collected remains dependent research and administrative purposes. The need for on the skill and conscientiousness of the individual objective scientific evaluation of such systems, and who completes the ratings. their constituent items, is emphasised by our find This small-scale assessment study suggests that ings. Such practice allows identification of poor- this approach to rapid coding of standardised infor reliability items, and subsequent revision of their mation not only provides reliable data but also definitions. The appropriateness of item sheets for introduces a useful aide-memoire and an instructive the particular patient group under study always intellectual training exercise for the aspiring requires evaluation. Ultimately, the reliability and psychiatrist in his everyday ward work.
References 'HILL, D., BIRLEY,J. L.T.,CAWLEY, R. H., KENDELL,R. E., —¿ (1968) The relationship between neurosis and psy LISHMAN,W. A., POST, F., RUTTER, M., WING, J. K. & 6WiNG,chosis,J. K.,BritishCOOPER,JournalJ. E.of &Ps\'chiatr\,"SARTORIOS,114,N.189-192.(1974) The WOLFF, H. H. (1973) Notes on Eliciting and Recording Clinical Information. Oxford University Press. Measurement and Classification of Psychiatric Symp 2K.ENDELL,R. E. & GOURLAY,J. (1970)The clinical distinc toms, London: Cambridge University Press. tion between psychotic and neurotic depression. 7CiccHETTl,D. V. (1978) Assessing observer and method British Journal of Psychiatry, 117,257-260. variability in medicine. Connecticut Medicine, 42, 3SHUR,E. (1982) Season of birth in high and low genetic 253-256. risk schizophrenia. British Journal of Psychiatry, 140, "THORLEY,G. (1982) The Bethlem Royal & Maudsley 410-415. Hospitals Clinical Data Register for Children and "GROSZ,H. J. & GROSSMAN,K. G. (1964) The sources of Adolescents. Journal of Adolescence,5, 179-190. observer variation and bias in clinical judgments, Journal of Nervous and Mental Disease, 138, 105-113.
A service for patients with Wilson's disease
T. R. DENING,Research Fellow, Department of Psychiatry; G. E. BERRIOS,Consultant and University Lecturer in Psychiatry; and C. A. SEYMOUR,Consultant and University Lecturer in Medicine, University of Cambridge Clinical School
Wilson's disease (WD) is an autosomal recessive dis who was responsible for the initial introduction of order of copper metabolism with an incidence of penicillamine3 and other agents, as well as many about 30per million (i.e. fewer than 2,000 in the UK). clinical and laboratory studies of WD and copper Nevertheless, it is important for two main reasons: its metabolism. In September 1987 JMW retired, and manifestations are protean and may lead it to present the responsibility for WD passed to CAS. The aim of to a range of specialists; and its otherwise lethal this paper is to describe the workings of the service course can be halted by treatment with chelating until Autumn 1987, with particular respect to agents such as penicillamine and trientine. Published psychiatric aspects, and then to discuss future cases' and systematic study2 have shown that neuro developments. psychiatrie symptomatology is important in a high The service as operated by JMW, Reader in Meta proportion. In fact, about one-fifth either present bolic Diseases and Consultant Physician, included psychiatrically or are at least seen by a psychiatrist clinical and laboratory components. All copper before WD is diagnosed. biochemistry was performed in a laboratory in the Addenbrooke's Hospital, Cambridge has been the Department of Medicine. Junior medical staff were centre for the largest series of WD in the UK (over shared with the rest of the academic unit, but only 200 cases) due to the presence of Dr John Walshe, involved with in-patients. All referrals, including