Development of a rating system for digestive system impairments: Korean Academy of Medical Sciences Guideline.

A systematic and effective welfare system for people with digestive system impairments is required. In Korea, an objective and scientific rating guideline does not exist to judge the digestive system impairments. Whether the impairments exist or not and the degree of it need to be examined. Thus, with these considerations we need a scientific rating guideline for digestive system impairments to fit our cultural and social background. In 2007, a research team, for the development of rating impairment guidelines, was organized under the supervision of Korean Academy of Medical Sciences. The rating guidelines for digestive system impairments was classified into upper and lower gastrointestinal tracts impairments and liver impairment. We developed objective rating guidelines for the upper gastrointestinal tract, the impairment generated after surgery for the stomach, duodenum, esophagus, and for the lower gastrointestinal tract, the impairment generated after construction and surgery for colon, rectum, anus, and intestinal stomas. We tried to make the rating impairment guidelines to include science, objectivity, convenience, rationality, and actuality. We especially emphasized objectivity as the most important value. We worked to make it easy and convenient to use for both the subjects who received the impairment ratings and the doctors who will give the ratings.

INTRODUCTION

The standard of living is continually improving with the increase of national wealth. Accordingly, interest in the lives and welfare of the disabled is also improving which requires execution of a systematic and effective policy for the disabled. In order to operate it, guidelines to rate the impairments objectively and scientifically is required (1-3). The impairment rating guidelines currently used in Korea causes distrust and complaints. This is due to diagnostic errors, bogus disabled, and the fact that guidelines for the impairment of the digestive system does not even exist (2, 7). There are many people unable to carry on normal lives due to serious digestive system diseases, and yet no help is given from the nation and society due to lack of proper guidelines. The United States has already a scientific impairment rating guideline prepared by the American Medical Association (AMA). Therefore, we have decided to develop our own scientific and objective digestive system impairment rating guidelines fitting the given conditions of Korea based on social and cultural realities.

MATERIALS AND METHODS

The research committee was organized by specialists who have knowledge and experience in rating digestive system impairments under the supervision of the Korean Academy of Medical Sciences (KAMS). The committee consists of the medical doctors of internal medicine, general surgery, family medicine, and medical law and ethics. The committee members received education on the background and purpose, basic concept, rating methods, and principles of impairment of the rating impairment guidelines. The members analyzed the systems of European union, U.S.A. and many countries in Asia including the digestive system impairment rating. Especially AMA Guides (8) that was reformed and put into practice from the year 2000 was heavily referred. We used these guidelines positively in a way by making them satisfy the conditions of Korea, and then developed the digestive system impairment evaluation guidelines under the management of KAMS.

In this evaluation guideline of the digestive system was divided into three parts: the upper and lower gastrointestinal tracts and the liver. We examined the lives of people with digestive diseases to see whether or not they could carry on with normal activities. We evaluated the loss of function in the digestive system as 100% impairment due to the possibility of death from function loss. We fixed the impairment rate in proportion to the impairment state with the relative rate to the loss before proper functioning.

RESULTS

General principles

We paid careful attention to the KAMS Guidelines to satisfy the requirements of science, objectivity, convenience, rationality, and actuality. We placed objectivity as the most important value. Impairment evaluation should be conducted when the symptoms are in a fixed state, but if there is an expected change of symptoms, then another evaluation should be made two years later. In principle, the subject of impairment for medical evaluation should be as fixed symptoms that are left without recovery upon completion of treatment. The source of impairment does not have to result from traumas, but may also come from congenital diseases and just as a disease itself. The impairment should be evaluated by specialists of the appropriate fields of which it belongs to. We evaluated the loss of function in the digestive system as 100% impairment due to the possibility death from the loss of functions. We fixed the impairment rate in proportion to the impairment state with the relative rate to the loss before functioning.

Evaluation guidelines for the upper gastrointestinal tract impairments

The upper digestive tract includes the esophagus, stomach, duodenum, small intestine, and pancreas. Useful objective methods for confirming upper gastrointestinal tract impairments are: 1) fluoroscopy, contrast media using radiological tests and imaging studies such as a computed tomography (CT) or an magnetic resonance imaging (MRI), 2) cytology test or endoscopy including a biopsy, 3) esophageal manometry, 4) gastric acid secretory studies, 5) absorption abnormality test, 6) stool studies, and 7) Helicobacter pylori urea breath test. Also, fat content in the stool and intestinal malabsorption may be examined.

The impairment rate, as signified in percentage, reflects the anatomical, physiological, and functional abnormality occurring in an organ or system and the ability to perform daily activities. Patients belong to the normal scope of gastrointestinal impairments if patients are able to perform daily activities; show regular and intermittent gastrointestinal manifestations without need of specific dietary treatment or medications; and are able to keep normal weight with the necessary nutrition.

We divided the upper gastrointestinal tract impairments into the stomach, the duodenum, the esophagus, and upper gastrointestinal tract after surgery (Table 1-3).

Table 1

Evaluation guidelines for stomach or duodenum impairment

Table 3

Evaluation guidelines of impairment after an operation of the upper digestive tract

Evaluation guidelines for the lower gastrointestinal tract impairments

The lower gastrointestinal tract impairments include the colon, the rectum, and the anus. The signs and symptoms of the lower gastrointestinal tract impairment are: abdominal pain, pelvic pain, perineal pain, difficulty of defecation, tenesmus, stool incontinence, hematochezia, abscess, fissure, and fistula. In general findings, fever, weight loss, weakness, anemia, etc. may indicate lower gastrointestinal tract impairment. Useful objective methods to confirm colon, rectum, and anus impairment are the following tests such as: 1) digital rectal examination, proctoscopy, sigmoidoscopy, colonoscopy, 2) biopsy, 3) microscopic examination of the stool and cultivation, 4) fluoroscopy and radiological test using contrast media, and 5) CT and MRI examinations.

The impairment rate, as signified in percentage, reflects the anatomical, physiological, and functional abnormality occurring in an organ or system and the ability to perform daily activities. Patients belong to the normal scope of gastrointestinal impairments if patients are able to perform daily activities; show regular and intermittent gastrointestinal manifestations without need of specific dietary treatment or medications; and are able to keep normal weight with necessary nutrition.

We divided the lower gastrointestinal impairments evaluation into the colon, rectum, anus, intestinal stomas and after surgery of the lower gastrointestinal tract (Table 4-7).

Table 4

Evaluation guidelines for colon and rectum impairment

Table 7

Evaluation guidelines of impairment after an operation of the lower digestive tract

Evaluation guidelines for liver impairment

The symptoms of hepatic bile impairment are pain, nausea, vomiting, anorexia, general weakness, fever, jaundice, and itching. The symptoms of progressive liver disease complications are edema, ascites, esophageal varix, portal hypertension which generates bleeding, hepatic encephalopathy, metabolic impairment, and the loss of kidney function. Useful objective methods to confirm liver impairments are 1) an abdominal sonogram, 2) radiological examination such as percutaneous and endoscopic cholangiography, 3) CT and MRI, 4) liver isotope studies, 5) liver biopsy & fine needle aspiration biopsy, and 6) a laboratory test for diagnosis of bile duct and other liver functions. The determination of impairment degree occurred by liver diseases is executed by specialists noting the clinical symptoms, results of the liver function test, and the results of the image test. The evaluation criterion of liver impairment is summarized in Table 8.

Table 8

Evaluation guidelines for liver impairment

DISCUSSION

We developed an evaluation guidelines for digestive system impairments under the supervision of KAMS suitable to the conditions of Korea by referring to the AMA Guides. The disabled people in Korea, social environment, and hospital environment were taken into consideration while drawing up the guidelines. We worked to make it easy and convenient to use for both the subjects who receive the impairment evaluation and the doctors who give the evaluation.

The guidelines of the impairment rating are the synthesis of science and public opinion (8). The rating of digestive system impairments of KAMS are the clinically evaluated ratings of physical impairments. The physical impairment of AMA Guides are also the ratings of physical impairments. In order to satisfy the scientific characteristics, we referred to the AMA Guides as our model. The impairment rate of AMA has scientific characteristics and public trust to be used as a "global standard" (4). To satisfy objectivity we considered the patient's signs but did not consider the patient's symptoms as much. For this we rated the impairment according to the objective signs and the results of examinations. Using this score we developed a method of evaluating the degree of impairment. We avoided excessively detailed evaluation for convenience, introducing a comprehensive evaluation method so that the evaluation of overall functions will be achieved. We made a sum total of the varied impairments of a specific area not to be greater than the total functional loss of the appropriate organ.

This impairment evaluation is divided into the upper and lower gastrointestinal tracts and liver. In regarding the upper gastrointestinal tract of the stomach, duodenum, and esophagus, we also determined the impairment rate after surgery for the upper gastrointestinal tract, unlike the AMA Guides. The decision to include the impairment rate after surgery is because many people, who undertook surgical operation for the upper gastrointestinal tract, complain of the difficulty in performing daily life tasks, but no objective evaluation guidelines had existed in the U.S.A. as well as in Korea for this situation. Accordingly, the impairment evaluation after surgery for the digestive system would be useful.

Regarding the lower gastrointestinal tract, we made consensus on the evaluation guidelines for impairment of constructed intestinal stomas. This new consensus was a modification of previously used guideline in Korea. The guidelines were converted into an impairment rating scale. The impairment evaluation of anal disease was determined objectively. Stool incontinence generated from anal sphincter impairment was given special consideration.

In choosing evaluation guidelines for the upper gastrointestinal tract, we considered weight loss. If the organ is unable to absorb nutrition, it causes weight loss. The measurement of weight loss is economical and easy in that both patients and doctors would agree objectively and it would be a useful evaluation guideline for upper gastrointestinal tract impairment. If the impairment can be cured with surgical treatment, the patient is to be reexamined after a year to receive an objective and rational evaluation. The same goes for lower gastrointestinal tract impairments.

The Child-Pugh classification should be followed objectively in the case of liver impairment, with leftover function of the liver. Complications such as ascites, spontaneous bacterial peritonitis, hepatic encephalopathy should be regarded, and then we made the entire impairment guidelines of liver disease objectively and easily.

These impairment guidelines are developed after Korean environment for disabled people and hospitals. Considering the reality, the present impairment guidelines needs supplementary and periodic improvements. With respect to the hospital environment, close examination might be needed for improved scientific evaluation. Not all hospitals possess very expensive and rare equipment. Therefore, doctors should be able to rate impairments objectively with general equipment. In some patients that need more attention, referral system to a hospital with special equipment is needed.

The evaluation of digestive system impairment is applied to a medically permanent impairment, a fixed physical state but not a temporary state of impairment. Permanent impairment means a fixed impairment which has not changed a year after evaluation (5, 6, 8). A certain time interval was set up for evaluation of the digestive system impairment after it is fixed. The fixation of symptoms is generally judged after completion of treatment, but it is not always the case. If it does not get worse or there is no possibility of getting better, it could be considered as a fixed symptom, even during treatment. If the symptom or impairment gets worse, another team of interval could be set up the patient. Regarding the symptom without an objective evaluation tool with which most people would agree, such as pain, the committee agreed to defer the impairment evaluation until a useful evaluation tool is developed (9, 10).

Table 2

Evaluation guidelines for esophagus impairment

Table 5

Evaluation guidelines for anal impairment

Table 6

Evaluation guidelines of impairment after an ostomy